Science Interviews

Interview

Tue, 9th Sep 2014

Medicine by email: a good or bad idea?

Emma Richards, Imperial College London, and Elinor Gunning, University College London

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Emails have been used by growing numbers of the general public for at least 15Stethoscope_in_drs_hands years, but you still can't email your doctor. So as the population grows and pressure mounts on services should you be able to email your GP? In an article in the British Medical Journal this week, GP Emma Richards, based at Imperial College London, is concerned about safety, confidentiality and workload. But Elinor Gunning, whoís also a GP, and based at University College London disagrees. Chris Smith spoke to Emma and Elinor about the pros and cons of emailing your GP...

Elinor - Weíre using email to communicate with our day-to-day lives and in many other industries. Medicine seem to have fallen behind a little bit. I've been lucky enough to have experienced in working in a surgery where they have used emails and I think that itís improved care for patients, certainly has improved access and convenience. And the doctors have also found it very useful.

Chris - What sorts of questions or communications have the doctors at the surgeries which you have worked been exchanging with patients?

Elinor - I found that the emails that our patients sent were actually really very appropriate. We generally find that after an episode of care thatís been a face-to-face episode Ė I fully admit that email can't substitute all the things that you can do in a face-to-face communication and the fact that you can do physical examination Ė but then, what I found really useful and the patients found convenient is that follow ups could be done through email. So you could communicate test results, the patient could tell you if nothing was improving in two weeks, and I think simple medical conditions and certainly, facilitating follow ups, self-care, communication of results. I think it can be a very useful addition to the sorts of communication we already use. 

Chris - Emma Richards...

Emma - I do think that there are some concerns though. Anything sort of new to be implemented really does need to be sort of robust and backed up by the evidence and I think at the moment, the majority GPs are a little bit wary of this. I think some of the main concerns around safety, the sorts of things that they might want to talk about on email. Certain follow ups for simple conditions, perhaps that would be appropriate, but actually, there's no way of limiting that Ė you know, what prevents someone from emailing about a chest pain on a Friday night thatís not going to get read until Monday? There's also concerns regarding confidentiality and actually, GP time. GP days are sort of 10 to 12 hours long and most of the time, you donít get a moment between seeing patients, doing paper work, going on visits, taking phone calls. I think it would be very difficult to squeeze that somewhere into the day. I think without a lot of sort of careful planning and more investment in general practice, we certainly more general practitioners in order to provide this kind of service, I just can't see at the moment how it could be done.

Chris - So Elinor, how do you manage patient expectations? Emma makes very important point that sheís off on her lunch break when during her lunch hour, sheís seeing 5 home visits, comes back to the surgery and in the meantime, 15 emails have turned up. None of them are prioritised because they just turn up in time order. How do you know which ones you're going to deal with first? You've now got a waiting room full of patients expecting to be seen.

Elinor - That was my concern when I started working in a practice that use email. I thought, ďHow on Earth am I going to manage all these as well as everything else?Ē And I think itís all to do with the actual planning of the service. It takes time and investment and very careful planning to actually insure that your email service runs smoothly and is safe. Basically, all the emails that will come to our practice would then go into a central inbox that would be reviewed by one of the admin staff. They would bounce on emails to you so you won't get an email that werenít relevant to you that were about very urgent things because they would be picked off and given to the on-call duty doctor. When we took the concerns and they signed the form or told us verbally, yes, they were happy for us to use this particular email address. They were told that the email you use should be for non-urgent things, that it wasnít going to be checked any more than every few hours. It might not going to respond to a couple of days. So, it would discourage people from using it inappropriately. And I really felt that that did actually help educate our patients as to the best use of emails so that actually, they could use it for quick and simple things. And also, from the doctorís point of view, when you're trying to respond to these questions, itís actually a lot easier to respond to 5 queries from patients via email than it is via telephone because it means that you can actually get through to people. It might be a little bit too late to be calling patients or if you do call patients quite often, you have to call three of four times to get through. So, you did feel like actually you were being more efficient.

Chris - Emma, do you think that this is a safe approach Ė just sending an email? You donít know actually really who itís gone to or who itís come from, do you? You also donít know if the patients read it. So, the advice youíve given them about the chest pain they were having, you donít know if thatís actually been digested and acted upon.

Emma - And you also donít know how the patient would be responding emotionally to  that email whether it be test results, whether it be advice about what needs to be done next.So, you donít get that feedback from the patient that you also would get in a face-to-face consultation or in a telephone consultation. We donít know that you're sending the email to that person, to that patient. In March, there was an email hacking scam in which a lot of people were told that their blood results showed they had cancer. So, weíd have to make sure that we could safeguard against hacking and that sort of thing. And educating patients would be one way of doing that, but in terms of losing that non-verbal communication that you get in a face-to-face consultation and over the phone, in terms of understanding, there's certainly more potential for miscommunication, misunderstanding, and possible clinical error.

Chris - Emma, what do the patients want because at the end of the day, they're the most important people in this conversation?

Emma - Patients want different things and we need to try and provide a service that meet everybodyís needs. Above all, itís very important that we reach out to those people that are in the greatest need and those that are elderly, infirm and certain socio-economic and ethnic minority groups. There has been some studies that show that these people tend not to use email. I think in that sense, a telephone is different from the internet because most people do have a phone, most people can pick up the phone. I think that some patients will find that email would be convenient for them, but you need to make sure that everybody gets a good service and good access, and itís going to be difficult to provide a service that suits everybody.

Chris - Elinor, your thoughts based on probably what Emma said and any concluding points you want to make.

Elinor - We shouldnít substitute every face-to-face encounter with an email. Thatís also absurd and not appropriate. But there are certain interactions that I think could be amenable to email use and that could benefit patients.

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I'm not quite sure how the health services function in Canada and the UK. 

Here in the USA, we still have doctors with private practices, and private insurance. 

Reading, understanding, and processing 100+ e-mails a day could be a huge drag on the system, and there would be a desire to bill someone for the time involved.

At one time, there was a movement towards "Health maintenance Organizations", where hospitals and clinics would be essentially paid a fixed amount per patient regardless of how much they actually used the system.  Then the idea was they would be better off investing in preventative care.

Anyway, for health maintenance, one might imagine a multi-tiered e-mail system in which some e-mails would be handled by nursing staff, and others would be referred for comment by the doctor (perhaps with the use of a secretary to do much of the typing and padding). CliffordK, Tue, 9th Sep 2014

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