Family Practice, 2016, Vol. 33, No. 2, 121–126 doi:10.1093/fampra/cmv101 Advance Access publication 28 December 2015
Review
Electronic mail communication between physicians and patients: a review of challenges and opportunities Jumana Antoun* Department of Family medicine, American University of Beirut, Beirut, Lebanon *Correspondence to Jumana Antoun, Department of Family Medicine, American University of Beirut, Beirut, PO Box 110236, Lebanon; E-mail:
[email protected]
Abstract Although promising benefits hold for email communication between physicians and patients in terms of lowering the costs of health care while maintaining or improving the quality of disease management and health promotion, physician use of email with patients is still low and lags behind the willingness of patients to communicate with their physicians through email. There is also a discrepancy between physicians’ willingness and actual practice of email communication. Several factors may explain these discrepancies. They include physicians differ in their experience and attitude towards information technology; some may not be convinced that patients appreciate, need and can communicate by email with their doctors; others are still waiting for robust evidence on service performance and efficiency in addition to patient satisfaction and outcome that support such practice; and many are reluctant to do so because of perceived barriers. This report is a review of the literature on the readiness for and adoption of physician–patient email communication, and how can challenges be or have been addressed. The need for Governmental support and directives for email communication to move forward is iterated, and opportunities for future research are pointed out. Key words: Communication, electronic mail, medical informatics, physician–patient relations, primary care, review.
Introduction Physician–patient communication is an important component of patient-centered care and is not limited to face-to-face interactions. Globalization, increased awareness of patients to control their health, lack of specialists in rural areas, the greater demand on primary care practitioners for the management of chronic diseases and the increase in their administrative workload such as prescription refills and management of laboratory results, have led to the expansion of health care delivery beyond the boundaries of the clinic walls. In the past 50 years, telephone consultations were one solution and occurred in 15% of ambulatory medical contacts (1). Recently, with the expansion of the internet use, electronic mail (email) communication has been gaining importance as a tool for communicating with the physician, continuing the office visit and developing interpersonal relationships (2). © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail:
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Email communication between physicians and patients is defined as a ‘computer-based communication between clinicians and patients within a contractual relationship in which the health care provider has taken on an explicit measure of responsibility for the clients care.’ (3) This is different from physician–patient interaction over the internet whereby although the physician might not know the patient, he/ she answers general or specific questions posted on a website. Relatively recent but little research is available on the use of email communication between physicians and patients. For instance, ‘Electronic Mail’ was introduced in the PubMed mesh terms in 2003. (http://www.ncbi.nlm.nih.gov/mesh/68034742) Few articles were initially published by early adopters analyzing their own email use with patients (4,5). Although promising benefits hold for email communication between physicians and patients in terms of lowering the costs of health care while maintaining or improving the quality
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122 of disease management and health promotion (6), physician use of email with patients is still low and lags behind the willingness of patients to communicate with their physicians through email (7–13). This narrative literature review aims to present an overview of the current literature about email communication to underline the current challenges and propose opportunities for future research. The review will highlight both the European and US perspective. An extensive PUBMED and OVID search was performed using the terms: electronic mail, electronic communication, patient–physician communication, email and electronic messaging. Further articles were identified using both backward and forward reference searching.
Physicians’ adoption of email communication with patients Despite the frequent use of internet and email with other physicians and administrative staff (14), and despite the growth and tremendous increase in the internet and general email use in the past years across all developed countries, physicians rarely use email communication with patients (15,16). Data from the European eHealth consumer trends survey have shown that there was only a subtle increase in the proportion of the population who approached a health care professional through the internet from 3.6 to 6.9% in 2005 and 2007, respectively (17). In 2004, a cross sectional survey of 4203 US primary care physicians revealed that only 16.6% of the physicians had used emails with their patients (18). Similarly in a survey of physicians in Florida during both 2005 and 2008, the increase in email use of physicians was marginal: 16.6–20.4% (19). These numbers are even lower in European countries, as in 2007, it was shown that only 7.4% of the European population communicated with a physician using email or the Web (20). These low frequencies of email communication by physicians are in contrast to a higher percentage of willingness to do so. For example in the UK, 52% of general practitioners responded as willing to use such a communication with their patients, and 37% had already received one or more email from their patients (14). Factors that may explain this discrepancy between physicians’ willingness and actual practice of email communication are: 1) physicians differ in their experience and attitude towards information technology, 2) some may not be convinced that patients appreciate, need and can communicate by email with their doctors, 3) others are still waiting for robust evidence on service performance and efficiency in addition to patient satisfaction and outcome that support such practice and 4) many are reluctant to do so because of perceived barriers.
