Digital Docs

In her sixth month of pregnancy, Christy Borack of Huntington Beach was diagnosed with a highly painful inflammation of the nasal passages that required frequent trips to a physician specialist in West Los Angeles. The drive alone from Orange County took nearly two hours round-trip, and she soon tired of it.

Then Borack found a faster way to pose her questions about medication side effects and other matters to her doctor: she e-mailed him. The doctor, Chester Griffiths, an ear, nose and throat specialist, responded quickly--always within a day or less--also by e-mail.

In one instance, Christy’s face became red after an injection of cortisone, and she was worried. If the drive to the doctor’s office had been shorter, she would have gone in. Instead, she sent e-mail, and Griffiths got back to her right away.

“It was great,” recalls Borack, whose husband, John, also sent an occasional e-mail to Griffiths. “Sometimes when you call a doctor, you may not hear from him for a couple days.”

Now, Borack hopes to find other doctors who make use of this high-tech house call. As the working mother of Kayla, now 6 months old, she figures an e-mailing pediatrician could be a real time saver.

Doctor-patient e-mail is an idea whose time has come, and consumers like the Boracks are driving the trend, says Dr. Tom Ferguson, a self-care advocate who publishes the Ferguson Report, a newsletter about online health information based in Austin, Texas.

Not everyone embraces this new concept. It puts off some patients who consider it too impersonal. And some doctors and their lawyers worry about e-mail being used against them in malpractice cases.

“And a lot of older doctors think it will dehumanize the practice of medicine,” says Alissa R. Spielberg, a medical ethicist at Harvard Medical School.

But Ferguson and others see doctor-patient e-mail, used to address everyday, nonurgent medical concerns, as a logical next step for the many doctors who are using the Internet for research and for conferring with colleagues.

E-mail has the potential to reshape medicine and the doctor-patient relationship, Ferguson believes, just as it has already reshaped the way we relate to business associates and loved ones.

While e-mail is a way of life in corporate America, doctors have been slow to tap its potential for patient communication. An estimated 1% to 2% of the nation’s 600,000 physicians use e-mail to communicate with their patients, Ferguson noted in a recent editorial in the Journal of the American Medical Assn.

The numbers, however, are “increasing really rapidly,” says Ferguson, as doctors and managed-care organizations explore the potential of cyberspace communication. Kaiser Permanente, the giant Oakland-based HMO, hopes to add an e-mail option for patients who log on to its current Web site, which already allows them to ask questions of pharmacists and schedule appointments, spokeswoman Anna-Lisa Silvetre says.

Within the next two years, 10% of physicians will use e-mail to keep in touch with patients, predicts Dr. David Sanders, co-founder and CEO of Salu.net, a Portland, Ore., firm that provides electronic services to doctors.

One barrier to doctor-patient e-mail--broad access to computers--is gradually falling. There are about 79 million Internet users over age 16 in the United States and Canada, according to Nielsen Media Research. And nearly nine out of 10 U.S. doctors have access to computers in their medical practices, according to the AMA.

*

For Griffiths, the West Los Angeles ear, nose and throat specialist, convenience is the main attraction of e-mail. On a typical day, he fields five or more e-mails from patients, who send him queries about prescription drugs, side effects, health insurance and surgery preparation. He sometimes downloads patients’ CAT scans to educate them about their medical condition or, with permission, sends consultation reports to referring doctors.

Patients tend to get to the point faster in e-mail than over the telephone, he says, noting: “I have not found a run-on e-mail yet.”

With e-mail, patients also can ask questions they forgot to ask--or didn’t have time to ask--before the doctor whisked them out of the exam room.

“I’m never sure how much patients hear after the first sentence,” says Dr. Stephen M. Borowitz, a pediatric gastroenterologist at the University of Virginia Health Sciences Center in Charlottesville.

Another potentially important benefit of e-mail is that it may encourage patients to ask questions they would be intimidated to ask in person. In a recent issue of JAMA, Borowitz and his colleagues at the University of Virginia reported on the results of a 33-month study in which patients could query doctors through a free online consultation service. They reported that many patients said they asked questions they were too timid to ask their own physician.

And e-mail is quick, Borowitz adds. It took an average of four minutes to read and respond to each message.

E-mail can provide “a way to short-circuit anxiety,” says Dr. Paul Zeltzer, a neuro-oncologist at Cedars-Sinai Medical Center and professor of pediatrics at UC Irvine who checks his e-mail four times a day. Recently, he sent an e-mail to reassure a patient that vomiting after brain surgery is normal.

“The use of e-mail between physician and patient could transform care if a clinician can intervene earlier and prevent a bad outcome,” says Wendy Everett, director of health care programs at the Institute for the Future, a Menlo Park, Calif., research firm.

Everett cites the example of a Boston doctor who asked patients with diabetes and high blood pressure to e-mail him their blood pressure and blood sugar readings and concluded that it produced better medical outcomes.

Moreover, Everett says e-mail could help doctors keep their patients because consumers who don’t get the information they need may be more likely to switch doctors.

Of course, medical e-mail has its downsides.

“People don’t pick up e-mail all the time,” says Dr. Richard Ellenbogen, a Los Angeles plastic and reconstructive surgeon. Sometimes, patients call up to verify the information they received by e-mail. “They want to hear from a live person,” he says.

As more doctors use e-mail, they should bear in mind the legal ramifications, notes John McDermott, a Los Angeles health care lawyer.

“E-mail does not give you the security that phone or the mail gives you,” he says.

*

Thanks to the federal government’s antitrust lawsuit against computer software maker Microsoft Corp., business e-mail is getting attention these days for the crucial role it can play in litigation. It’s no different in medicine, where plaintiffs’ lawyers could use doctors’ e-mail with patients as legal ammunition in malpractice lawsuits, notes McDermott.

McDermott says e-mail is often sought as evidence in health care cases, although he and others are not aware of e-mail playing a role in medical malpractice cases. They believe, however, that such cases will surface.

The use of e-mail is untested but not entirely uncharted territory. Suggested guidelines for the clinical use of electronic mail with patients have been issued by the American Medical Informatics Assn., a Bethesda, Md.-based organization.

Under the guidelines, physicians are advised not to use e-mail for urgent matters and to inform patients about typical response time. Printing messages and placing them in the patient’s chart is advised, as is requesting that patients include their name and patient ID number in the message.

Physicians should ask a patient’s permission before forwarding e-mail to someone else, such as a referring doctor. The use of encryption technology--a security measure that scrambles the message in transit then unscrambles it for the recipient--should be considered, according to the association.

Patients should understand that the e-mail is not entirely secure and that it may become part of their medical chart, say doctors who use it regularly.

Medical e-mail should be viewed differently from casual online chats, Spielberg says.

“Think of each e-mail as a letter you composed and wrote on your letterhead and signed, not as a casual conversation in the corridor,” she says.

*

Copies of the American Medical Informatics Assn.’s guidelines can be obtained by fax at no charge by calling (800) 819-2334 and asking for document No. 406.