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The use of email is so widespread in our domestic and working lives that many patients would like to be able to communicate with their doctor by email, seeing it as a straightforward extension of normal medical services. Emails have revolutionised communication in General Practice over the last decade and take many forms:
- Internal email between staff members - eg, messages concerning patient care.
- External email between patients and clinicians - eg, questions regarding treatment, seeking repeat prescriptions.
- External email between clinicians - eg, seeking advice/updates regarding shared care patients.
- External email between clinicians and other health workers - eg, public health 'cascade' systems for disseminating information quickly.
- External email between practice, clinical commissioning group (CCG) and other health authority administrators.
Whilst our lives increasingly revolve around the checking of electronic inboxes, the most controversial of these uses is for clinical consultation. Despite policy pressure to introduce consultations by email and internet video, there has been a general reluctance among GPs to implement alternatives to face-to-face consultations.
Email's asynchronicity (parties do not have to be simultaneously present, unlike telephone conversations) and the speed of its transmission are particularly valued features. It offers the sense of time efficiency and '24/7' availability but there are intrinsic risks, such as the lack of absolute security (always a concern when handling confidential clinical information) and concerns that, almost by their ease, demand on a doctor's time may actually increase, creating additional workload in an already overstretched system.
In some countries, email is more widely used by primary care professionals. In Denmark, patients can engage in electronic communication with the GP via the official Danish health website. In the USA, health maintenance organisations have embraced email for consulting with their patients and US medical organisations have provided guidelines relating to the use of email consultations. In certain areas of the world where huge geographical distances may separate doctors and patients, or generalists and specialists, email has also been embraced as a useful way to transfer text or visual images to allow consultation at a distance.
In a US study, a large majority of respondents wanted to have access to email consultations and over a third were prepared to pay for such a service, although this does not necessarily translate into similar attitudes in the UK.
However, in the UK there is a lack of formal systems available for using email consultation and bodies representing medical professionals have largely advised against its use for consultation with patients.
A 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'.
Doctors have tended to be more reserved in their enthusiasm for the clinical use of emails generally and many have not adopted email consultations, as they continue to have legitimate professional concerns regarding quality, confidentiality, liability and remuneration.[5, 6]
The current importance placed on patient satisfaction and increased access may drive email consultation to mainstream and widespread use. Further pragmatic trials, investigating how well they work and in which areas they are best employed, are needed.
Current regulatory framework
UK medical indemnity organisations and the General Medical Council (GMC) have been cautious in their 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.
Telephone communication and email communication between patients and doctors have increasingly become part of normal day-to-day practice and indeed an essential part, particularly in cases of geographical isolation. However, telephone or email communication must not impact negatively on the quality of care that patients receive. Advise particular caution where the patient is not known to the doctor, no examination is available and there is little provision for follow-up or monitoring of the patient subsequently. Where doctors consider prescribing following email contact with patients, the GMC has published further guidance on remote prescribing.
- Always consider carefully whether the use of email services best serves patients' interests.
- Consider seeking the advice of the British Medical Association (BMA) and/or indemnity organisation as to how best to organise such activities to ensure adequate quality of care, confidentiality and documentation.
- Appropriate arrangements for the security of personal information must be made where information is sent or received by email or other electronic means.
- If necessary, take appropriate authoritative professional advice on how to keep information secure before connecting to a network and record the fact that such advice has been taken.
- Due to the risk of email interception, make data anonymous or encrypted where practicable. Where it is impracticable, ask whether the benefits of electronic transmission are sufficient to warrant sending insecure, identifiable data.
Convenience of communication
- Emails can be sent and received from many places and take little time to transmit, compared to surface mail.
- They may reduce the need for some face-to-face consultations - eg, straightforward medication enquiries.
- They provide a useful 'hard record' of information that patients and doctors may not be able to retain after verbal communication (eg, addresses and telephone numbers of services to which patients are referred, test results with interpretations and advice, instructions on how to take drugs).
- They can be of unlimited length - in addition to text, users can send virtually any kind of electronic file as an attachment.