Characteristics of current users of email communication between physician and patients and opportunities for further research Physicians’ characteristics Early physician adopters and current users of email communication with patients were more likely to be enthusiastic and less worried about time pressures (21), younger and university based (22) and work in large practices (18) or capital areas as compared to rural areas (23). When asked about their motives to use the internet, physicians were divided into 4 types: internet critic (10%), efficiency oriented physicians (32%), internet advocate (35.25%) and driven self-expressionist (18%), the last 2 types of which were more likely to communicate with patients using the internet (24). Interestingly, patients were more motivated to use online communication when
their physicians were motivated. Therefore, physicians buy in and perceived need for this communication is a key factor to further adoption of email communications. Further studies should explore different strategies that may encourage physician non-users.
Patients’ characteristics Many physicians do not consider email communication to be in demand, necessary or feasible at the current time, and believe that their patients only want face to face consultations (25); this is despite the fact that several surveys have reported patients to be willing to do so. For example, in a study of six-resource limited community clinics in San Francisco, 60% of respondents used email, and 71% were interested in using email to communicate with health care providers (26). In addition, a very large study at the University of Kentucky showed that 70% of patients were willing to use e-mail to communicate with their doctors (21). Similarly in the UK, a bit more than half of patients indicated that they would like to communicate with their providers by email (11). Nevertheless a much lower percentage of these patients (6–19%) reported having actually used email to communicate with their health care providers (11,21,26). It is believed that the need lies for certain populations such as those who live at distances from the clinic or overseas, deaf or homebound patients (27). This is in contrast to actual current use where most patients who have used email with their physicians were younger (13), healthier, and had higher education and income (21). Knowing that patients of ethnic minorities and those of Asian descent were less likely to use physician-patient email communication (13,18), and that black women, older patients and patients with Medicaid are also less likely to have email than their counterparts (12), there exist arguments on the unethicality of introducing email communication at the UK national health system because of equity reasons. The utilization of email communication bears an injustice component among patients who do not have access to the internet, especially the poor and elderly (27). The counterargument however is that elderly, ethnic minorities or technology naïve patients should have the choice to use email communication if they are willing. For example although elderly patients, on one hand, are less likely to have internet access and more likely to bear physical morbidities that affect their typing or reading abilities, on the other hand they also have more comorbid conditions that may hinder their transport to the physician. Therefore, email communication might be an opportunity for them to discuss a number of problems and follow ups that do not require a formal visit. And as a matter of fact in a community based practice in Southern California, 1.3% of patients over 65 years of age communicated with their physician by email, and almost half reported willingness to use such a communication (28). One may however strongly argue for the use of telephone communication over email in such situations. For instance in a primary care practice, when asked about their preference of which communication tool for test notification, 55% of patients preferred telephone as compared to 5% who favoured email (29). In addition, when using a Tele Consult system that allowed patients to either phone their physician or send an email, the majority of consultations were telephone based, 84% of 250 random consultations, and both patients and physicians preferred telephone over email consultations (30). In addition in a qualitative study of non-users of a web portal, one participant mentioned that the information seemed more trustworthy when it was explained verbally (31). It is hence apparent that patients still prefer to talk to the doctor either by telephone or in person even though they positively value the immediate answer through the use of a web portal (32,33) Interestingly this online
Email communication opportunities and challenges messaging system was correlated with decrease in the office visits but not the number of phone calls (32). Further research is needed to evaluate feasibility and acceptability of email communication by different patient populations of various backgrounds and resources, and to compare and contrast such data with data on telephone communication.
