Sunday, December 06, 2009

The Inefficiency of Medical E-Mail

I am fortunate to work at an institution that has a fully deployed electronic medical record (EMR) system that incorporates outpatient physician notes and inpatient notes under one umbrella. By and large, patient care is facilitated since both outpatient and inpatient notes appear simultaneously in the patient's chart, along side telephone messages and clinical results. While there are plenty of kinks to work out, most of us have to admit that there are huge patient care advantages to such a system.

The system also promotes a secure e-mail service for patients to e-mail their physician and a mechanism to have their results forwarded directly to them. With the ability to empower patients directly, many would consider this as the Utopian model for heath care delivery of the future.

And what could be better? Patients get virtually unlimited access to their health care provider, 24-7. Results are whisked to the patient. Speed. Efficiency. "Green." It's all good, right?


At least until a complicated health care situation occurs.

Then the four-page e-mail is sent, asking for clarification. A lengthy reply is made attempting to answer every question. The response is quickly followed by questions. More answers. "What do you mean?" "But what I thought you said..." More responses. More questions. "But have you considered ...?" "But I have to be in New York that weekend. Do I really need it?" "I've been thinking..." "What about....?" "Like I said..." Back and forth. A constant stream of electronic anxiety.

Then a pause.

"Doctor, why haven't you answered my question, doctor? I sent you three mesages today and haven't heard from you. Doctor? Your nurse practitioner wrote that you'd ... I don't understand why there's such a disconnect...."

Hours and hours of back and forth, pounding on a keyboard producing the cold, hard blandness of text. Broken streams of communication. No emotion. No visual cues. No empathy. No give and take.

Just text.

* Click clack, clack click. *

It's about as inefficient as it can get, absorbing huge amounts of physician and nursing time.

Granted, it doesn't happen often. Most patients are sensitive to this mode of communication and e-mail's inherent limitations. But occassionally there are the highly computer-saavy patients who live online, over-use the service, and expect their answers instantaneously. The reality is that few doctors type well, are still putting their hands on and in patients, and do not continuously reside at a computer screen (despite what the hospital administration wants you to believe). That being said, there are still many times where it is far more efficient to see the doctor in person when tough treatment decisions have to be made.

That is, of course, as long as the doctor can pull his face from the computer screen during the office visit.


Photo credit.


Natalie Hodge MD FAAP said...

Eloquently Spoken Dr Wes, We have been communicating with patients in our house call model since 2005, but here is how we have solved it, if it's more than a simple exchange, then we followup with a visit in the home. Clearly we are a direct practice model in which the patient pays for the physician services in our monthly membership model ( it's 125$) a month per patient. So it becomes more like this... blah blah about the ear, but i think he's ok, and then " but we are going out of town" then we say, "how's three oclock, I'll be over" and then it's done. When the anxiety or unsureness of a patient intervenes then it's always best for a face to face house call. For primary care about 90% of what we do is reassurance, and house calls just make it more convenient for patients. Great to see your exhange on HLuks posterous.

Best, Natalie Hodge MD FAAP

Michael Kirsch, M.D. said...

Our office is about to convert to EMR, which will torture us for the next 6 months or so. Of course, it brings great advantages, but it will be another force that separates us from patients. Patients have told me of physicians who are hunched over their laptops and make no eye contact during office visits. With regard to e-mail, another inevitable technological 'advance',are you concerned that this would join the hours of gratis phone medicine that we already donate each week? More thoughts at

DrWes said...


... are you concerned that this would join the hours of gratis phone medicine that we already donate each week?

There is no question that hours of "gratis" time are already added for patient care with the advent of secure medical e-mail. But real market forces are in play as doctors strive to demonstrate "quality" by increasing their "quantity" of care to patients. Will doctors who do not offer such a service be viewed as inferior somehow? I suspect so.

