Doctors have traditionally been considered rather slow to adapt to new technology. In fact, a recent ACA survey showed that approximately 18 percent of chiropractors still do not use a computer in their practice,1 and although there is no hard evidence on the subject, it is estimated that less than a third of all practicing doctors of chiropractic have internet access or use that technology in conjunction with their practice.
This past May, a report from the Healtheon Corporation shed new light on the subject and underscored the importance of e-mail as a method of doctor-patient communication. Known as the Internet Survey of Medicine,2 the report, part of an ongoing research project, documented the computer needs and expectations of nearly 10,000 physicians over the last three years.
The statistics contained in that report show just how much of an effect the internet is beginning to have on the average physician's practice.
• 85 percent of the physicians surveyed use the internet. That's a jump of 42% over the past three months, and an eye-popping 875% since 1997.
• More than 63 percent of physicians surveyed use their e-mail account daily.
• A third (33 percent) of physicians have used e-mail to communicate with their patients.
• Doctor-patient communication via e-mail has increased 20 percent in the last three months and 200 percent in the last year. In 1997, according to Healtheon, electronic communication between patients and their doctors "did not even register as a significant behavior" when physicians were questioned about it.3
• Professional (doctor to doctor) communication via e-mail rose by 33 percent in the last 12 months.
Dr. Ed Fotsch, vice president of member organizations for Healtheon, said, "Physicians are indicating that they are now seeing the services they need to deliver better care -- such as secure e-mail capabilities and practice web sites -- and have a greater incentive for joining the internet revolution."3
"Medical professionals want to establish a dialogue with their patients that is better than ill-timed phone calls and messages," Dr. Fotsch continued. "The changes in attitude and use in the last few months even caught our researchers off guard -- many of the burgeoning trends that we saw last year are now becoming realities."2
Other Statistics
The Internet Survey of Medicine may be news to the chiropractic profession, but it's just the latest in a growing number of articles revealing the importance of e-mail to the patient-doctor relationship. In the past year, several reports have appeared in peer-reviewed journals highlighting the significance of e-mail and the way doctors (and patients) use it to interact with each other.
• More and more people are using the internet for their health. A 1997 survey from the research firm CyberDialogue indicated that 43% of U.S. adults aged 18 and older who had accessed the internet in the previous 12 months used it to obtain health or medical information.4
• Even though most people can get the health information they want from another source, they prefer to receive it from their personal physician. A survey released in 1996 found that patients ranked "information from my own doctor's office" as the type of health information they desired most.5
• One reason so many people are embracing the Net for health information is the belief that the modern day patient-doctor conversation lacks the personal touch and attention to detail of days gone by. A report in JAMA found that many patients go on line because they are left "wanting more" than what they get in a typical office consultation.6
• Another reason patients turn to cyberspace is the intimidation factor. People are usually less inhibited and will express themselves more freely behind the safety of a computer screen than in person. A study in JAMA7 showed that some families who used an e-mail patient "consultation service" felt more comfortable speaking with an anonymous medical expert than having in-person conversations with their own physicians. And a 1998 study of dermatology websites suggested that patients would seek answers to medical issues even from physicians with whom they have no pre-existing relationship.8
The Promises (and Problems) of E-Mail
Communicating with patients via e-mail opens up a whole world of possibilities for your practice. Admittedly, e-mail isn't the perfect form of communication, and there are a number of drawbacks. Nevertheless, there are several reasons why getting an e-mail account makes sense.
E-mail is inexpensive. Most internet service providers offer unlimited access and an e-mail account for less than $20 a month. Spread the costs out over a month, and that's approximately 66 cents a day -- about the price of a hamburger at your local McDonalds. You could probably find that much money looking under the cushions of the couch in your waiting room. That $20 gives you access to the greatest resource of information in history. You can search for and print chiropractic articles; hold online chat sessions; visit hundreds of chiropractic and health-related websites -- all without worrying about long-distance charges.
E-mail is also much faster than traditional forms of correspondence. Sending a letter could take days to reach its intended reader. A fax could lay unread in someone's in-box for hours. When you send an e-mail, however, it usually gets to the reader within a matter of seconds, even if that person lives halfway across the country.
E-mail can be a better alternative to a phone call or face to face conversation. While not as formal as a letter, you can choose your words more carefully in an e-mail message. E-mail messages also have more permanence. While phone messages can be overlooked or lost under mounds of paperwork, an e-mail message is easy to look up, and it will remain on file in your computer until you delete it.
E-Mail in the Office
When used in your office, an e-mail account gives you another avenue of communicating with patients and other chiropractors. Because the person receiving your message does not have to be on line the same time as you, e-mail could help prevent the problems of "telephone tag" and clears up the interruptions associated with phone calls or electronic pages.
E-mail can help clarify advice and be used as a followup or adjunct to patient visits. Sometimes patients who are ill or worried about their condition may feel nervous asking questions, or they may not fully understand your instructions. Sending an e-mail would clear up any ambiguities. It would also provide your patients some comfort by knowing they have a doctor who is willing to take the time and make sure they are doing all right.
An e-mail could also be used to relay information to your patients that you may not have readily available in the office. Say, for instance, a patient asks you about glucosamine sulfate. You may not have that information at your fingertips, but if you do some research and then e-mail that information to the patient, it lets them know you really do care. It establishes a sense of good will and trust in that patient.
E-mail can also increase your level of professional communication. There are hundreds of chiropractic message boards and dozens of e-mail lists you can access for free. With an e-mail account, you can share information with other DCs, get advice about cases and build professional relationships with chiropractors across town or across the globe.
