The pitfalls of email communication with patients

A recent article in the Wall Street Journal reviewed the emerging role of email in healthcare, arguing that doctors should more aggressively offer their patients the option to communicate with each other through email. Unlike other professionals in the United States, doctors have generally resisted the adoption of email into their practices. But according to the WSJ article, email can result in many benefits to both the doctor and patient. With email capability, patients have more immediate access to the office staff and can potentially get their problems and concerns addressed more quickly. They can also maximize their cost savings by minimizing office visits and reducing lost time from work. The author further elaborates that although doctors are not permitted to submit a charge to Medicare for email communication, they can benefit by delivering better medical care which results from the ability to monitor their patients’ conditions more closely through email.

Although these points are all valid, some areas of concern remain. In my own medical practice, I formerly used email with patients for about two years. But I eventually abandoned email and don’t ever envision going back. For sure, most patients loved using email. The option to report any symptom or concern at any time of the day without having to bother with telephone menu prompts or dealing with the hassles of making appointments proved to be tremendously convenient. And for those questions that were straightforward and consisted of hardly two sentences at most, email at times was a definite time saver.

Not infrequently, however, email could create a fair amount of inefficiency and confusion. Mostly everyone has either sent or received an email in which the content somehow did not fully convey the point intended. Despite reading, and rereading the message, the intent of the email was never fully apparent. I often felt that my responses were clear and concise, only later to learn that further clarification was required. On several occasions, I recall dispensing advice under the assumption that a patient was already taking a certain medication when in fact, they were not – all leading to confusion and the inevitable thread of emails that seemed endless. In the end, the potential back and forth that can occur with email often resulted in the need for an office visit in order to clarify the mess that was created from the original email.

Most worrisome to me, however, was the very real possibility that a diagnosis could be missed whenever an office visit was replaced by an email communication. There is an aspect of the doctor-patient interaction that that cannot be duplicated through the email process. Since the beginning of modern medicine, the face-to-face doctor-patient interaction has always been regarded as paramount to all successful medical decision making. It is only through the office visit that one can observe body language and identify other physical cues that assist in making the right diagnosis. Simply put, without this interaction you potentially miss the boat on what the patient needs.

Those on the side of more email use would counter-argue that it would only be medical issues of a “minor” degree that would be relegated to email status. That is fine, but in everyday life it is pretty much impossible for most patients to know what is a “minor” issue that is email appropriate and what is more serious and in need of a visit or immediate phone call. Seemingly trivial medical symptoms can often represent a serious condition. For patients to rely on an immediate email response or for the physician to sift through the nuances of an email to determine whether something is emergent or not becomes a gargantuan task.

I have concluded that email communication can work in a safe and efficient manner only if certain restrictions and systems are in place:

1. Security. Email should require logging into a secure system, which often requires several steps, such as entering in a medical record number and password. This would prevent any aspect of your conversation with the doctor from getting stolen. I think that it would be safe to say that many would prefer that their hemorrhoids remain a private matter and not circulating freely in cyberspace.

2. Receipt confirmation. Email sent to the Doctor should have a receipt confirmation in the form of an autoreply. In this way, the patient will know right away if their message arrived safely.

3. Word limitation. Email messages should be limited to 140 characters, similar to Twitter. Word limiations prevent patients from posing questions that are too complicated to answer by way of email. Likewise, doctor responses should be limited to the same extent. If it can’t be done in 140 characters, then the issue requires a call.

4. Word scanning. Medical email software should have a built in review process in place that scans each email created by the patient and clears it before allowing it to be sent. It would screen for “alarm” words in the email, such as “chest pain”, “stroke”, “gun-shot wound” or “suicidal”. If such words are in any way contained within the email message, then the message does not get sent and the patient gets a reply – “based on the content of your email please call the office immediately.”

5. Email delivery. It should be understood that email is read only once per day and each email sent will have only one reply. This prevents the back and forth that can happen with email use.

