“You’ve Got Mail”: Issues in Communicating With Patients and Their Families by E-Mail

“You’ve got mail” is a common refrain heard by 32 million America Online subscribers. Just as the telephone transformed both American society and the practice of medicine,¹ electronic communication (e-mail) is having a similar impact and will become an integral part of pediatrics. In the words of Jerome Kassirer, former editor of the New England Journal of Medicine, e-mail and electronic transfer of information has the potential to “induce cultural changes in the delivery of care even more revolutionary than any restructuring that is going on today.”²

In this issue Pediatrics, Kleiner and colleagues³ report the results of a survey of parent and physician attitudes toward the use of e-mail. The results are not surprising. The majority of families have access to e-mail, with access significantly related to family income and education. Most families want to communicate with us, and our practices, by e-mail. They express some concern about confidentiality. We, on the other hand, are quite ambivalent. Although only a small number of physicians were included in the survey, 79% indicated that they were not comfortable with e-mail communication with patients. These data are consistent with a recent survey of 834 physicians, which showed that 14% regularly or frequently use e-mail to provide clinical information to patients.⁴ Thirty-nine percent indicated that they do not currently e-mail clinical information but would if security/privacy were fully guaranteed, and 40% responded that even if issues of security/privacy could be resolved they would not e-mail information.

There are numerous benefits of e-mail.^{1,5, 6} Communication is dysynchronous; that is, the 2 parties involved do not have to be in contact simultaneously to “speak with each other,” ending needless telephone-tag. Communication is rapid, relatively inexpensive, simple, and convenient. It is available day or night, weekday, or weekend. It bypasses intermediaries who may be unhelpful, and it conveys a certain anonymity that some patients prefer, particularly for transmitting sensitive information. Unlike notes about a telephone conversation, e-mail notes can be detailed and cumulative; that is, reflect an entire exchange about a single subject, and enrich the medical record. They are also easier to save than notes from a telephone conversation. Physicians can clarify advice that was provided over the telephone or in face-to-face encounters and easily provide references to information available on the Internet. Finally, patients can become more active partners in their own care.

What are the risks of e-mail? Will we be overwhelmed by the workload, who will pay for our time, and will conducting any other business become virtually impossible? The data from Kleiner hint at 1 critical aspect of doctor-patient e-mail communication. Much of what families would like is the ability to “talk” to our offices, not just us. Camp and school forms, immunization records, subspecialty approvals, prescription refills, scheduling appointments, and other activities related to providing care can be handled through e-mail. Poole and Glade⁷ estimate that 75% of calls entering a practice are nonclinical. As we develop e-mail communication centers in our offices, it is critically important that families have the ability to link with our offices, not directly to us. Messages should be triaged to the appropriate individual, just as telephone messages are categorized and distributed. Interestingly, one of the early reports of e-mail came from a pediatric gastroenterology group that in 1995 began providing preliminary consultations by e-mail.⁸ Of the 1239 consultations requested, 81% came from parents, 10% from physicians, and 9% from other health care professionals. They took an average of 3.95 minutes for the physician to read and formulate a 1-page response. How many of these e-mail consultations resulted in a visit is not reported, although the vast majority of consultations, 92%, originated from outside the referral area for this practice. Obviously, the experience of primary care clinicians who begin communicating with their patients with e-mail is likely to be a bit different, because they have an ongoing, longitudinal relationship with them, but nevertheless, this study suggests that most e-mail communications will be brief and will not result in a health care visit.

There are other risks of e-mail communication. Foremost are those related to privacy and security.^{1, 9} Currently, health care is undergoing dramatic revision with respect to these issues. The Institute of Medicine recently released a report entitled “Protecting Data Privacy in Health Services Research.”¹⁰ Although this report focuses on issues related to research, they are just as applicable to those of e-mail communication. The new Health Insurance Portability and Accountability Act also will help guide us with respect to the ethical and legal challenges of e-mail.¹¹ However, physicians will need to guard against using issues related to privacy and confidentiality, as a reason not to use e-mail. It is uncertain if e-mail is any less secure than medical records, faxes, answering machines, and voice mail.

There are other fascinating aspects of e-mail that physicians should be aware of if they engage in electronic communication with patients.¹ First, e-mail communication should become part of the medical record. Although telephone conversations rarely make it into the medical record, because of the permanency of e-mail, ensuring that exchanges are incorporated into the chart will be important. Second, if physicians begin offering extensive consultation by e-mail in states where they are not licensed, are they practicing medicine? There is little legal precedent to guide us in this area. Third, some believe that patients should be informed of the potential risks and benefits of e-mail and that informed consent should be obtained from patients before any electronic communication. Patients seeking help because they are acutely ill need to be directed away from e-mail and toward a “ live” source of care. Certainly patients should be informed of the limitations of e-mail, but many will still want to use the resource despite these limitations. The American Medical Informatics Association has addressed many of these issues in their e-mail guidelines, including how messages should be handled (subject heading, turnaround time, archiving of transactions, confirmation of patient requests, acknowledgment of messages, tone and type of language to use, etc) and medicolegal issues (patient consent, permissible transactions and content, encryption, confidentiality, etc).⁹

Recently, the Institute of Medicine released a report entitled “Crossing the Quality Chasm,” which calls for dramatic reengineering of how medicine is practiced.¹² They propose 6 quality aims for the 21st century, including a system of care that is patient-centered, timely, and efficient. Such a system would provide care that is respectful of and responsive to individual patient preferences, needs, and values and ensures that patient values guide all clinical decisions. In addition, the IOM report suggests that the future health care system should reduce waits and harmful delays in receiving care. They specifically cite e-mail communication as a way to ensure that our health care system is more accessible, efficient, responsive, patient-centered, and of higher quality.¹⁰

There are numerous research questions yet unanswered about e-mail communication. Does e-mail improve quality of care? It likely improves satisfaction with care, but satisfaction is only 1 dimension of quality. How burdensome will e-mail be on a practice? Much of what is now conducted by telephone will be done by e-mail, so it is not clear if e-mail will result in either additional or a redistribution of work, or a combination of both. Can e-mail help to reduce medical errors, enhance adherence with medications, and reduce health care costs? These are important goals of contemporary medicine. Will e-mail assist in providing patient-centered care, or will it simply become another barrier to effective doctor-patient communication? What are the perceived barriers to greater use of e-mail between patients and providers and how can they be reduced? Medicine has often been reluctant to embrace certain types of change, but at a time when consumerism is an important aspect of medicine, rejecting e-mail will be difficult to do. Finally, what will the impact of the so-called “digital-divide” be on health care disparities? It is possible that e-mail could serve to reduce rather than exacerbate disparity by lowering classical barriers to health care access.

The 3 of us have embraced e-mail, as have virtually all of our colleagues and friends. It allows an open conduit for communication at all times, virtually anywhere. Although most physicians are using e-mail with family, friends, and colleagues, few have made the leap to clinical e-mail with patients. The ease, reliability, and speed of this form of communication needs to be extended to our patients and their families. Most are hoping for it, many are expecting it, and some will demand it.

• Copyright © 2002 by the American Academy of Pediatrics