Thursday, April 24, 2008

Thoughts on Patient-Physician Email

I'm a believer in patient-physician email communication. Let's face it -- just about every profession has enthusiastically adopted email as a rapid, non-interrupting, easily documented form of communication -- so why hasn't medicine?

There are many reasons. Here are just a few:

1. Physicians -- particularly older physicians -- may simply not use email. A recent study showed that less than half of physicians use email for medicial practice.

2. Physicians may fear providing patients easy access to them through email. Some providers I've spoken to worry that their inboxes will be filled with long, nonspecific complaints from patients rather than communications on important topics. One study even suggested that emailing patients could decrease provider income.

3. HIPAA. The Health Insurance Portability and Accountability Act requires that electronic protected health information (EPHI), including email, be communicated in a secure way -- that is, through an encrypted system. There are many commercial services available that allow encrypted patient-physician communications. For examples, of this search Google for [HIPAA and email]. In practice, however, most physicians do not have access to these encrypted email systems and are unwilling to pay for these services. In addition, patients may be unwilling to use proprietary online systems to communicate with their doctors when their everyday (unencrypted) email system is quick and simple. I've had patients complain unhappily that an encrypted online email system was too complicated to use, and why couldn't they just send me a plain old email...?

The time for the typical office visit has shrunk. Due to many factors including declining reimbursement and the need to see more patients per day, most office visits are now scheduled for 15 minutes or less. Neither physicians or patients are happy about this. Fifteen minutes is hardly enough time for adequate patient education or for forming a bond with your physician.

Enter email, a service which allows more time for physician patient-communication and helps people feel closer to their doctor. A few potential uses for email include:
  • Asking about lab results
  • Reporting potential side effects of medications
  • Clarifying whether it's safe to take a certain medication
  • Reporting home blood pressure readings
  • Reporting blood sugar readings
  • Giving positive feedback
  • Giving negative feedback
  • Asking for prescription renewals
  • Reporting new minor (but important) symptoms
  • Communication new medical issues when out of the country
  • And many others
Of course, any of these communications could also be made with a phone call -- but with a lot more hassle for everyone involved.

Take this example. Let's say a patient on a cholesterol lowering medication (Lipitor) has a twinge of pain in his left arm. He's heard that Lipitor can cause muscle problems, and is concerned that the twinge might be caused by the medication. One option is to schedule an office visit, but he's reluctant to do this for such a minor problem. Another option is to call the doctor's office, speak with a secretary (who would then take time deciding about the severity of the problem), have a note left for the doctor, who would then call him back later in the day to reassure him that this twinge doesn't represent a problem with Lipitor. Or the patient might not even ask the question, figuring that the pain is nothing significant, but still remain worried that it's a side effect of his medication and might even stop taking the Lipitor out of concern.

Alternatively, he could write an email describing the problem and receive a reply reassuring him that the pain is not consistent with a side effect from the Lipitor and he should make an appointment to be seen if it continues. Simple, almost effortless, and everyone is satisfied.

To summarize:
  • Many patients would like to email their physicians.
  • Many physicians are either unfamiliar with email or uncomfortable with giving patients the additional access that email provides.
  • Email has the potential to strengthen the physician-patient relationship and improve both patient education and the quality of care.
  • The HIPAA privacy law prohibits email between physicians and patients unless this communication is encrypted.
  • Many commercial solutions for encrypted email between physicians and patients exist. Unfortunately, many of these solutions are either expensive, proprietary, and/or cumbersome to use. (If you would like to suggest a commercial email system that is inexpensive/free and easy to use, please comment.)
  • Encrypted email systems that are cumbersome to use and/or require an elaborate login process will frustrate patients and discourage them from emailing providers.
  • Many patients would prefer to use plain, unencrypted email to communicate with their physicians.
Ideally, an encrypted email system between patients and providers should be used. But what if one is not available and/or the patient would like to give permission to communicate protected health information over insecure, unencrypted email?

Different institutions have come up with their own solutions to this problem. This is an excerpt from Yale's Guidance on the Use of Email Containing Protected Health Information:
A provider may obtain informed consent from a patient via electronic messaging (e.g., email) by conducting the following consent exchange upon presentation of a patient query via electronic messaging (this example is for an email exchange):

I will be happy to respond to your query but to do so via email you must provide your consent, recognizing that email is not a secure form of communication. There is some risk that any protected health information that may be contained in such email may be disclosed to, or intercepted by, unauthorized third parties. I will use the minimum necessary amount of protected health information to respond to your query.

If you wish to conduct this discussion via email, please indicate your acceptance of this risk with your email reply. Alternatively, please call my office to arrange a phone conversation or office visit.
Columbia University also has a policy on email on their HIPAA information page:
If a patient requests email communications containing their PHI, the individual receiving the request must obtain a completed Request for Email Communications form from the patient AND must provide the patient with the Important Information about Provider/Patient Email form prior to processing the patient’s request.
(If you're interested, I've extracted the text from the forms on Kidney Notes.)

If you have other solutions to the problem of physician-patient email, please feel free to comment.

(This three part series was originally posted on Tech Medicine.)


Anonymous said...

The biggest question about patient-physician email not being talked about is the inherent difficulty in ALL patient-physician communication and how this might be exacerbated by communicating through electronic means. Face-to-face communication with patients can be difficult and complex when dealing with technical explanations of complicated diseases. On top of dealing with these issues, providers must also be able to tailor their message according to the patient's level of education and social/cultural context in order to communicate clearly and effectively. Relegating communication to emails will take away the single most powerful tool in determining whether or not a message is understood--nonverbal communicative cues (such as body language and tone). This is a significant and largely ignored barrier to effective implementation of email communication. How will providers know if their email messages are being received and understood?

Ted Eytan said...

HI Joshua,

I thought I'd provide a comment based on the experience of one health system, where all of the doctors, young and old, are trading secure e-mail with their patients.

I also suggest a closer reading of the Kaiser Permanente study. As you read the paper, you'll notice both a drop in phone calls and in in person visits for the PHR group, with a nice explanation in the discussion of why this is better for a practice (and a health system) in multiple financing models.

It's important to point out as you did that patients want this, and we do want to take good care of them. Luckily, there are now models of how to do this well.