BMJ  2004;329:E324 (16 October), doi:10.1136/bmj.329.7471.E324

BMJ USA: Editor's choice

Editor's choice

You've got mail

The Internet changes everything, and health care is no exception. The Internet is already one of the leading sources of health information, both for patients and clinicians. Some day we will have fully integrated and secure electronic health records accessible to patients and authorized professionals anywhere there is Internet access, which by then will be everywhere.

One of our challenges right now, however, is figuring out the role of email in the clinical relationship. Most patients have access to email, and virtually all doctors do. I email my doctor occasionally with questions or requests that don't require an immediate answer and find it to be a useful way to communicate. It seems to work well for prescription refills, routine lab results, simple triage questions, and other issues for which asynchronous communication is appropriate.

In two articles in this issue, Josip Car and Aziz Sheikh review both the evidence for the effectiveness of email consultations in medical care and current patient and physician attitudes towards email use (p 533, p 538). It is still largely an unexplored and anecdotal field, and advantages and disadvantages are easy to hypothesize about but remain largely unproven. We do know that less than 10% of patients email their doctors, but most would like to. Up to a quarter of US physicians email at least some of their patients, but the criteria for and content of these messages is not clear.

There are as many questions as answers about email. Does it add to clinicians' work burden and increase costs, or can judicious use of email and wise triage replace costlier forms of care? Will patients be satisfied with an email response to a question from their doctor? If email is just a few keystrokes away, will ease of access lead to a flood of inappropriate mail that adds to workload without decreasing subsequent visits? And can a way be found to reimburse clinicians for their time spent answering email?

Steven Waldren and David Kibbe (p 503) feel that email can best be used as part of a fully electronic health record, arguing that stand-alone applications are an invitation for errors. They also point out that the standard email being exchanged today between doctors and patients fails to meet necessary standards for confidentiality. In an interview with Anne Harding (p 545), David Brailer, President Bush's health information technology czar, says that email is an essential component of clinical care, although he concedes that Medicare does not currently reimburse doctors for email consultations.

There is still a lot to be done.

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