PEDIATRICS Vol. 114 No. 4 October 2004, pp. 988-991 (doi:10.1542/peds.2004-0015)
Follow-up After a Pediatric Emergency Department Visit: Telephone Versus E-Mail?
From the Division of Pediatric Emergency Medicine, Population Health Sciences, Research Institute, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Ontario, Canada
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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Objective.The Internet has become in recent years an unlimited source of health-related information and revolutionized health information access. Follow-up after an emergency department (ED) visit is important for continuity of care but is difficult to achieve. We conducted this study to determine whether e-mail could become a method for a follow-up contact after leaving the pediatric ED.
Methods.Over a 2-month period, parents who had a telephone line and e-mail access and whose child was discharged from the ED at the Hospital for Sick Children in Toronto were randomized to receive an e-mail or a telephone follow-up. Main outcome measure was the response rates by parents to the telephone or e-mail.
Results.A total of 265 (79%) of the 337 families who were approached had Internet access, and the majority (75%) check e-mails at least once a day. Eighty-seven percent (85 of 98) and 53% (53 of 100) of the families who were contacted by telephone or e-mail, respectively, were reached within an average of 17 and 46 hours, respectively. Fourteen percent of families from the study population were unreachable either by telephone or by e-mail. Most (57%) parents who did not respond to the e-mail did not check or did not remember reading the e-mail or had trouble with access. Ten percent of the e-mails were undeliverable.
Conclusions.The telephone is better than e-mail as a follow-up channel with families of children who visit the pediatric ED. The main reason for not responding to e-mails is "technical problems." E-mail could be a mean for follow-up contact for part of our patient population, especially for nonurgent purposes.
Key Words: emergency • Internet • follow-up • e-mail
Abbreviations: ED, emergency department
The Internet has become an unlimited source of health-related information and revolutionized health information access by parents.1–5 For many, it has become a significant resource for dissemination of information.1 Although some shortcomings such as readability of the material and reliability5–8 limit the use of the information, there is no doubt that its accessibility is continuously on the rise. It is estimated that in September 2002, 606 million people around the world had access to the Internet, 30% of them in North America.9
Follow-up after an emergency department (ED) visit is important for continuity of care, monitoring changes in patient health, and informing patients of the results of tests taken during their visit. However, reaching patients by telephone is problematic as a result of an incorrect telephone number on the patient’s chart or absence from home at the time of the call. Mailing parents, faxing them, or contacting their primary physician in the community via telephone or fax are alternatives, although not necessarily much better in terms of success in reaching them.
In late 2000, a group from New York looked at electronic mail (e-mail) as a means to follow-up patients and found the telephone to be a better modality to contact patients after an ED visit.10 However, that study was done on an adult population, in a different medical system than ours and 3 years earlier than this study, when e-mail access was significantly lower. The purpose of this study was to determine whether e-mail could become a method for a follow-up contact a few days after leaving the pediatric ED and to compare e-mail with telephone as a means of contact.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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This study was approved by the Research Ethics Board at the Hospital for Sick Children. The study was conducted over a 2-month period in the Division of Pediatric Emergency Medicine at the Hospital for Sick Children (Toronto, Ontario, Canada), an urban tertiary-care center that provides care for 50 000 patients every year. In the ED, an attending staff physician reviews the charts from the previous day and contacts by telephone between 1 and 10 patients per day. The time commitment for this activity is at least 1 hour a day.
A unique e-mail account was created for the purpose of the study by the Information Technology team, and the hospital server was used for sending and receiving the e-mails. The computer server was available at all times during the study period. The study was conducted between May 1, 2003, and June 30, 2003. Trained research assistants approached parents or guardians of pediatric patients before discharge from the ED between the hours of 9:00 AM and 2:00 AM, 7 days a week.
We included all parents with a personal e-mail account and a personal telephone line. We excluded families who were unable to conduct an interview in English or when the child was given a triage score of "resuscitation" as per the pediatric CTAS Guidelines,11 as a result of high probability of admission and the stressful state in which parents might be. A log was kept of all parents who were approached. All parents/guardians who participated were asked to sign an informed consent form, and children 7 years and older were asked to read an assent form.
