Does electronic communication actually improve care?

The subject heading of a recent email correspondence read “beware, graphic picture ahead!” Obviously this piqued my curiosity, so, with one eye closed, I scrolled down on my iPhone to a picture of my patient’s tongue, which, truth be told, had a certain “you haven’t seen anything yet quality.”

The tongue in question? Maybe some white spots, certainly nothing gruesome, and most assuredly nothing I hadn’t seen before in my 12+ years in clinical practice. My advice to the patient, after confirming through a few back and forth emails that this was not an immediate threat to her, was that she see her dentist and/or primary care doctor for evaluation. If she wasn’t able to book either of them, then, yes, I would be happy to take a look myself.

What was remarkable about this exchange was not that a patient was asking for guidance, or for that matter, a diagnosis, about a symptom that drew her concern. Rather, it was that this correspondence did not involve an actual doctor-patient conversation, in the traditional sense of the word. Currently, a little under one third of physicians say the communicate with patients by email, according to Manhattan Research. That said, the practice is far from routine. On the patient side, data from the National Health Interview Survey found that just over five percent of Americans say they email with their doctor.

A number of explanations have been offered for physicians’ reluctance to use email rather than a traditional face-to-face visit. Frequently cited is the concern about increasing workload without a commensurate increase in compensation. Yet as my lawyer husband reminds me, “not every minute can be monetized in medicine.”

In other words, doctors are not lawyers worried about billable hours. Nevertheless, with reimbursements from Medicare and insurance companies down, and pressure to create revenue for our hospitals and practices ever on the rise, it is becoming increasingly difficult for physicians of this generation to engage in “pro bono” work, to borrow a term from our lawyer brothers and sisters.

Not unexpectedly, a major concern (and one which most physicians freely acknowledge) is patient privacy, data security, and liability. The EMR, which has already been adopted more universally as federal requirements have mandated, is likely going to be the IT wave of the future for even the most reluctant among us. Indeed, in July 2010, the Centers for Medicare and Medicaid Services and the Office of the National Coordinator for Health Information Technology announced final rules to implement the provisions of the America Recovery and Reinvestment Act of 2009.

My belief is that while EMR reimbursements are not currently linked directly to electronic communication with patients, there will likely be some financial incentive to use the electronic messaging tools available in the EMR, and this may encourage more use, thereby solving the “billable hours” barrier to entry I mentioned earlier.

Additionally, some private health plans such as Aetna and CIGNA have explored reimbursement for providers for virtual or “e-visits.” Another option which may be even more popular with physicians, is a “one size fits all” annual fee that they charge a patient for access to email correspondence with their doctors.

But here is the real question: Is the care of our patients being compromised by the use of electronic communication? Or are we improving communication and thereby enhancing efficiency, and then ultimately, patient care? I am fairly certain it will take a generation or two to know for sure. In the meantime, I propose that we all keep an open mind, adapt to the changing world we live in, and — as we do in the office — tailor our approach to each case as it comes.

Natalie Azar is a rheumatologist who blogs at The Doctor Blog.

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  • Ron Smith

    Good post. Here’s my perspective.

    As one who uses all digital technologies up to and beyond the bleeding edge in my practice I would like to offer a response to the following:

    “But here is the real question: Is the care of our patients being compromised by the use of electronic communication? Or are we improving communication and thereby enhancing efficiency, and then ultimately, patient care?”

    YES and YES!

    I answer email a lot. I even run my own mail server (among all the other servers I run including my own EMR host servers). The typical sequence of events from first time parents in my Pediatrics practice goes something like this.

    1. Its after hours so they call the office still without thinking about email.

    2. The call gets transferred to the Children’s Healthcare of Atlanta after hours phone advice line triage.

    3. Their problem involves a rash. The phone advice line refers them back to my answering service which sends me a text message.

    4. I call the patient back. They tell me about the rash. I ask them to send me a picture of it by email. I’ll either email or if need be call them back.

    5. I get the email with the picture. Its something simple and even characteristic like the recent run of Coxsackie Hand-Foot-Mouth.

    6. I either email or call them back if need be and explain that they don’t need to go to the urgent care or ER. I tell them even whether I think I need to see them the next day (I like my patients, but if they don’t need services in the office I don’t want them there).

