Physicians avoid email – are we Luddites?

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Category : Medical Rants

It’s no LOL: Few US Doctors Answer E-Mails From Patients

Kreuziger’s experience is shared by most Americans: They want the convenience of e-mail for non-urgent medical issues, but fewer than a third of U.S. doctors use e-mail to communicate with patients, according to recent physician surveys.

“People are able to file their taxes online, buy and sell household goods, and manage their financial accounts,” said Susannah Fox of the Pew Internet & American Life Project. “The health care industry seems to be lagging behind other industries.”

Doctors have their reasons for not hitting the reply button more often. Some worry it will increase their workload, and most physicians don’t get reimbursed for it by insurance companies. Others fear hackers could compromise patient privacy _ even though doctors who do e-mail generally do it through password-protected Web sites.

There are also concerns that patients will send urgent messages that don’t get answered promptly. And any snafu raises the specter of legal liability.

Many patients would like to use e-mail for routine matters such as asking for a prescription refill, getting lab results or scheduling a visit. Doing so, they say, would help avoid phone tag or taking time off work to come in for a minor problem.

Still, a survey conducted early last year by Manhattan Research found that only 31 percent of doctors e-mailed their patients in the first quarter of 2007.

Physicians eschew email for several reasons.  As is usual, it all comes back to time and money.

If you email your lawyer, you may well receive a bill for the time necessary to handle that email.  You will also receive a very long paragraph designed to protect that correspondence from liability.

As I write repeatedly, physicians are not paid for their time, they are paid by the widget.  The patient visit is our version of the widget.  Anything that we do to prepare for that visit, communicate between visits, review the tests induced by that visit or discuss you problem with another physician is gratis.  We cannot bill for the proper use of time to improve the patient experience.

I believe that the major reason that physicians avoid email is time.  Email takes time, and that time is not seen as a good business investment.  This same concept explains why physicians try to avoid telephone calls.

Some physicians are also concerned about liability issues.  I have heard lawyers advise that we should avoid email for this reason.

When I was still doing outpatient medicine, I used email with patients who so desired.  Naively I did not worry about these concerns.  Now I am obviously an early adopter of computer concepts.  I was more concerned about efficient patient communication than I was with “productivity.” (see my rant about productivity from Monday.  I did not worry about liability issues, but rather simplifying patient communication.

Retainer physicians use email.  When I interviewed my two retainer colleagues, they bragged about the use of email in their practice.

We have a disconnect between patient desires and physician convenience.  We are not in a service business (although we should be) because the patient is not paying for his or her service.  The third party arrangement (insurance) has a negative modifying effect on the desirable service relationship.

I know all the excuses for physicians to avoid email.  I reject the excuses, and urge my colleagues to join the 21st century.

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Comments (9)

I love email. I would much rather a pt email me than call me. I can answer on my time and terms. I am not trapped on the phone anwering alot of other questions; so it is actually more time efficient for me.

I keep my email open at all times in the hospital so I answer back very promptly. I dont care about the billing aspect as I am a salaried physician.

The only limitation is the privacy. I warn pts about security issues and get informed consent from them.

I’m a physician and I almost never answer email.
The main reason I don’t use email is fear of being sued. The patient may describe symptoms but a physical exam is impossible over the phone. There are serious signs and symptoms that a physician may notice (e.g. a little skin rash, a swollen lymph node) that may not raise the concern of the patient. Any email a physician writes is a document that can be used against him by a lawyer any time in the future, and I’m not willing to take that risk.
I always answer phone calls (and that takes longer than writing an email), and I’m still very cautious about recommending anything over the phone.
Physicians get sued often for absolutely ridiculous reasons and it’s not our fault that we have to protect ourselves.

In 1996, the Federal Gov’t passed a bill called the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This Federal law is very strict on how information is shared concerning private health information. Your doctor is smart not to use email because he can’t be 100% sure that you will be the only one to view that email therefore, he would not protecting your right to medical health privacy and can be fined HEAVILY by the Federal Gov’t. Plus, for your own personal protection, it isn’t smart to use email for this type of personal information because anyone can hack in to your computer. You should be glad your physician is abiding by the HIPAA guidelines. It IS for your protection.

