Provider-patient e-mail could transform medicine

Docs say it improves relationships, cuts time

One of Paul Ford’s patients was on a sailboat in the South Pacific when a traveling companion became ill. The patient e-mailed Ford, who sent a reply with instructions. Another patient was in England when she experienced a severe earache that made her wary of getting on a plane to come home. Ford helped her by e-mail.

Paul M. Ford, MD, an assistant professor of medicine at Stanford University in Palo Alto, CA, who practices internal medicine, has been using e-mail with his patients for about five years. An athlete with exercise-induced asthma e-mails him weekly to report on his condition; Ford responds by e-mail with instructions for fine-tuning his regimen. Patients with diabetes and hypertension e-mail him weekly with their readings, and he adjusts their medications by e-mail.

Ford is on the cutting edge of using a technological tool that could transform the day-to-day practice of medicine. Only about 5% to 10% of physicians currently correspond with their patients by e-mail, up from 1% to 2% one year ago, but Ford and other experts say the benefits are enormous for both patients and physicians. And they say a growing number of patients who use e-mail routinely to contact business associates, friends, and family are demanding the service.

Tom Ferguson, MD, an Austin, TX-based consultant — considered by many to be the guru of on-line health — says physicians are catching on that using e-mail can help them use their time more effectively. E-mail gives them the ability to follow up with patients more easily, improve relationships with existing patients, and help attract new ones.

"The small group of clinicians who routinely use provider-patient e-mail say that it has revolutionized their practice in very positive ways," says Ferguson, who has written a dozen books on consumer health and is editor and publisher of The Ferguson Report: The Newsletter of Consumer Health Informatics and Online Health. "In many cases, they can avoid the need for a clinic visit by an on-line exchange. And there is always a full record of the on-line conversation, so it can automatically become a part of the patient’s medical record."

Ferguson says 25% to 30% of doctor-patient e-mail deals with follow-up questions after an office visit, a perfect example of the benefits of e-mail. "It’s wonderful as a doctor to say, Send me an e-mail in 10 days and let me know how you’re doing.’ You usually don’t know what happens to the patient. Think how good that could be for your clinical expertise."

E-mail can be a timesaver, Ferguson says. Nurses and doctors can use it to help patients decide whether their problem warrants an office visit, and they can stockpile answers to frequently asked questions. With one simple click, staff could insert information on how to take a baby’s temperature or how to change a dressing. "You don’t have to start all over again every time," he says. "If you’re talking on the phone, you have to say it every time."

Ford says he believes e-mail has the potential to save time and money. "E-mail unloads a lot of the administrative stuff you have to do in medicine," he says. "I really believe if we had more patients using e-mail, it would decrease our overall practice costs. We wouldn’t need so many people to answer the telephone, so many people in the file room moving charts around. Also, patients would feel more connected to the practice, which could help financially in the long run."

Ford’s practice of 10 physicians has a central e-mail address and a software filtering program that helps automatically route messages to the appropriate people. An automatic reply is sent to tell patients their message was received and who will take care of their request. Sometimes, the practice adds standardized reminders to the automatic message such as information about flu shots. Many of the messages involve prescription refills, appointments, and specialist referrals that can be handled by someone other than a doctor. Physicians only give out their private e-mail addresses when they feel it’s appropriate.

"E-mail allows the doctor and the patient to have some type of ongoing conversation," Ford says. "Without e-mail, when a patient leaves my office and they try to call and talk to me, it’s very difficult. There are all these blocks set up. E-mail removes the barriers between doctors and patients."

Daniel Hoch, MD, assistant in neurology and director of neurology operations improvement at Massachusetts General Hospital in Boston, is running a pilot e-mail program with about 10 patients and is applying for a grant to fund a study with 50 more. He says the impetus for the program was the need to improve control of communication with patients.

"The telephone is no longer adequate," he says. "There are too many calls, and people are dissatisfied with a quick answer. The Web-based approach is more convenient, and more information can be given."

The neurology department has had a service for about a year that allows patients to post a message to Hoch on a bulletin board. He answers directly to the bulletin board, and the postings are saved to provide a record of the interaction that is easy to review. The site is password-protected and more secure than standard e-mail, he says.

He uses e-mail for such purposes as answering patient questions, leaving instructions for medication changes, and directing patients to Internet sites that might supply more information. Hoch says his gut feeling is that e-mail will cut phone time by 25% to 50%; his study will provide more precise information. "We’ve generally found it more efficient than phone calls. There is the ability to take care of business from remote sites, to do so at odd hours without worrying about waking someone up, and it is often faster than phone tag," he says.

Another huge benefit is that since e-mail messages can be printed out, unlike phone conversations, there is a written record for both the patient and the physician.

"Computers are no more going to go away than the telephone or television," Hoch says. "They will revolutionize the practice of medicine and how clinicians interact with patients. Physicians should jump in now and take an active role in the way these processes develop."

[For more information, contact:

Paul M. Ford, MD, Assistant Professor of Medicine, Stanford Medical Group, 900 Blake Wilbur Drive, Room W2080, Palo Alto, CA 94304-2205. Telephone: (650) 723-6028. Web address: www-med. stanford.edu/shs/smg.

Tom Ferguson, MD, Editor and Publisher of The Ferguson Report, 3805 Stevenson Ave., Austin, TX 78703. Telephone: (512) 474-1141. Web address: www.healthy.net/selfcare. E-mail: doctom@doctom.com.

Daniel Hoch, MD, Assistant in Neurology, Massachusetts General Hospital, Department of Neurology, Fruit St., Boston, MA 02114. Web address: neuro-www.mgh.harvard.edu.

Also, check out the Oct. 21, 1998, edition of the Journal of the American Medical Association. An editorial by Tom Ferguson accompanied several articles on patient-physician e-mail.

The American Medical Informatics Association Internet Working Group, of which Ferguson is a member, has developed "Guidelines for the Clinical Use of E-mail with Patients." The guidelines are available at www.amia.org/positio2.htm.]