Electronic Patient-Physician Communication: Problems and Promise

The introduction of the telephone into medical practice in the last decades of the 19th century was greeted with both celebration and trepidation. Invented in 1876 by Alexander Graham Bell, the telephone was commercially introduced in the late 1870s. It was not until World War I, however, that the telephone became a common utility [1]. Although some physicians heralded the advantages of efficiency and accessibility that the telephone offered, others expressed concerns about being overwhelmed by patients seeking over-the-telephone care, the safety of telephone diagnosis, and problems of privacy. By the mid-1920s, the telephone was fully integrated into physician practice, as it was in broader society. The telephone had become a mandatory medical technology, as central to practice as the stethoscope and sphygmomanometer [2]. We are again on the threshold of a dramatic expansion in communications technology that may have profound effects on the patientphysician relationship and the practice of medicine. We are approaching a critical mass of Internet users that will lead to a wide diffusion of electronic communications within medical practice [3, 4]. The American Medical Informatics Association recently published recommendations to guide computer-based communications between clinicians and patients [5]. Little attention, however, is being paid to the implications of direct electronic linkages between physicians and patients. Unless implemented with substantial forethought, these linkages may disturb delicate balances in the patientphysician relationship, widen social disparities in health outcomes, and create barriers to access. We attempt to identify some of the promise and pitfalls of electronic patientphysician communication before such technology becomes widely distributed. Furthermore, we propose a research agenda to provide data that is useful for careful shaping of the communications infrastructure. The Present State of Electronic Medicine Internet technologies have become useful tools for medical practice. Online, physicians can search the medical literature and find both synoptic and full-text medical journal content [6-10]. Patients have access to medical information, self-help and support groups, and even medical experts [11-13]. The World Wide Web can be used to link patient data across multiple institutions for retrieval by providers at the point of service or by researchers [14, 15]. The Internet also allows visual contact. For example, the National Library of Medicine's Telemedicine Initiative enables parents of premature infants to videoconference from home with the neonatal intensive care unit [16]. Although the Internet community has always resisted national and international efforts to regulate its structure or content [17, 18], a motion is under way to impose an organizational structure and monitor the quality of the largely unchecked, unstructured, and unregulated volumes of medical information found on the Web [19-21]. Journals, professional organizations [19, 21, 22], and the federal government [23-27] have proposed monitoring medical information on the Internet and regulating telemedicine technologies. Early federal efforts along these lines include the Congressional Telecommunications Act of 1996 [28] as well as the U.S. Food and Drug Administration's proposed oversight of telemedicine applications and clinical software [22]. Direct electronic communication linkages between physicians and patients are also evolving, although so far these are under considerably less scrutiny. One such linkage is simple e-mail. Approximately 40 000 000 persons in the United States use the Internet [29], and anecdotal reports are emerging of its use for communication between physicians and patients. In university health service settings, in which both patients and physicians tend to have access to e-mail, an initial investigation has demonstrated the potential for widespread acceptance of electronic patientphysician communications by this method [30, 31]. The Promise of E-Mail E-mail can connect physicians with patients, thereby increasing access to care, enhancing patient education, augmenting screening programs, and improving adherence to treatment plans. Barriers to access often arise simply because physicians can be difficult to reach [32]. Unlike telephone conversations, which require both parties to be available at the same time, e-mail, like voice mail, is an asynchronous mode of communication [33, 34], essentially creating continuous access to the health care system. A widening gap is developing between the crucial need for transmitting more information and the relatively few and often brief face-to-face opportunities for communication between physicians and patients. The quality of these personal encounters is further diminished by the need for physicians to address administrative issues, such as referrals, insurance approvals, and rejected claims, during precious contact time. Inadequate communication, now more the rule than the exception, leads to increased stress [35], diminished satisfaction [36, 37], decreased adherence to therapeutic regimens [38, 39], and elevated risk for malpractice claims [40]. Linking patients and physicians through e-mail could increase the involvement of patients in the supervision and documentation of their own health care, processes that may activate patients and contribute to improved health [41-44]. An example of electronic linkages activating patients is CHESS (Comprehensive Health Enhancement Support System), an interactive computer-based system used to support persons with AIDS and HIV infection [45]. Telephone and voice mail technologies have been effective in screening for mental disorders and substance abuse [46, 47]. For example, computer-generated telephone reminders can improve compliance with preschool immunization visits [48]. Standard e-mail or e-mail with an interface allowing structured data entry may allow more effective triage and automation of messaging than voice and video mail do. Whether e-mail between physicians and patients can have advantages for the therapeutic relationship is a question worthy of investigation. We propose a research agenda structured around foreseeable problem areas in electronic patientphysician communication. Potential Pitfalls of E-Mail and the Need for a Research Agenda Inappropriate Use of Communication Tools Health care providers need a framework for choosing the communication mode that is most appropriate for each situation. Certain kinds of communication needs may be satisfied through e-mail. For example, the patient may use e-mail to make an appointment. He or she may request general information, such as a list of low-sodium foods, or specific information, such as a modified insulin dosage based on home monitoring of glucose levels. The physician might initiate e-mail contact to conduct routine guidance and education (for example, to advise a new mother to put her baby to sleep on his back), to remind a patient of an upcoming visit, or to check on a patient's progress (for example, in a smoking cessation program). In contrast, the use of e-mail might be contraindicated in some areas, and face-to-face or telephone contact might be required. Use of e-mail by patients for urgent needs could lead to problems not being addressed quickly enough. It might also be inappropriate for physicians to use e-mail to communicate abnormal or confusing test results or to relay bad news. The diagnosis of a new problem requiring a complex and dynamic dialogue might be best handled synchronously. Face-to-face contacts are optimal for making many diagnoses, although elaborate telephone triage systems have been successfully used for this purpose [49]. Preference for the use of e-mail will depend on the context as well as on the individual physician and patient. Just as some physicians now feel more comfortable than others with telephone medicine, so must physicians exercise personal discretion in their use of e-mail. Used properly, e-mail may promote increased contact between physicians and patients. By increasing opportunities for communication before and after visits, e-mail might help optimize the value of personal encounters. Empirical studies, as well as expert consensus panels, are needed to develop general guidelines to direct patients and clinicians to use the contextually appropriate mode of communication. Evidence-based indications and contraindications for e-mail in the medical context must be clearly specified so that e-mail is used appropriately and does not become a barrier to telephone or face-to-face contact. Security and Confidentiality The confidentiality of medical information [50] and the privacy of e-mail are paramount. Patients or physicians who use e-mail in the workplace for medical interchange are not assured of confidentiality and may inadvertently expose sensitive details of illness or social circumstances to an employer. Furthermore, patients who use family e-mail accounts at home may lack privacy from spouses, children, or parents. Medical account addresses could be distinct from other personal or professional ones. Medical e-mail addresses and the messages generated through them should be reliably documented in and linked to the patient's medical record. Such linkage can be accomplished in various ways, from simply including a patient identifier to embedding a hypertext link to a Web-enabled medical record [14]. A critical decision will be the selection of a set of national health identifiers, as called for by the Health Portability Act of 1996 [23]. Naive use of broadly disseminated identifiers may be unwise. For example, one proposed identifier, the Social Security number, can easily be used to identify a patient and link his or her health record to other records, such as those in financial and marketing databases [51]. The Computer Science and Telecommunication Board of the National Research Council [52] r