Should patients be able to email their general practitioner?

Workload

The addition of email services has the potential to increase general practitioners’ workload, but if the service is well planned and managed then email can be a more efficient way to manage some routine conditions and requests than traditional methods. A 2012 Cochrane review found that the evidence on whether service efficiency and performance improved with the use of email was inconclusive.6 However, a prospective study of email use in secondary care in the United States indicated that physicians found answering patients’ questions by email 57% faster than by telephone (2.2 min versus 5.2 min) and also removed the frustration of having to make multiple call back attempts if patients failed to answer their telephones.7 In addition, a review in The BMJ of several qualitative studies showed that doctors who use email view it as a useful addition to other communication options. The authors proposed that email could improve the management of chronic conditions, provide continuity of care, and increase flexibility in responding to non-urgent queries.2

Before implementing an email service patients and clinicians need to understand the limitations of email and which kinds of inquiries are suitable for discussion this way. Reassuringly, the evidence indicates that patients use email appropriately: a qualitative study of email use in UK primary care and a systematic review of 24 US studies found that patients are mindful of overloading their general practitioner with too many, or inappropriate, emails.8 9 Patients’ communications were generally “brief, formal, and medically relevant,” and many (77% in one study) raised only a single problem.9 Patients were also good at selecting the appropriate form of communication, using email for straightforward matters but preferring to be seen face to face if they thought their question more serious.10

Patient safety

A 2012 Cochrane review found no evidence that using email caused harm, although high quality studies are lacking.6 Patient safety remains one of the most cited concerns about email use,1 2 8 including worries that patients will use emails inappropriately to request emergency advice and fears about confidentiality and the security of practice computer systems. Similar concerns can be applied to other forms of communication, such as telephone, fax, and post, which are now well established and trusted.

Many resources exist to help minimise these risks when developing email services, including guidance from medical indemnity providers such as the Medical Protection Society.1 2 11 Comprehensive patient education, adequate email triaging systems, the use of a secure server, and patient consent are crucial.2 Patients must be made aware that emails may not be read immediately. The terms and conditions of email use can be covered comprehensively when patients give consent for email use and reiterated in each email response.

Patient proximity and communication

An email consultation will never be able to reproduce the subtleties of communication in a face to face encounter, and there is no possibility of a physical examination. However, email can help follow-up after a standard consultation, the communication of results, and self management, while promoting and maintaining the doctor-patient relationship through providing continuity of care.

Patient satisfaction with email communication is generally high,2 8 and qualitative research has shown that patients appreciate the personalised care and direct access to their GP.8 Email services might also facilitate access for those patients less able to use traditional methods of communication, such as housebound patients, those with hearing difficulties, or younger patients, who may be more likely to engage with this modern approach.4 10 12 Admittedly, some patient groups, such as those unable to use the technology or with language or literacy barriers, will be unable to benefit from email services. However, this is not a reason to deny this form of access to other patients. General practice should facilitate a variety of options for access, in order to improve care for all.

GPs and our professional bodies, as experts in our patients’ care, should embrace the use of email to develop a safe and effective service. Although more research, investment, and official guidelines are needed, sufficient strategies already exist to support the safe implementation of email services. The flavour of current UK health policy suggests that email use will soon be inevitable. If we do not engage with email now, implementation without our input may mean that GPs miss out on a vital opportunity to shape its use, to the detriment of patients and clinicians.

Unclear benefit

No evidence shows that email communication with patients is effective in improving access or saving money.6 A Cochrane review of nine randomised controlled trials of email consultations found no difference in outcomes such as patient understanding, health status, or behaviours. The review concluded that the “evidence base was limited with variable results and missing data” and therefore “recommendations for clinical practice could not be made.”

Some of the studies found that email intervention increased doctors’ workload.14 15 Similarly, a recent study showed 50% more face to face follow-up appointments after initial consultations by telephone rather than face to face.16 The BMA said that patients contacted practices more often when telephone services were available and that some did so instead of self care, which could also be true for email consultations.17 Consultations using telephone or email share many characteristics, but telephone consultations offer emotional cues, such as tone of voice, as well as clinical clues, such as a wheeze. Telephone facilitates two-way discussion in real time, to gather information, ask and answer questions, and check understanding. None of this can be done with a single email.

Professional unease

In an online forum’s recent poll, 68 of 72 UK general practitioners who responded were against email contact with patients. Many said that the current workload was unrelenting and that email would direct resources away from face to face contact with patients.18

Those in the greatest need of healthcare, such as elderly or infirm patients, may struggle to engage with email because of a lack of facilities or knowhow. A Californian cross sectional survey of more than 4000 patients older than 65 showed that less than half of those offered email consultations were enthusiastic about it, and their enthusiasm decreased with rising age and more self reported ill health.19 Similar barriers exist for ethnic minorities and poor people, potentially creating a “digital divide” of widening health inequalities.20

UK patients can already request repeat prescriptions and appointments online through most practice websites and can telephone for test results. Delicate results require a two way conversation, which can sometimes be managed by telephone, but many doctors would prefer to see these patients face to face.

Most online appointments are booked immediately, and prescription requests usually stipulate a 48 hour turnaround, incorporating a shared understanding of timescale and urgency. The number of phone calls that can be scheduled into consultation slots or added after surgery within a working day is limited. However, the idea that patients can email unlimited requests and questions fills many GPs with dread—not only in terms of time but also clinical safety. Without immediate triage, what happens to the suicidal patient who sends an email on Friday night that goes unread until Monday, or the patient with chest pain who thinks she’s dealt with the problem because she has emailed her doctor, who is on holiday? Triage systems may help to avoid this, but a randomised controlled trial showed that two thirds of patients are not keen on clinic staff intercepting their emails and prefer to message their doctor personally and privately.14

A recent observational study showed the importance of non-verbal communication such as eye contact and social touch in demonstrating empathy in consultations21 and the phenomenon of the “doctor as a drug,” where the interpersonal exchange between doctor and patient, both verbal and non-verbal is therapeutic22; both would be diminished, or lost entirely, in electronic exchange. Misunderstandings might also increase the risk of clinical error and mismanagement.23

Insufficient safeguards

These concerns are not new. A qualitative study in 2010 recognised that reluctance in adopting email communication often related to a lack of understood “rules of engagement.”24

The UK lacks consistent guidance on how to run such email services. The General Medical Council gives only general advice on remote prescribing and confidentiality.25 26 The Royal College of General Practitioners gives no specific guidance. The medical indemnifier the Medical Protection Society gives some basic guidance on email communication, which reminds doctors to “set aside time in the working day to respond to email enquiries” and “not to underestimate the time and planning required to set up and maintain such a system.”11 Practices would need systems to maintain confidentiality and patient safety, and all information exchanged by email would later have to be saved to the patient’s notes. Doctors’ NHS email is encrypted and secure, but patients’ email accounts are not guaranteed to be safe from interception—and how do you know whether the person sending an email is actually the patient? And what of human error—for example, inadvertently sending an email to the wrong person?27

Even if we had clear guidance, clinicians may not follow it. In a cross sectional survey of more than 4000 clinicians in Florida using email, only 6.7% adhered to at least half of the guidelines for email communication, perhaps because of lack of awareness, disagreement with guidance, or impracticability.28

Given the complexities of using email and understandable caution among GPs, it seems premature to be insisting that patients can have email communication with GPs. The Department of Health should first issue clear guidance on what can safely and appropriately be communicated by email and what resources are needed.