Lack of robust evidence on email communication with patients Physicians may be still waiting for robust evidence on service performance and efficiency in addition to patient satisfaction and outcome that support the practice of communicating by email with their patients. Interestingly, five recent (2012) Cochrane database systematic reviews showed a lack of good quality articles and, authors were hence unable to assess outcomes of interest (6,34–37). These include health care professional outcomes such as professional knowledge, behaviours and performance; patient outcomes such as patient understanding, skills acquisition and treatment outcomes; as well as health services outcome such as service use and coordination of a health problem. Potential harms such as safety or quality of care, breaches in privacy, technology failures and the appropriateness of the email as mode of communication were also evaluated. All 5 reviews concluded that the available evidence is very limited with
123 missing data and variable results, and included recommendations for strategies and ideas for future research (Table 1). Interestingly, physicians favour the use of telephone consultation despite the fact that robust evidence is also lacking. For instance, a Cochrane database systematic review in 2004 did not find convincing evidence about the effect of telephone consultation on service use, patients’ satisfaction and cost and safety (39). Further research is needed to explore the reasons behind the different attitudes towards telephone and email consultations.
Barriers and opportunities Physicians perceived a number of barriers and concerns about the use of email communication with patients. Recurring themes include: 1) potential increase in workload, 2) lack of reimbursement 3) security and confidentiality issues and 4) medico legal concerns. Many of these potential barriers can be or have been partially addressed, and there a number of research opportunities to further understand these barriers and evaluate the effectiveness of methods that address them.
Increase in workload Although physicians who were satisfied in communicating with their patients by email reported that this task was time saving and helped deliver better care (40), many consider the potential for increase in
Table 1. listing of available Cochrane database systematic reviews about email use in health care and their recommendations for future research Title
Outcome
Studies included (N)
Recommendations for further research
Email for clinical communication between patients/ caregivers and health care professionals (35)a
Patient outcomes, health service performance, service efficiency and acceptability
Email for the provision of information on disease prevention and health promotion (37)a
Outcomes for health care professionals, patients and caregivers, and health services, Including harms Compared to standard mail or usual care
Email for clinical communication between health care professionals (36)a
Healthcare professional outcomes, patient outcomes, health service performance and service efficiency and acceptability Comparison to other forms of communicating clinical information Outcomes for health professionals, patients and caregivers, and health services, including potential harms Comparison to other forms of coordinating appointments and reminders Outcomes, including harms, for health professionals, patients and caregivers and health services Comparison to SMS/text messaging, telephone communication or usual care
Patient’s understanding (1) Patient’s health and wellbeing (2) Patient/caregiver views (2) Patient’s behaviours and actions (2) Health service outcome: resource use (3) Patient or caregiver behaviours/ actions (2) Patients or caregiver understanding and support (1) Health services outcomes: uptake of preventive screening (3) Health Professional action and performance Patient behaviours Patient satisfaction (1)
Describe and address barriers for trial development and implementation Take into account the rapidly changing nature of technology in designing and conducting future studies Pursue qualitative research methods to explore the factors that are important to the public, patients, physicians and other stakeholders Attempt rigorous randomized controlled trials and registered large trials as compared to studies carried by clinicians in their small practices Avoid studies about perceptions or attitudes and focus more on objectively measured outcomes Assess impact on workload Compare email and telephone communication methods Evaluate cost effectiveness Consider the effect of age and time knowing since physicians’ qualifications are important confounding variables
Email for the coordination of health care appointments and attendance reminders (34)a
Email for communicating results of diagnostic medical investigations to patients (38)a
Cochrane database systematic review.
a
None
0 studies0 None
124 workload as a barrier for such a practice (14,25,41). For instance, general practitioners were shown to be apprehensive of overload of information and patients’ demands that may affect their quality of life. This is especially in complex situations where they may have to deal with long threads of emails with back and forth questions and replies (27). Interestingly, current literature has not yet shown that email communication with patients increases physicians’ workload. For example, early adopters have reported an average of 2–5 messages per day only (2,16,23), and in a setting of university students’ clinic, there was an average of only 8.6 email contacts per week (23). Therefore, current literature mostly describes workload from opportunistic email communication, and further data is needed to evaluate the effect of more frequent and systematic adoption of email communication on physician workload.