DB:

How can you decry the payment scheme now present wherein a physician is not compensated for time spent on patient care outside of the office, while at the same time chiding said physician for not using technology to communicate with a patient outside of the office, for which (s)he will not be compensated? Wouldn’t this become just one more example of physicians providing care without compensation, thereby proving to policy makers that they need not add compensation in any system for this service since it is already routinely provided for free? “Concierge” practices provide this service precisely because they are paid to do so.

While I routinely find myself nodding in agreement with your posts, this one is not one of your better efforts. I’m afraid that you can’t have it both ways.

I agree with bingo. You correctly identified the problem but ignored the obvious solution. If someone wants to pay me $50 per email, I will email them all day long. I have found that many emails complaints require me to pull the chart or give a task to my staff which means I have to get up from the computer to gather the necessary info, etc… Email for prescription refills? Email your pharmacy not your doctor! I’d likely get an email asking for a refills on the little white pill. Or Lipitor without a dosage. Like many, my day is full with patients in the office right in front of me, along with hospital rounds and nursing home visits. Were does the extra time get created for me to answer emails as well? I am able to post here today because there is no one in the hospital today!

There are more than one problem with physicians and e-mail. However, I think it is something that can certainly be a powerful tool. But, it stands a high probability of turning into a ball and chain instead.

There is more than one way to skin a cat, and there is more than one way to talk about a kluge (or kludge). http://en.wikipedia.org/wiki/Kludge#Spelling

What I think is necessary is an elegant solution and a compelling argument. Which will come first is the question. However, it willbe important for physicians and patients to understand that e-mail has VAST limitations and there will need to be stringent controls on communications via a medium that does not convey tone as unconsciously as voice.

you want doctors to use email?

1. pay them more per visit, so they can see fewer patients and have time to email and manage other things outside of the clinic visit. The payment per visit, if appropriately increased, could then be seen as a “global fee” and the email/phonecalls/paperwork would be part of the package.

or

2. pay the same amount per visit, but pay an additional retainer fee that covers all the non visit work and would allow the doctor to see fewer patients.

or

3. pay directly per email/phonecall/paperwork done by the doc. this gets a little nickel and dimey for my tastes, but I suppose it could work.

1 or 2 are the way to go, imo.

Until you make the changes above, good luck. Keep in mind, however, that with the primary care shortage getting worse, any plan that includes, “the doctor then can see fewer patients” is going to be an issue.

Doctors need to stop taking such a passive attitude towards how they get paid and instead decide how they need to charge in order to provide the service that their patients want–and then swim upstream and do it. In the final analysis they are independent businessmen and woman and have the final say so about the terms of their service–as long as they act like other businessmen and take a little risk.

Customer point of view:

Whats to stop the doctor from hiring a nurse to answer all his emails? actually come to think about it, that sounds like a good idea. A doctor really isn’t needed for most basic medical questions, so a nurse or intern could act as a filter, sending the hard questions to the doctor, or simply scheduling appointments with the patient because a physical exam is necessary.

Yes, it would be awesome to be able to email a doctor and say “I have sore nostrils, what can I do?” but there would have to be rules about encryption, and most home users don’t have it and most doctors don’t have time to set it up, and people’s eyes glaze over as soon as they hear the word. Global Web Security is working on your killer app, they call it MailCloak. It does encryption for almost everything, from Gmail, Hotmail, Yahoo on Firefox and IE, to Outlook and Outlook Express. Check it out.

You are right. the payment system is messed up in America. Customers can’t get services they want and providers don’t get paid for the services they deliver, they get paid “per widget” as you called it. This system increases costs by incentivising the sale of more widgets, which means doctors make more money when their patients stay sick (just as mechanics make more money when cars have more problems)

Maybe the retainer + hourly idea for doctors makes sense. I would definitely agree to pay that way, hell I would even pay a doctor by the hour to take a cab to my house and examine me, just like I would pay a computer consultant to come to my office and give my LAN a checkup. To me computer consultants, mechanics and doctors basically offer similar services – they make sure your mission critical equipment works by troubleshooting it and applying their knowledge/tools to fix the problem (ok so mechanics are more like surgeon not GPs).

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