Perhaps most important, e-mail can be used as a marketing tool for your practice. By collecting e-mail addresses from your patients, you can set up a patient newsletter, provide online discounts and links to websites, and deliver breaking news and health-related stories with just a few keystrokes.
E-Mail Concerns
This is not to say that e-mail should take the place of or become the primary means of communication between doctors and their patients. Urgent care needs should always be addressed in a face-to-face conversation or over the telephone. And it would be inappropriate for physicians to use e-mail to deliver abnormal or confusing test results, or to relay bad news to patients or their family members.
Doctors and patients have shared concerns about sending confidential information via normal e-mail. E-mail accounts are not as private as many people would like to think. Many workplace e-mail accounts, for instance, are read by more than one person. Sending sensitive details to such an account could expose the patient to unwanted embarrassment.
Still other doctors have reservations about the number of messages they could end up receiving. Some have nightmarish visions of finding their e-mail inbox filled with long, verbose messages from patients. Others are worried that patients who do not have internet access would be at a disadvantage versus patients who do have an e-mail account.
The negative aspects of e-mail are legitimate and should not be taken lightly. These issues need to be addressed before you begin corresponding with patients electronically. Care must be taken that your patients' messages are handled confidentially and that you respond to them in a timely and professional manner.
Guidelines for Doctors and Patients
Because the internet is constantly in a state of change, the rules and regulations that govern it -- and to some extent, the use of e-mail -- are also continually evolving. What may be considered appropriate one day may be unsuitable the next. If you are considering implementing e-mail into your practice, it pays to have some guidelines in place to improve communication and ensure patient satisfaction.
At this time, few organizations have written specific guidelines for the way doctors and patients should interact when using e-mail. By far, the best one available is "Guidelines for the Clinical Use of Electronic Mail with Patients," written by Drs. Beverley Kane and Daniel Sands of the American Medical Informatics Association. The original article appeared in the January/February 1998 issue of the Journal of the AMIA, but you can download a free copy at www.amia.org/pubs/pospaper/position2.htm. In addition, the Journal of the American Medical Association dedicated its entire October 21, 1998 issue to the theme of computers, the internet and their effect on health care. Users can download full-text versions from some of that issue's articles at the AMA's website (www.ama-assn.org ), or they can order a copy of the entire issue.
Final Comments: A Comparison Between E-Mail, the Telephone and Changing Physician Opinions
E-mail between doctors and patients offers considerable opportunities for better communication. This new method of communication could have a profound impact on the traditional doctor-patient relationship. Anecdotal reports have already begun to show the effect e-mail has on some practices. So why are some doctors still skeptical of the idea?
In "Electronic Patient-Physician Communication: Problems and Promise," Drs. Kenneth Mandl, Isaac Kohane and Allan Brant may have found an answer. In the article, they draw an interesting parallel between its communicative counterpart -- the telephone -- and its eventual impact on the medical profession.
The telephone was invented in 1876 by Alexander Graham Bell and was introduced commercially later that decade, but it didn't become a common household item 40 years later. At the time, while some doctors "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, however, the telephone had become an integral part of any medical practice and was considered "as central to practice as the stethoscope and sphygmomanometer."9
Such is the situation e-mail faces today. More than 34 percent of the respondents in the Internet Survey of Medicine named security and privacy as a primary concern in the use of e-mail or other interactive internet services. Doctors also cited a lack of time (49 percent), lack of meaningful content and network services (20 percent) and cost (10 percent) as the main reasons why some they are wary of integrating e-mail into their practice.
Coincidentally, the reasons doctors gave about not using e-mail now are the same reasons many doctors used for not adding a telephone into their practices just 75 years ago. However, before you say that e-mail is just a waste of time and money, stop and think what it would be like trying to operate your practice without a telephone today. In fact, imagine going just a week without a telephone.
Scary thought, isn't it? Well, that's what you'll be facing in the next few years if you don't add a computer with internet access and an e-mail account to your office. Just as the adjusting table and x-ray machine are considered indispensable to the practicing chiropractor of today, so will e-mail become a standard piece of equipment for the chiropractor of the 21st century.
References
- The chiropractic practice -- now, and then. Dynamic Chiropractic May 31, 1999; p. 1, 20, 21.
- Eight in ten doctors now on Net. May 6, 1999. Available at MSNBC (www.msnbc.com ).
- Research shows 42 percent growth in physician use of Internet in last three months. May 6, 1999. Available at Healtheon.com (www.healtheon.com ).
- Brown M. The HealthMed Retrievers: Profiles of Consumers Using Online Health and Medical Information. New York: Cyber Dialogue, 1998.
- Brown M. Consumer Health and Medical Information on the Internet. New York: FIND/SVP Emerging Technologies Research Group, 1996;46.
- Spielberg AR. On call and online: sociohistorical, legal and ethical implications of e-mail for the patient-physician relationship. JAMA 1998;280:1353-1359.
- Borowitz SM, Wyatt JC. The origin, content and workload of e-mail consultations. JAMA 1998;280:1321-1324.
- Eysenbach G, Diepgen TL. Responses to unsolicited patient e-mail requests for medical advice on the World Wide Web. JAMA 1998;280:1333-1335.
- Mandl KD, Kohane IS, Brandt AM. Electronic patient-physician communication: problems and promise. Annals of Internal Medicine Sep 15 1998;129:195-500.