Lack of reimbursement Lack of reimbursement is one of the issues that may discourage physicians from use of email communication with patients (16,27,41). In response to this concern, few models for reimbursing email consultations have been developed (30,42). Probably the most elaborate is the system in Demark whereby email communication with patients is reimbursed by the National health coverage. This system is used in over 5000 health institutions and over 5 million clinical messages are transferred monthly, yet the attitudes of physicians and patients towards such an endeavour still ought to be explored (30,42). Interestingly, although one study in a large family medicine practice in the US showed that 42% percent of patients are willing to pay a small annual fee to have email access to their physicians (12), The ‘meaningful use’ initiative in the US advocates patient engagement by encouraging them to use portals for free; however doctors and health care practices get incentives if their patients use these portals (43).
Security, confidentiality and privacy issues Although some physicians believed that the mere availability of email communication between physicians and patients gives the latter a sense of personal security irrespective of their actual use of the email (40), data and records security, patient confidentiality and privacy issues were perceived as important concerns that hinder the use of such a communication (14,16,27). Some physicians also feared the associated risk of receiving spam emails, viruses or being hacked (27). Others worried about the uncertainty of email receipt by patients, and the lack of integration with medical records (27). In response to these concerns, secure messaging softwares that allow physicians to send encrypted secure emails to their patients have been developed (44). Another solution is, and with the increasing use of electronic health records, the use of patient portals. These are ‘secure online websites that give patients convenient 24-h access to personal health information from anywhere with an Internet connection.’ (45) Despite these proposed solutions, there are still perceived challenges from both physicians’ and patients’ perspective. From the physician point of view, the technical demand of encrypted emails or secure messaging and the costs of implementation of electronic health records could be prohibiting. As for patients’ experience, data have shown that only 10% of patients used an e-messaging service using a portal, their motivation to do so decreased with time, and their participation leveled off after the first 2 months (34). Further research is needed to unravel and address barriers for e-messaging and e-portals use. For instance, it was shown that patients tend to forget their user
Family Practice, 2016, Vol. 33, No. 2 names and password or how to log in with time, hence designing a less complicated but secure logging method may be useful (31).
Fear of medico legal issues in handling sensitive and urgent matters Physicians were concerned about the content of email communications and the suitability of such a vehicle to discuss mental and sensitive problems, and address new or urgent symptoms (22). Some physicians also reported the fear of medical errors due to the absence of physical examinations, in addition to potential miscommunication and litigation for medical negligence (15,27). Some were adamant concerning the effect of email communication on patientphysician relationship with the lack of face-to-face interaction and hence detection of non-verbal clues (27). Interestingly, and in response to such fears in 1998 and 2001, the American Medical Association (AMA) and the American Medical Information Association (AMIA) established guidelines for proper use of email communication between patients and physicians (3). These include recommendations about the establishments of email uses and expected turnaround time, technical tips, completion of informed consent, documentation in the chart and assurance of privacy and confidentiality (Table 2) (3).The implementation of these guidelines may be facilitated by the use of patient portals as they are more structured and secure than traditional email, and are linked to electronic health record. To our knowledge, and in contrast to the US, no published guidelines on the use of email communication between patients and physicians are currently available in Europe. Although some articles mention the presence of guidelines in Denmark (42), Finland and EU policy (23), the content is not readily available.
Role of governmental support and directives Governmental support and efforts such as the development of guiding steps may be crucial for the advancement of physician–patient email communication. Table 3 lists some of the initiatives in different countries and shows an association between the frequencies of physician–patient email communication and these directives. For example, Danish governments encourage online communication and accordingly they ranked on top of the list in the European eHealth consumer trends survey in terms of proportion of the patient population who uses the internet for health care issues, and particularly in communicating with their physicians (17). This parallels various governmental decisions such as mandatory online services to be offered by general practitioners by 2009, and the establishment of the Danish National Health Portal to facilitate online communication between patients and the health sector in 2005 (42). Similarly in Germany, the increase in buying medicine online between 2005 and 2007 may be related to a new legislation that was established (17). This is despite the fact that the German Medical association heavily criticized a London based German internet clinic, and considered that it violated the professional conduct of the German doctors who are supposed to embrace personal contact in patient care (46). Concerning the European Union, all member countries agreed on the importance of the 2012–2020 eHealth action plan for the implementation of eHealth services in European countries. Nevertheless, and during a conference held in Dublin in 2013 that included all EU prime ministers, some argued that further testing is needed to establish the benefit of eHealth before IT initiatives become the norm, while others expressed the need to give patients the opportunity to choose to use eHealth services or not (48).