Access to healthcare
Increased access to care for those who find coming into a surgery or hospital difficult (eg, 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 (eg, 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.
- Potentially, could help to diffuse 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 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 a 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 and environmental savings compared to paper and telephonic communication.
- Increased inequalities - those least likely to have access to the technology will be disenfranchised in favour of the well-off and the young.
- Inappropriate ease of access to medical advice - the threshold for patients contacting their doctor about low-priority issues may be lowered, '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.
- The person you are communicating with may not be the person you think you are communicating with.
- Lack of non-verbal clues in history taking.
- Inability to perform a 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 - unauthorised interception of unencrypted emails, receipt or retrieval of emails by unauthorised people and other mechanisms remain a real and ever-present risk.
Safety and security
Surveys have shown that up to 90% of patients who use emails to communicate with their doctors impart important and sensitive medical information - a potential threat to their confidentiality. One way of ensuring confidentiality is to limit email use for areas where the risk of breach of confidentiality is lower - for example:
- 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.
Protocols can be developed as to 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, or for complex or sensitive issues. The use of secure software and strict adherence to peer-reviewed protocols and procedures can increase the safety of clinical email communication but medico-legal concerns continue to deter many doctors from their use.
- Patients and doctors should communicate only through designated email addresses and services.
- Emails can be triaged, as telephone calls are, before routing to the appropriate person for a response.
- An automatic reply can acknowledge receipt of a patient's email; patients should be requested to acknowledge reading a doctor's email.
- Emails should be flagged as 'unresolved' until acknowledgment is received.
- Use customised templates or protocols to meet the needs of various tasks (such as repeat prescriptions) to improve communication and increase quality and safety.
Software must be of a high standard and:
- Be easily adopted (combine seamlessly with existing technologies).
- Adapt to the organisation's growing requirements for managing personal health information.
- Enable communication over various operating systems and software programs.
- Be 'user-friendly' - for doctors and patients alike.
- Have effective, invisible security over wired and wireless environments.
- Have simple, reliable authentication methods.
- Be integrated with the existing medical records system.
- Allow the use of customised templates.
- Allow automation functions (eg, automatic replies).
- Have a system for preventing messages being sent to an addressee if previous messages remained unanswered for longer than a defined permissible time.
- Have integrated customisable message-content filtering (if thought necessary).
- Have routine virus scanning.
- Be able to track, log, archive and audit messages.
Further reading and references
Ferguson J; How to do a telemedical consultation. J Telemed Telecare. 200612(5):220-7.
Brant H, Atherton H, Ziebland S, et al; Using alternatives to face-to-face consultations: a survey of prevalence and attitudes in general practice. Br J Gen Pract. 2016 May 23. pii: bjgpJul-2016-66-648-Brant-FL-P.
Atherton H, Pappas Y, Heneghan C, et al; Experiences of using email for general practice consultations: a qualitative study. Br J Gen Pract. 2013 Nov63(616):e760-7. doi: 10.3399/bjgp13X674440.
Car J, Sheikh A; Email consultations in health care: 2--acceptability and safe application. BMJ. 2004 Aug 21329(7463):439-42.
Neville RG, Marsden W, McCowan C, et al; Email consultations in general practice. Inform Prim Care. 200412(4):207-14.
Neville RG, Marsden W, McCowan C, et al; A survey of GP attitudes to and experiences of email consultations. Inform Prim Care. 200412(4):201-6.
Richards H, King G, Reid M, et al; Remote working: survey of attitudes to eHealth of doctors and nurses in rural general practices in the United Kingdom. Fam Pract. 2005 Feb22(1):2-7. Epub 2005 Jan 10.
Caffery LJ, Smith AC; A literature review of email-based telemedicine. Stud Health Technol Inform. 2010161:20-34.
Good practice in prescribing and managing medicines and devices; General Medical Council, February 2013
Confidentiality; General Medical Council (GMC), 2009
Car J, Sheikh A; Email consultations in health care: 1--scope and effectiveness. BMJ. 2004 Aug 21329(7463):435-8.