Email Consultations in Health Care

Practising good medicine requires effective communication between patient and doctor, between doctors, and between doctors and other healthcare practitioners. Email communication offers a chance to enhance clinical communication through its various unique features as an asynchronous communication tool, its flexibility as an information transmission medium, and its increasing availability. However, there are disadvantages to its use, such as its lack of absolute security (always a concern when handling confidential clinical information) and the fact that it may make doctors too accessible to their patients, and swamp them with extra work whilst originally purporting to decrease clinical workload.

In certain areas of the world, for example parts of Australia, where huge geographical distances may separate doctors and patients, or generalists and specialists, email has already been embraced as a useful way to transfer text or visual images to allow consultation at a distance.¹ In the UK, however, there is unlikely to be a geographical justification for the routine use of such 'telemedicine' technology, although there are several forward-looking practitioners using some of these methods, and many ongoing pilot schemes.²

At present, both the UK medical indemnity organisations and the GMC recommend a cautious approach to the use of telephone and email consultations as part of routine medical practice. This is primarily because of concerns about confidentiality (emails can potentially be intercepted at various points along their transmission), and quality of care issues to do with the absence of face-to-face history taking and examination, if attempting to reach a diagnosis.

The GMC accepts that telephone and email communication between patients and doctors may be part of normal day-to-day practice and indeed essential, particularly in cases of geographical isolation. However, the GMC warn that the use of these means of communication must not impact negatively on the quality of care that patients receive. They advise particular caution in the following areas:³

• Scenarios where the patient is not previously known to the doctor, and
• No examination can be provided, and
• There is little or no provision for appropriate monitoring of the patient or follow-up care.

The GMC advise that doctors who wish to use telephone and email communications clinically should consider carefully whether such services will best serve their patients' interests, and that they may need to seek the advice of their professional association and/or indemnity organisation as to how best to organise such activities to ensure adequate quality of care, confidentiality and documentation.

• Convenience of communication:
  • Emails can be sent and received from many places and take little time to transmit.
  • Possibility to reduce the need for face-to-face consultation (e.g. enquiry about whether or not a new prescription is in addition to, or in place of, previous medication).
  • Useful 'hard record' of information that patients and doctors may not be able to retain after verbal communication (e.g. addresses and telephone numbers of services to which patients are referred, test results with interpretations and advice, instructions on how to take drugs.)
  • Unlimited length (as well as text, users can send virtually any kind of electronic file as an attachment).
• Access to healthcare:
  • Increased access to care (e.g. for those with physical disabilities or those living in remote communities).
• Ability to share information:
  • Improved opportunities for information sharing between doctors and patients and between doctors (e.g. patient information leaflets, links to internet resources, specialist advice/algorithm on therapeutic monitoring in primary care).
  • User-friendly medium for patients to seek clarification after a face-to-face consultation.
  • Potential enhanced reporting of adverse events.
  • Allows patients to discuss content of messages with family or friends to help enhance understanding.
• Patient satisfaction:
  • Potentially more equanimous medium diffusing traditional barriers of age, status and personal unfamiliarity.
  • Possibility of communicating with a clinician whilst retaining anonymity.
  • Relatively rapid speed of communication (although dependent on the 'schedule' of the receiver of the email).
  • May be suitable for groups of patients that are reluctant to seek face-to-face contact.
• Quality of care:
  • Ease of communication means that doctors may consult widely with colleagues for advice.
  • Email provides clear typewritten record of consultation and so reduces uncertainty associated with transcription into record and poor legibility of handwritten record.
• Efficiency of practice:
  • Ability to offer routine transactions and patient education information to several people simultaneously.
  • Potential cost savings compared to paper and telephonic communication.

• Although it may increase access, this may be at the expense of disenfranchising those least likely to have access to the technology, by favouring the well-off and young.
• Inappropriately easy access to medical advice; the ease of email use may lower the threshold for patients contacting their doctor about low-priority issues, 'swamping' the doctor with extra work (this has certainly been the experience of many people with regards to workload, since emails became a norm of communication in commerce).
• Limitation of the use of non-verbal clues in history taking.
• Inability to perform physical examination.
• Loss of the 'personal touches' of a consultation that may have a significant influence on healing and the therapeutic relationship.
• Potential increase in risk of miscommunication and diagnostic error.
• Possible delayed response to a communication that ought to require more prompt action.
• Threats to patient privacy due to unauthorised interception of unencrypted emails, receipt or retrieval of emails by unauthorised people and other mechanisms.

There is an increasing body of evidence that the vast majority of patients (90% in one US sample) would welcome the ability to expand the range of communication they have with their doctors, specifically via email. The same survey found that for 56% of respondents, the ability to use email communication would influence their choice of practitioner, with 37% being prepared to pay for such a service,⁵ although this does not necessarily translate into similar attitudes in the UK. However, a recent primary care trial in Dundee used email communication to facilitate repeat prescriptions, appointment booking and clinical enquiries and found that 'it worked well within an urban practice, was deemed helpful by patients, and resulted in no apparent increase in GP workload'.⁶

There may not be a similar level of enthusiasm for the clinical use of emails generally among the medical profession,^7,8 but further pragmatic trials investigating how well they work, and in which areas they are best employed, may improve enthusiasm and healthcare delivery from both medical and patient viewpoints.

Surveys have shown that up to 90% of patients that use emails to communicate with their doctors impart important and sensitive medical information, a potential threat to their confidentiality.⁵ One way of ensuring confidentiality is to only use emails for areas where the risk of breach of confidentiality is extremely low, for example:⁵

• Appointment scheduling
• Reporting of home records such as peak expiratory flow or blood pressure
• Ordering repeat prescriptions
• Obtaining test results
• Limited consultations for a predefined set of conditions/follow-up schedules.

It may be a good idea to agree a protocol of what types of issue patients can and cannot use email for, when communicating with their doctors. Any email communication from a medical practice should outline this policy, and indicate that emails should not be used for urgent matters, complex or sensitive issues. Through the use of secure software and strict adherence to peer-reviewed protocols and procedures, there is scope to use clinical email communication safely.⁵

However, the number of safeguards and adaptations required to ensure that emails are a safe way to communicate with patients, and with other doctors about our patients, may put many off from using them on medicolegal grounds. For example, some clinicians currently accept email referrals that keep all clinical information in a separate password-protected Word document attachment, with the password sent by a separate email. However, one has to question whether such safeguards negate any advantages that email had in the first place in terms of ease of communication. Below are some potential useful safeguards required for clinical email systems.

• Population surveys show that patients increasingly want to be able to communicate with healthcare professionals by email.
• Few doctors currently do so as there are legitimate professional issues concerning the quality of consultations, confidentiality, liability and the issue of remuneration for work done.
• Initial use of emails in the healthcare sector has grown without an adequate supporting infrastructure to address security issues.
• Ensuring privacy, confidentiality and information-security is vital for email consultations and various user-friendly safeguards are now becoming available.
• Email consultations are a radical shift from the traditional oral modes of communication, supplemented by physical examination; both patients and doctors need education in how to use them safely and effectively.