I also think that "fee-for-service" medicine as we know it is about to meet its demise with the current health care reform efforts underway. Soon, this new avenue of electronic patient care will become the expectation rather the exception. Answering brief questions or performing med refills and such probably does afford advantages in the long run. But determining when to call an end to an e-mail thread in favor for an office visit may become our most important skill to impart to our new medical school graduates. Worse, getting a patient to come in to the office might become our next great medical challenge as waiting times grow with the flood of new patients when health care is perceived as "free."

From a monetary perspective, salaried positions have historically been met with acceptance by workers when their salary was commensurate with the income demanded by the marketplace. Provided doctors are compensated fairly, compensation for computer time will just be factored into a doctor's day. The problem comes when computer demands rise too high, since eventually there will be a trade-off between the time necessary to "talk" to a computer and time necessary to talk to patients.

Unknown said...

Dr Wes,

The etiology of email back in the days of ARPA and the "old internet" has not evolved sufficiently to handle the new proposed purposed of email.

As originally envisioned, email was informative only. It was never intended as a medium for prompting or arguing for a decision or for exchanging sensitive information.

The use of email as of today, completely distorts the architecture of email and therefore, should not be used for medical decision making.

In the case of many Q&A's. it is best to use the email to transmit a single document and for any doctor to respond to that single document. Email is notoriously difficult to keep threaded because it requires cooperation for both the addressee and the sender. Lastly, most email clients cannot enforce thread integrity, once broken.

Therefore, I recommend a "live" sharable document as a better method to respond to difficult questions.

DrV said...

Wes. It's rare that receive a patient email that isn't 1000 or 2000 words. These 'encounters' need to be limited and constrained in some way, I think. But I don't know how.

Good post. It brings up lots of ideas in my head for my own blog. Thanks

Anonymous said...

**** warning - way off topic *****

I post the following as a long time reader worried for a friend.

I am hoping that perhaps a reader of this blog or Dr Wes might have thoughts about this case that might help point her in what direction to go as a next step.

Several years ago my daughter had two fainting spells and a hypoxic seizure following both. She underwent some testing then and every test was inconclusive. Her MD's opinion at that time was that she must have had a virus of some sort.

A couple of years later while we were starting the building process she had two more. Again the MD's determined that nothing chronically was wrong with her.

The very weekend that we moved into our house DD passed out again. That time we rushed her to the ER. The ER MD said that he believed that it was not a fainting spell but rather a seizure that caused her to lose consciousness. We followed up with our MD who referred her out to a neuro MD. Before we could even make it to the neuro appt - she passed out again.

Over the course of about six months - the neuro MD did a work up including EEG, MRI and CT scan. Nothing was found.

A little over a year ago DD had a couple of more fainting spells - this time at church. We took her back to the neuro who reread her MRI and thought that he saw something - so they admitted her to the hospital for further testing and a sleep deprivation EEG. Again - nothing . . . all tests came back normal.

In the last two months - DD has experienced some increasing but perplexing symptoms. Increased weakness, increased heart rate, unexplained but severe drops in her blood pressure, difficulty breathing, etc. She has had episodes at school that have led her to the nurses office. The nurse has been wonderful in helping to document DD's symptoms and keeping us aware of what is going on.

Last Wednesday DD passed out at school and her BP was found to be only 72/38 and her heart rate was 160. DH picked her up and took her to the ER where the MD said "maybe she has a virus or maybe she is just dehydrated" but he didn't do any lab work on her.

On Friday I took her to our primary MD - her vitals were off slightly and her heart rate was 124 (too high for a young girl her age). His assessment and her EKG lead him to believe that something cardiac may be going on - so he is referring us to a pediatric cardiologist.

On Saturday, I had to work early in the a.m. at the inpatient facility. By 9:00 DH was calling me to tell me that DD had once again passed out at home. He didn't feel it was necessary to take her to the ER . . . so we didn't. Our plan was just to have her lay low until Monday when we could call our regular MD to see if he could get us in with the carido asap.

Tonight DD came to me she was shakey and complaining of feeling lightheaded/weak. She was once again very pale. I listened to her heart and lung sounds - her heart sounds are irregular and fast w/ a heart rate of 102. Her BP is also down. I've been in touch with our primary MD through the ER. She is now in bed resting.