So patients can do all of that, and maybe get an accurate answer from the doctor. Or dare they pick up the phone and punch in 7 keys to speak with a live person, make an appointment, and have their best chance of getting the right treatment? You make the call.

Robert Sadaty is an internal medicine physician who blogs at Doc Chat.

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  • Craig Koniver, MD

    Why not try a secure messaging system? I currently use Avado, a patient relationship management platform and find this to be a great option. I frequently email my patients and cannot envision a time without it. My patients love the convenience and so do I. Many, many questions can be easily answered by email and do not require a face to face interaction.

    The key here is establishing a CONNECTION with your patients. Without that, of course, you are always going to worry about missing this or misinterpretation of that. But when you really get to know your patients, then you can let go of those fears that you outlined.

    I find that most doctors skim over this point and just assume they connect well with their patients or shrug off this idea saying they are too busy with too many patients.

    This blog itself highlights the very impractical nature of our modern healthcare model–fear of interacting and connecting with our patients….

    • Howard Luks MD

      Agree Avado and RegisterPatient make email communication simple abd effective. guidlines and policies are necessary too

  • Anonymous

    It seems to me that if you were confused over the content of the e-mail, you should have called.

  • Barack Hussein Obama

    I guess I don’t buy into the idea that a doctor needs to communicate electronically with patients in order to connect with them.  Previous generations of doctors connected with their patients just fine without having the option of email.  If a practice has the means of fitting patients into the days schedule on short notice then seeing the patient, face to face, is always preferable.  It might be less convenient for the patient, but that’s life.   

    The scary thing about email is that you could lose precious time for illnesses such as stroke.  I once flew to a CME conference on the West Coast, turned on my phone once the plane landed, only to read an email from a patient that he was having numbness and tingling down his arm with a headache, timed 2 hours earlier.  Fortunately, all was OK.  It could have been different.  Had there not been an email option he/she would have called the office or 911.  You get a few of these emails in a row and you curse the day you ever decided to offer email in the first place!

  • Dave Chase

    It’s important that expectations are set clearly with patients. This is good to do initially but also refresh that message periodically as individuals can forget this. I think more important than limiting to 140 characters is using a rich messaging system that has forms that help the patient ask a question (e.g., drop down choices, checkboxes, etc.). A lot of patients aren’t sure how to ask a question or describe a situation and a tool can help with that. Fortunately, there’s tool out there to help with that sort of thing. 

    Without a doubt, the biggest obstacle to productive use of messaging is the reimbursement model. If one is still in the “do more, bill more” model where email isn’t reimbursed, email is simply viewed as more non-reimbursable work. In contrast, those who are on a retainer-based model or they are getting bundled payments, email is a no brainer. Of course, there’s MDs doing email out of the kindness of their heart (or they realize there’s indirect marketing benefits) but that will remain a small subset for the foreseeable future. 

  • Guest

    Dare to press 7 keys on a phone?  Are you kidding?  I have spent countless hours on the phone with receptionists explaining my situation and the help I’m looking for only to have to explain it ALL over again to a nurse, who then HOPEFULLY accurately represents my case to the doctor.  I’d rather be able to directly address my physician and represent MYSELF.  If you’d like to triage it to a nurse from there (not sure why that isn’t proposed as an option in your blog), that’s fine, but at least I know I’m being heard by the person who can actually do something, and not processed through the patient phone shuffle.

  • Kalon_Mitchell

    What this article and other similar articles do not consider is that most communication between a patient and a doctor’s office is not related to obtaining a diagnosis.  It is related to confirming appointments, refilling prescriptions, conveying lab results or other medical data, questions regarding bills, obtaining insurance information, medication history, and other information that can be exchanged more clearly, concisely and efficiently through electronic communication than through a phone call or personal visit.

    In addition, electronic communication includes the added convenience to both parties of not requiring mutual availability which is required for phone and visits.