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Table 2. The AMIA Internet Working Group, Task Force on Guidelines for the Use of Clinic-Patient Electronic Mail (3) 1.Establishments of Email uses and expected turnaround time a.Describe the types of topics that will be discussed through email b.Emphasize that emails use is not for sensitive, private issues or urgent issues c.Set the expected turnaround time and the policies in case of vacation and unavailability 2.Technical TIPS a.Mention the reason for the consultation in the subject of the email for better triage of the messages b.Include the patient identification number in the body of the message for better retrieval of the medical file c.Both physicians and patients must use autoreply and acknowledge options to insure the receipt of the emails d.Send an email confirming the completed request 3.Completion of Informed Consent a.Insure that the medical record include a signed informed consent by the patient that covers all the above items b.Include a statement that releases the physician from liability in case of technical failures and that emails are not completely safe especially if patients use their work emails 4.Documentation in the chart a.All email communications should be printed and included in the medical chart of the patient. b.In the presence of electronic medical record, the email should be attached to the medical record if the email system was not integrated with the medical record 5.Assurance of privacy and confidentiality a.Encrypted messages should be used to safe transmission of emails b.Patients should be informed if any of the office staff might have access to the emails for triage purposes such as a nurse or secretary
Table 3. Non exhaustive listing of governmental initiatives and the countries’ corresponding use of email communication between physicians and patients (17,19,20,47) Country
Communicate with a health care professional in 2005 (%)
Communicate with a health care professional in 2007 (%)
Governmental initiativesa
USA Denmark Germany Greece Latvia Norway Poland Portugal
7.7–16.6 6.7 3.2 2.2 1.9 1.4 1.6 0.7
N/A 10.2 6.3 3.5 0.9 1 2.5 1
Implemented with financial incentives (meaningful use) Implemented Implemented Implementation in progress to be finished in 2015 Planning stage Envisioned future activities Envisioned future activities Envisioned future activities
a Initiatives could be one or more of the following: implementation of electronic health record, implementation of public national health portal, development of common standards that allow for health information exchange, implementation of information and communication technology infrastructure and National legislation.
It is important to note that although the EU has directives and initiatives targeting telemedicine, such as a commission staff working document to describe the current legal framework for telemedicine services and the patients’ right in cross border health care, online communication is not tackled (49,50). Interestingly, current policies in the UK do not encourage email communication, and the British Medical Association as well as the Royal College of General Practitioners have abstained from releasing any guidelines on email consultation use (49). This may explain why European physicians lag behind their US counterparts in communicating with their patients by email, hence the urgent need for the EU to join forces and agree on common grounds, initiatives and guidelines in relation to email communication between patients and physicians.
Conclusion Physicians’ use of email with patients is still low and lags behind the willingness of patients to communicate with their physicians through email. Factors behind this lag include physician and patient characteristics, lack of robust evidence and perceived barriers. The questions remain whether physicians should or will respond to this demand, and whether email communication should not necessarily be the
norm, but rather just an alternative way of communication for particular patients and or physicians. Further research is needed to better understand the factors behind the slow and scarce adoption of email use, and test currently available and proposed opportunities that may enhance it. Governmental support and directives may play an important role in moving forward email communication between physicians and patients. This is important as email communication ‘has the potential to reshape medicine and the patient–doctor relationship’ or ‘is likely to induce cultural changes in the delivery of care even more revolutionary than managed care’ (51). For some physicians, it is the only way forward, or else ‘we will be left in the dark ages.’ (25).
Acknowledgement The author acknowledges Dr. Nathalie K. Zgheib for her valuable comments and edits to the manuscript.
Declaration Funding: This research received no specific grant form any funding agency in the public, commercial or not-for-profit-sectors. Ethical approval: none. Conflict of interest: none.
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