Enhancing Doctor-Patient Communication Using Email: A Pilot Study

Shou Ling Leong, MD; Dennis Gingrich, MD; Peter R. Lewis, MD; David T. Mauger, PhD; John H. George, PhD

Disclosures

J Am Board Fam Med. 2005;18(3):180-188. 

In This Article

Discussion

In our study, e-mail communication was judged to be a convenient form of communication between the patient and the physician. Satisfaction for patients was improved, and satisfaction for physicians seemed to be improved, but no improvement could be confirmed through statistical analysis of the data. The volume of messages and time spent answering messages for the e-mail group of physicians was not increased. However, the physicians commented that if e-mail were to be offered to a larger group of patients, additional support staff would be required to effectively manage the e-mail messages from patients. A triage system similar to that used by Stanford Medical Group in Palo Alto, California, where a staff member would route e-mail to the appropriate person could help reduce the time burden on the physicians.[16]

Table 5 lists some important guidelines for e-mail communication between physician and patient. E-mail communication is ideal for short questions, brief updates, follow-ups, or clarification of instructions. It is not intended to replace the office visit. Issues that are complex, contain uncertainty, or would require negotiation should be addressed face-to-face in the office. To avoid legal and liability complications, an existent patient-physician relationship should be in place before offering advice via e-mail. With the Health Insurance Portability and Accountability Act (HIPAA) regulation, extra diligence is required to insure privacy. Before using e-mail to exchange information, physicians must obtain written informed consent from patients. Patients need to understand that e-mail communication is nonsecure and confidentiality cannot be guaranteed. E-mail should not be used for urgent or sensitive matters. Sands and others[12,23] have provided useful guidelines for the appropriate use of e-mail. Since the conclusion of the study in July 2002, the Penn State Hershey Medical Center has issued a set of updated guidelines for e-mail communication with patients based on current national guidelines. The Penn State Hershey Medical Center Patient's Guide to e-mail is accessible at http://www.hmc.psu.edu/visitors/HIPAAemail.pdf .

One limitation of this study is that neither physicians (who were placed in groups by the principal investigator to maintain a balance in physician characteristics) nor patients (who were assigned to their respective physician's group to maintain the doctor-patient relationship) were randomized, thereby creating uncertainty regarding the effects of the intervention. The small sample size of 8 physicians limited the potential for yielding statistically significant data. The patients were from a university hospital-affiliated family practice office and were well-educated and Internet-savvy; therefore, the results may not be generalizable to other office settings and patient populations. The control group reported a higher rate of Internet use than the e-mail group ( Table 2 ). The significance of this is unclear. The utility of the health information web site was modest, with declining interest and rating of the site over time. It is not known whether this is a reflection of the quality of the web site or is a typical pattern of use for web resources. More data are needed in this area.

Most e-mail messages from this study were for updates on conditions (32%), short medical consultations (31%), and questions related to medications (16%). These types of information allow the physicians to manage the patients' medical problems beyond the office visit. By improving access to care and communication between patients and physicians, e-mail has the potential to help prevent medical errors. For example, with the ease of e-mail communication, patients may be more likely to report potential medication side effects before the next office visit, adding to medication safety. Coupled with a well-developed patient education web site, e-mail has the potential to improve patient education and improve management of diseases. In this study, the amount of time used to answer messages from patients was not increased, suggesting that potentially improved access by e-mail does not cause undue burden on the physician or practice.

E-mail is a widely used mode of communication. As we move toward using an electronic medical records system, e-mail would be a useful component. The medical field needs to define appropriate uses for this communication, develop standards and guidelines, ensure privacy and security, and assess and address issues related to compensation for service and legal and ethical implications. After taking the appropriate measures to address these important concerns, e-mail holds enormous potential as a practice tool to enhance health care delivery, as well as the health outcomes of patients.

This work has been presented at the 36th Society of Teachers of Family Medicine Annual Spring Conference; 2004 Sep 20-24; Atlanta, Georgia, and the 31st Annual North American Primary Care Research Group; 2003 Oct 25-28; Banff, Alberta, Canada.

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