    This article also makes the assumption that doctors would personally review and possibly respond to all emails.  Does this happen with phone calls and other forms of patient interaction?  Not very likely.

    Like office visits and phone calls, patients communication will be triaged by office staff who will determine if the doctor should be involved.  The doctor does not sit in the front office and ask every patient who walks in “how may I help you?”.

    The real excuse is money.  As long as the doctor fears that email interactions might cost them office visits, they will not be accepted as a method of diagnostic interaction with the patient.  This is expected.  The answer is not to use them for this purpose.  They can still be used to significantly improve the customer experience and staff efficiency if they are only used for administrative purposes.  Once a reimbursement system is in place for diagnostic uses, the tools to securely interact with patients will already be in place.

    Kalon Mitchell
    President, MedTranDirect

  • HouseDoc

    In a recent Sermo survey, 51% of physicians said that they would exchange email messages with patients, if the service were secure, and they were allowed to charge for it. More articles on the subject on twitter@housedocus. 

  • Anonymous

    What’s the problem? If the email conversation is first initiated by the patient, we should conclude that the patient is giving their express permission for such a dialog. From that point on, sole responsibility for HIPAA privacy rights falls upon the patient. As an added measure of reassurance for the provider, any emails that come from the provider should contain an industry standard disclaimer to protect the provider from any legal responsibility whatsoever. When a new patient fills out the many forms required by the provider, one of the questions should ask whether the patient agrees to electronic communications. Leave it to our broken health care delivery system to create another tempest-in-a-tea pot! Geez!

    • John Key

       Too many folks worrying about the nuts and bolts, and concentrating on why it won’t work rather than why it should.

  • AdvocacyRSS

    I have to concur with the author’s statements regarding “missed diagnoses”.  E-mail should not be replaced as a means of communication between the patient and physician when discussing health concerns.  There needs to be a better strategy across the board for closing the communication gap between physicians and patients.  Yet, choosing e-mail to close that gap should be strictly utilized for  informational purposes – and not for symptomatic responses.  As an advocate and parent of a child with a rare disease – I coach families on how to communicate with their physicians.  While I recommend all patients be prepared at the time of the appointment – I also encourage physicians to take the time to listen to their patients.  Too often, patients do not respect the time of their physicians.  And, once they get their physician’s attention – do not utilize their time efficiently.  Thus, e-mail would bridge this gap for those occurrences when patients have information that is beneficial to the physician.  However, e-mail – without proper guidelines – gives the patient too much latitude for inconsequential discussions.   On occasion, I have used e-mail with physicians when they have asked for specific information.  Yet, I kept the discussion limited with facts and precise information so as not to burden them with unnecessary chatter.  And let’s be realistic – I would prefer my physician use his/her time more efficiently – rather than spending time reading e-mails.

  • natsera

    I would LOVE to get a real person who could take care of me on the phone if only I COULD. When I have a urinary infection, and am in acute pain NOW, (on Friday), I don’t want to be told the next available opening is on Monday. I’m diabetic, and I CAN’T WAIT that long!

    I would MUCH rather have an intelligent person screening calls, who could make rational decisions about what can wait, and what needs to be taken care of NOW.  “I’m sorry, but we can’t call in prescriptions unless we see you, and the next available appointment is on Monday.” Well, I’m not SO stupid as to think that painful bloody urine is not urgent and can wait. Call in a prescription, and if it doesn’t work, I’ll gladly come in on Monday. Don’t just leave me hanging!

    My other beef is, what about when you call, and you get “I’m away from my desk right now; please leave a message” and no one ever calls you back?

    So rather than quibble about phone vs. e-mail, why don’t you docs figure out a way in which you can give appropriate care, take care of urgencies as needed, and do what you’re paid to do?

  • Barack Hussein Obama

    First of all, I don’t think that email should be even considered until there is some type of reimbursement method.  Like any other professional in the U.S., you should bet reimbursed for your professional opinion.  If the patient can’t afford it, then get on the phone.  It couldn’t be more simple.

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