Wednesday, April 01, 2009

The Problems With Medical E-mail

Ask a business executive what they think about corporate e-mail, they'll tell you: "I love it! It's so efficient!"

As any nurse practitioner what they think about secure patient e-mail, they'll tell you: "I hate it. It's so inefficient."

So why the difference?

Perhaps because corporate e-mail is often one-way transmissions of information (broadcasting) so the information can often be ignored. We do not have the luxury of ignoring e-mails in medicine. These e-mails are always two-way, very personal communications, often about significant patient concerns. For nurses and doctors, there is a remarkable efficency in punching 10 munbers on a phone and speaking with the patient directly, or if they're not there, leaving a message acknowledging that you tried to connect. With e-mail, typing much more to compose an e-mail is just not as efficient as the spoken word and invariably takes much longer to craft a response that is accurate and grammatically correct.

Further, e-mail lacks the subtlties of the emotion conveyed with the spoken word. You can't hear the tremulous nature of the patient's voice or the patient's rapid breathing in the background. Worse, responses in e-mails might be misconstrued by the patient. Defusing such concerns quickly is impossible by back-and-forth e-mail communication. Finally, if the doctor or nurse has the caps-lock key depressed, IT MIGHT BE PERCEIVED THAT YOU ARE SHOUTING AT THEM!

Certainly, electronic communication has its advantages at times. Simple, quick questions that are reaffirmation of appointment times, clarifications, or reminders can be efficiently managed to everyone's satisfaction in medicine, but to look to e-mail as the way to cut office clerical staff as a means of cost-cutting, is missing the forest for the trees.



Jay said...


I'll take it one step farther. I don't even like talking to patients on the phone.

There is so much subtle information picked up with facial expressions and body language that can't be replicated in a faceless conversation.

I'm sure you've seen this as well. You say something important -- there's a long pause. Did they hear you? Did they understand you? Are they taken aback by what you said? Did they grossly misunderstand your intent? Do they trust you?

No way to tell any of this without face to face contact. That's where you make a connection, create empathy and engender trust.


Anonymous said...

The other side of the coin, is that during telephone or face-to- face conversations either person may miss important information, becauses of anxiety, misunderstanding, or thinking about something else. Not infrequently a patient calls back for clarification or because they forgot what the doctor said. Putting it down in an email message can be quite helpful, especially since it gives you time to put down exactly what you mean. The problem is that routine email is not encripted or HIPAA compliant, which is why we developed an on line service, for exchanging emails between doctors and patients. Its free and easy to use.

Jay said...


We do have stacks of pamphlets about common problems, and I'll commonly draw diagrams to help make my point. Wes has a remarkedly complete afib patient information monograph available on this site.

However, with the limited amount of time I have available, I really can't possibly convey the subtle details into a detailed email -- especially because I would inevitably leave something important out.

My "best" patients come prepared with a pen to take notes and a list of questions. I also strongly encourage that they bring someone else along who can help remember things.

Outside of a "concierge" style practice, I think detailed unreimbursed email correspondence is probably a luxury we can't afford.

Just my two cents,


Anonymous said...

I've done email as a provider and as a patient. Hated it as a provider for the reasons Dr. Wes points out (unless it was to confirm an appt or lab result). My PCP and his subspecialty colleagues use Relay Health for secure email communication. All of my PCP's emails are routed thru his MA, so I know that I cannot state anything too technical or the MA won't understand it. If I need Rx refills or lab results then Relay health is okay, otherwise I hate it from the pt perspective as well.