Parents/guardians were asked to provide information on their age, level of education, years in Canada, and primary language spoken at home as well as computer, Internet, and e-mail access and use; their personal e-mail address; and the best contact telephone number. The last 2 items were confirmed by the parent/guardian at the beginning and the end of the survey to avoid errors during transcription of the information. Figure 1 describes the flow of events in the study. Parents were randomly assigned to receive an e-mail 24 to 96 hours after their child’s discharge from the ED or to receive a telephone call. They were not told to which group they were randomized. During the call by the research assistant and in the e-mail, parents were asked 1) "Did your child go to his primary care physician for a follow-up since you left the ED at the Hospital for Sick Children?" 2) "Your satisfaction from the overall treatment in the ED at the Hospital for Sick Children was (please choose 1 of the following): very satisfied/satisfied/not so satisfied/dissatisfied."
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Up to 5 attempts were made to telephone the families, at different hours of the day, from 24 hours and up to 96 hours after recruitment to the study. The e-mail was sent only once at 24 hours after recruitment, and the subject of the e-mail was "Follow-up from the Hospital for Sick Children Emergency Department."
We defined early and late responders as parents who responded to the e-mail in the first 3 days after it was sent and after 3 days, respectively. Parents who did not reply to the e-mail were contacted via telephone (up to 5 attempts at different hours of the day) starting 10 days after the e-mail was sent to determine the reason for not responding.
The main outcome measure was the response rates by parents to the telephone call or parental reply to the e-mail sent by the study team. Secondary outcome measures were the reasons for not replying to the e-mail and the number of hours from initial trial of follow-up to the e-mail reply or contact by telephone.
Data were collected on a Microsoft Excel (Microsoft Corp, Redmond, WA) spreadsheet. Statistical analyses used SPSS for Windows version 10.0 for calculation of response rate and comparisons between the telephone and e-mail groups and between parents who did and did not respond to the e-mail. Because of multiple comparisons, significance was considered at P < .01.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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During the 2-month period of this study, 337 families were approached before their child was discharged from the pediatric ED. A total of 265 (79%) had Internet access, personal e-mail, and telephone line available. We excluded families when they were not interested in participation (49), had a language barrier (13), and were admitted to the hospital after consent was obtained (5). A total of 198 families were randomized to be followed up by telephone (98) or e-mail (100). The characteristics of both groups are presented in Table 1.
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Of the 98 families who were contacted by telephone, 85 (87%) were reached within an average of 17 hours (range: 0–98 since first telephone call) and after an average of 2.4 attempts (SD: 1.0–3.8). Of the 100 families contacted via e-mail only, 53 (53%) responded in a mean of 46 hours (range: 0–242 hours after sending the e-mail). Differences between families who did and did not respond to e-mail within 3 days (72 hours) are described in Table 2. Ten (10%) of the e-mails sent were returned by the accepting server and were considered undeliverable e-mail that could not be received by the parents.
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The group of parents in the e-mail group that had received the e-mail and did not respond (n = 47) was contacted by telephone. Of this group, 21 (57%) did not check the e-mail, did not remember reading the e-mail, or had problems with e-mail access; 1 (3%) did not have time to respond; and 15 (40%) were not reached even after 5 attempts to contact them by telephone at different hours of the day over 96 hours.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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We found that a telephone call was better than an e-mail as a channel to contact families of children who visit the pediatric ED. Follow-up after an ED visit is done for continuity of care, monitoring changes in patient health, and, at times, to inform patients of the results of tests taken during their visit, such as cultures or radiographic findings. Other educational and research purposes might also entail follow-up. Most of the bidirectional information could be given over the telephone and does not necessitate an additional visit to the ED.12 We did not find in the literature an indication regarding parental preferred route of follow-up.