    Time elapsed: about 30 minutes.

    Next time, they go straight to email. Time elapsed: 20 seconds.

    Money saved: 100 copay at the ER or something less but more than a regular office copay at an urgent care. Email alone means I saved a little for the cost of the after hours phone advice line contact.

    Money earned: $0 no matter how I care for them.. Convenience factor for me: 100 fold email over conventional after-hours phone care.

    Goal of after hour advice for me: Most parents need simple reassurance that they can be seen in the office the next day. They want to know that they don’t have to go to the ER or urgent care. I’m not trying to diagnose but I’m focused on when and where a patient needs to get care. When they realize how accessible we are by email, parents breath a sigh of relief. Their confidence level in me and my practice begins to rise. My parents tell other parents ‘you’ve got to go see Dr. Ron.’

    It’s not only good care, its the best care in my opinion. This is the new primary care for Pediatrics.

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • southerndoc1

      “It’s not only good care, its the best care in my opinion.”
      I don’t see why e-mail (with its lack of inflection, tendency towards misinterpretation, lack of quick back-and-forth questions/answers) is in any way better than an old-fashioned phone call from the doc on call, ESPECIALLY if the goal is so often just reassurance. Seems like a big step backwards to me.

      • Ron Smith

        It is more effective because of the digital age we live in. My parents not only are versed in these communication technologies, they are awed when an old codger like me has embraced them. Earned or not, there is an admiration that the current generation has for professionals who make themselves accessible in these ways.

        Most of the time those parents only need reassurance, not a full blown phone consult. Twenty seconds is just as good as 20 minutes for them.

        Ron Smith, MD
        www (adot) ronsmithmd (adot) com

        • Sue Ringgold

          And, a picture is worth one thousand words!

  • buzzkillerjsmith

    The answer to your question, Dr. A., is not bloody likely. Electronic communication might be quicker than phone calls in some cases, especially since patients do not have a chance to ask questions (or at least the barrier to asking questions is higher,), but does it decrease suffering and prolong life? I’d be interested in the studies showing it does.

    • https://www.facebook.com/arobert6 Alice Robertson

      It rocked my world during my daughter’s cancer. It’s the number one reason I miss that doctor. Plus it saved me many sleepless nights. Question…why are doctors using electronic communication here but balking about it’s other uses. It’s obvious you can type and communicate well when you want to. Sincerely…I ask because I see all these doctors pounding away on keyboards to share openly (which is a good opportunity) and think patients are looking at this as the fat doctor telling them that being overweight (or over-eating) isn’t healthy. They are like….wait….you do it?

  • morebuzzkills

    Electronic communication has effectively turned H&P’s and soap notes into formulaic pieces of insurance jargon…which I’m pretty sure was not their original purposes.

    • https://www.facebook.com/arobert6 Alice Robertson

      I don’t know… at Cleveland Clinic the patients are absolutely delighted because apparently we won’t need to order medical records. There was huge applause over the new system that will allow us to see not only the facts, but the doctor’s notes.

      Maybe it’s their great software but honestly patients are thrilled. They worked with the Gimme My Damn Data group.

  • Andrea Borondy Kitts

    As the care giver of a now deceased stage 4 lung cancer patient (my husband) I am so thankful our Oncologist used e-mail routinely with me. I was able to get quick answers to some items, a phone call back if we needed discussion. I was would send him statuses, heads up on completed tests, he would send me the test results and I could review results and research options so we were ready for decisions at our next appointment. Email was a significant quality of life improvement for us.

    • https://www.facebook.com/arobert6 Alice Robertson

      Same here…our ENT said I could email anytime and he would set us up for next day appointments. He went the second mile. It’s sorta funny to go back four years here and hear doctors all panic stricken about a patient may…omg….text them. So a Interventional Radiologist who used to post here started to place his phone number on the end of emails, etc. I asked him a year later how that went and he said no patient had called him (although his colleagues warned him not to do it). My GP friend had the exact same experience. Patients did not want to call the doctor for nothing, they didn’t want to party or spend the night they just wanted timely answers:) All the dire predictions didn’t pan out.