Email is a great way to communicate with patients, but it is important that doctors follow guidelines on its use, say Helen Sowerbutts and Caroline Fertleman
Many industries have been revolutionised by the use of email, and parts of Europe and North America have embraced its use in healthcare. Today’s focus on patient centred care and accessibility means that email will become a key method of communication with patients.
However, considerable apprehension exists in the United Kingdom. Although medical protection agencies and the General Medical Council have published basic guidance,anecdotal experience suggests that many clinicians are unaware of this or unsure of how it applies to their practice. Doctors are using email without referring to guidelines, with potential patient safety and medicolegal implications.
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Publication date: 12 Jan 2016
It’s easy to understand the attraction of email. It is quick and flexible and, unlike telephone communication, it provides a chain of correspondence that can be stored for reference. Parties do not need to be simultaneously available, and an increasing body of evidence suggests that many patients prefer email for certain types of correspondence.
Several reviews have shown how email can be used. Most experience comes from those with regular caseloads.  The main uses reported are for questions about management and medication; a smaller proportion of emails are requests for results or reviews or thank you messages.
We recently surveyed the opinions of over 2000 health professionals at two hospitals and found that the following issues are commonly raised.
Clinicians are nervous that it may lead to excessive demands on their time. However, many of the published reports suggest that the actual time spent corresponding with patients on a daily basis is minimal, although this will depend on the area of practice of the clinician.
Some evidence shows that by avoiding the need to schedule or repeat phone calls or arrange appointments email can save both time and resources. However, appropriate administrative procedures, including how emails will be filed, need to be installed first for this to be effective.
It is also possible for clinicians to audit their experience and review job plans in recognition of the workload generated if necessary.
Concerns about confidentiality
Perhaps one of the greatest concerns is confidentiality, although patients may be less concerned about it than clinicians. This has been partly remedied now that NHS.net can send email securely to non-NHS addresses.
Personal experience has shown that using the encrypted service could be perceived as cumbersome by patients and may discourage use. We would therefore recommend routinely asking patients beforehand for their preference between using the more time consuming NHS.net encrypted system or replying to emails from NHS.net in the traditional manner.
Regardless of the system used, patients must be aware of which household members can access emails and should consider what information they are happy to receive before corresponding by email.
We would advise institutions to formulate procedures to ensure that valid consent has been obtained, including the type of information the patient is willing to discuss. Particular care should be taken when there are potential capacity issues and language barriers.
Although confidentiality remains a concern, doctors rarely obtain written consent before sending letters, which may also be intercepted, misdirected, or read by other household members.
A first email sent in clinic can be used to check that it has been correctly received, potentially limiting the risk of confidentiality breaches, although the risk of family members
reading emails remains a concern.
Over-reliance by patients is another area of concern, but some evidence suggests that in practice this is uncommon and can be relatively easily managed. It is advisable to agree in advance realistic expectations for the timing and frequency of responses.
Use of email can be revoked if patients seem to be abusing the service. This may be easier than with other means of communication as you can generate standardised responses to block certain addresses.
Use common sense
The lack of dialogue, personal contact, and ability to ensure that messages are understood are inevitable consequences of using email. Doctors should use common sense about what they discuss. As a rule, sensitive, complex, or critical messages should be communicated directly to the patient. However, some patients may feel better able to express themselves using email as there is time to plan their points or questions and translate messages.
Patients and clinicians should be aware that it is rarely appropriate to discuss emergency issues by email. This should be included in any guidance, and you should always have safety netting advice in email signatures and out of office replies.
In conclusion, it is perhaps best to view the use of email as a complementary method of communication, to be used alongside other methods. Although research suggests that patients are keen to access healthcare in different ways, it is important that clinicians do not overlook those patients who do not have email access.
Wherever email is used, local information technology governance team approved guidance and patient information should be available and regularly reviewed. This may need to be adapted for professionals working in different specialties and domains—for example, acute versus community services.
In response to our survey results we have developed and successfully launched local trust guidance for patients and staff that specifically deals with the issues discussed above. Although yet to be formally appraised, it has received positive feedback so far, and the format could easily be adapted to suit other trusts and departments.
A patient’s view
Michael Seres, a patients’ advocate and founder of the smart health technology company 11Health, says:
Email, like all forms of communication, is simply a part of the toolkit available to patients. It is not a replacement, just an added opportunity. The key phrase in this article is “common sense,” which should underpin how patients and doctors use email. A real issue behind use of email is fear: fear among doctors that they will be bombarded, yet the evidence, as outlined in the article, is to the contrary. I believe that in many instances email saves time, can be more efficient, and can certainly be more cost effective. It is never “one size fits all.” I have been using email and text for over two years now. The key is that there needs to be mutual respect and empathy so that this form of communication is not misused. As always, it is about building an empathetic relationship and using simple common sense.
Competing interests: We have read and understood BMJ’s policy on declaration of interests and have no relevant interests to declare.
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Helen Sowerbutts specialty training year 6 paediatric registrar, Imperial College Healthcare Trust, London
Caroline Fertleman consultant paediatrician, Whittington Health, London