Although the rate of reaching parents over the telephone in our study is much higher than reported previously,10,12,13 we were unable to contact 13% of our patients’ families. Difficulties in reaching families over the telephone could be attributable to incorrect data entry of parents’ telephone number by the information clerks and unavailability at home, at work, or on their cellular telephone. Another possibility is the growing habit of screening incoming telephone calls through identifying devices and purposely not answering the telephone to hear first a voice mail and determine whether to respond to the caller. Incorrect telephone number was reported previously as a significant reason for failure to reach 13% to 34% of adult patients in the United States.13,14 In Canada, however, parents are not billed for ED visits, which might explain the very small portion (3%) of incorrect numbers given by parents. Two previous reports on telephone follow-up in the pediatric population showed similar success in reaching parents as this study.15–17 Leaving a voice mail might have encouraged some of the parents to respond to our survey or answer the telephone.
A minority (10%) of the e-mails that we sent did not arrive to the parents’ e-mail accounts. Reasons for not responding to the e-mails sent were found to be "technical problems" in reading the e-mails and being reluctant to check, read, or respond to our e-mail. Another possible explanation is the growing use of anti-spam software by Internet providers or computer users18 and the possibility that some parents deleted the e-mail because they were unfamiliar with our e-mail address or mistakenly thought that it was a spam mail, although the subject of the e-mail clearly stated that it was from the Hospital for Sick Children.
Although e-mail was not as good as a telephone call, we were able to reach more parents compared with Ezenkwele et al10 (50% and 41%, respectively). Although our research assistants e-mailed only once (and not twice), most likely the difference is attributable to higher accessibility to Internet and e-mail over the 3 years between these 2 studies. Also, it is possible that the rate of e-mail response would have been higher if we told the parents that they will get or might get an e-mail a day after their visit. Expecting an e-mail might have encouraged them to look for the e-mail and answer it promptly.
Traditional ways of communicating between health care providers and parents, such as the telephone, are hard to change. As parents become more familiar with the electronic communication pathways, especially wireless, reaching families for a follow-up will become easier. Managing the growing problem of spam mail and information overload will also help to ensure delivery of important health care information and follow-up of patients and families.
A large proportion (79%) of our patient population have both telephone and e-mail, and the majority (75%) of them check e-mails at least once a day, yet e-mail failed to be an optimal route for reaching parents and receiving information. E-mail is a more passive and nonintrusive way of communication compared with a telephone call. Unlike a telephone ring, there is no clear stimulation to respond immediately. The telephone is also current practice, making e-mail an unusual way of communication for most of the population.
The type of message given to the family at discharge and in the introduction of the e-mail is important. If parents understand that medically important information might be sent to them by e-mail, then they might be more receptive and active at responding.
We were disappointed to learn that we were unable to reach some patients at all. Twenty-eight (14%) families (13 in the telephone group and 15 from the e-mail group) were unreachable even by telephone. The implications of not reaching the families could become of great importance for some of these children, such as when a positive culture is found and a change in management is mandatory or when a new interpretation of an imaging test necessitates bringing back the child to the ED. In our ED, a staff physician contacts the community pediatrician of these families for additional follow-up.
E-mail is still a possible way of communication with at least part of our patient population: those in need of nonimmediate follow-up. This route could be used for parents with higher education but also for families who should be contacted for satisfaction surveys, for sending nonurgent clinical data such as information on conditions or medications, for nonurgent subspecialty appointment, or for purposes of billing. However, ways to ensure acceptance of the e-mail and alternative routes for families who do not receive the e-mail must be in place to ensure reaching those who do not accept or do not respond.
E-mail is here to stay. Although the telephone call is still a better way to communicate with parents, e-mail is growing in popularity and should not be abandoned as a means to contact patients and their parents. E-mail as a means of follow-up is fast, less time consuming, and lower in cost as compared with the telephone. More information can be transferred to the parents, and the information could stay available for repeated reading over a long period of time.
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FOOTNOTES |
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Accepted Mar 17, 2004.
Reprint requests to (R.D.G.) Division of Pediatric Emergency Medicine, Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8. E-mail: ran.goldman{at}sickkids.ca
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PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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