The MD is going to get on the phone personally tomorrow to see about getting her in to the pediatric cardiologist asap . . . but in the mean time I'm a barrel of nerves. I don't know what is going on with DD and as a nurse I feel like I should be able to at least help the MD figure out what is wrong with her. As a mom - I'm having flashbacks to the days of when my late DD was alive and no one knew WTH was wrong with her either! I worry that we aren't doing enough or that what we are doing isn't fast enough or that DD is more ill than everyone thinks.

Brandon said...

In our practice, we’ve been exploring with the idea of opening up the doc’s email accounts to patients. And many of the concerns discussed here have come up as well.

In general pediatrics for example, I often here doc’s go over the same instructions or advice over and over when talking with parents. For the most part, parents have similar questions about feeding habits, diaper rashes, colds, ear aches and things like that. It seems to me that shooting back an email with “basic” advice is more efficient than a 15 minute call.

And if the email from a parent starts to get too complicated (like described in the post), the doctors should then suggest to the patients to come in the office to discuss further. In other words, not everything has to be resolved over email.

Michael Kirsch, M.D. said...


I certainly agree that the times they are a changin' for medical practice. Telemedicine will gain a foothold in the medical landscape, robotic surgery from a distance, and routine cyber-communications between physicians and patients. Will medical care be better? Of course, but there will be a cost. The doctor-patient relationship will be totally reengineered. I suspect that there will be less humanity and technology takes over. E-mailing is but a small example of the tsunami that awaits us. Hope I don't drown.

E-mailing is a tricky issue. For now, we get loads of phone calls - some legit and some by folks who want an 'office visit on the phone'. However, every call takes time to reach the caller and then sort out the issue. E-mailing will add to this burden and has many obvious liability concerns. For those of us in private practice where margins are tight, siphoning more office visits into cyberspace poses other concerns.

Anonymous said...

Dr. Wes, mine is a patient's view. I'm a patient at your facility, scheduled for open heart surgery, and I LOVE the email. I don't think I abuse it and really never expect to get a reply from the doc, but rather from the his staff. However, the system only permits notes to be addressed directly to the doc. Why not allow a note to be addressed to the PA? I would add that all the med staff at this facility seem to take the email very seriously. I can't tell you how shocked I was when my cardiac surgeon called me LONG Distance this weekend in reply to a minor matter that could have been answered by his staff on Monday. Ummm. Maybe a query could be classified by the patient as to its urgency. I certainly feel guilty that the doc had to take time out of his weekend for such a minor matter. I understand your concerns, (and the length of this disproves my point) but I think your email system will evolve and will become increasingly valuable to both doc and patient.

keith said...


I suspect the e-mail from Anonymous highlights the problems with using e-mail for communication.

It was interesting to hear a friend who goes to a PCP at your fine institution tell how every communication for an appt. or problem seemed to require an e-mail first. She was bemoaning the loss of the personal touch that is rapidly fading from medicine. Of course I have heard others state that it is marvelous that they can send e-mails to their physician and see their tests on line.

It will be more and more of a challenge to find a middle ground as more patients become increasingly more comfortable with this new portal for doctor advice, but in some ways no different than what we have been struggling with for years with phone calls. I would agree that the easiest solutions may be for doctors to become employees where the incentive of face to face assessment is removed and less complicated problems can be handled without direct interaction. But in terms of determining compensation and incentivising physicians to do this work, it must be counted and paid for in some fashion, which the current reimbusement system does not do.

I recall in the days of capitation, our practice would actually welcome these phone calls since we could often handle the issue without tying up office resources, and the pay was the same regardless. It also afforded more freedom to have the patient come in when clincal judgement dictated witout the feeling that the patient was being brought in simply so that the service could be compensated. This is where e-mails would have been an excellent tool, but they don't work so well under a strictly fee for service system unless some value is assigned to the service. Otherwise it becomes a loss leader to satisfy patiens who wish to use it.