BMJ  2004;329:E325-E326 (16 October), doi:10.1136/bmj.329.7471.E325

BMJ USA: Editorial

Editorial

Email in clinical care

Best as part of an electronic health record

In two articles in this issue of BMJ USA, Car and Sheikh do a more than an adequate job of summarizing what is known about the value of email as a tool to improve and augment patient-provider communication (pp 533, 538). It is important to place electronic communications and messaging within the larger context of medical practice adoption of health information technology (HIT), and especially, electronic health records (EHRs). As Car and Sheikh point out, email is a great tool to communicate with patients for reasons such as appointment and preventive health reminders or to communicate small, discrete packets of information. The asynchronous nature of email can afford efficiency to patients and providers that other forms of communication cannot. And email has value beyond patient communication. Providers can use email to communicate with specialist or other members of the care team.

With dwindling reimbursement, providers cannot introduce new services that may jeopardize their ability to keep their doors open. Research is needed on reimbursement models that align these costs and benefits.

However, to derive the most benefit from email communications in a busy medical practice, we believe that the communication must be integrated or seamlessly interfaced with an EHR software system acting as the "central nervous system" for care management. This integration allows for automated preventive health reminders and for the easy migration of data between the EHR and email. The clinician, for example, while reviewing the health record, should be able to start composition of an email with one click. At the end of the email communications, another click should be all that is necessary to add the email messages to the health record.

The integration of email into the EHR is necessary for several reasons. First, ready access to the patient record is needed. There is a high potential for errors when data are transcribed from one location to another. Through integration with an EHR, the data can be imported into the message without the need for transcription, thereby eliminating a potential source of errors. As the scenario in the above paragraph demonstrates, email integration into the EHR can also lower the threshold to document virtual encounters. Improved documentation can increase quality of care and patient safety. Advanced features of an EHR, such as decision support, can also be leveraged to further increase quality and safety during email communications.

There is scant evidence on reimbursement models, costs, and financial benefits of email to help providers judge the feasibility of adding this service. The potential negative impact on workflow if email is not integrated into the EHR makes the business case for stand-alone email communications difficult to justify. A recent story in the Wall Street Journal reported on pilot projects by Blue Cross and Blue Shield to reimburse for email consultation.¹

Second, we believe that "buy in" from the many stakeholders involved in the HIT business case favors integration of email into comprehensive primary care EHR systems. In other industries, the consumer would pay for a portion of the increased operational costs associated with a productivity-enhancing tool such as email, but in the health care system these costs cannot be passed on to consumers due to regulations and caps on reimbursement. With dwindling reimbursement, providers cannot introduce new services that may jeopardize their ability to keep their doors open. Research is needed on reimbursement models that align these costs and benefits.

Probably the biggest technical issue with email is confidentiality. To ensure confidentiality, the recipient (patient) must be authenticated and the message itself must be transmitted in an encrypted manner. There are many methodologies to accomplish this secure messaging; unfortunately, they lack the ease and user-friendliness of traditional email.

The EHR and secure messaging are critical components of the new model of care endorsed by the Future of Family Medicine project that was recently introduced by organized family medicine.² These technologies together can be leveraged to improve quality, safety, and efficiency in a practice. With patient access to the EHR, the technologies allow for a patient-centered model. All are enablers of the new model's move toward aggressive health promotion, prevention, and effective chronic disease management, as well as acute management of disease. Email can eliminate some of the access barriers to family physicians, another tenet of the new model. We agree with Car and Sheikh that "we need to ensure that those without email access to care are not unduly disadvantaged," but concerns such as these must not be addressed by limiting adoption of HIT.

We also agree with their recommendation that both additional original research and meta-analyses are needed on HIT's impact on the delivery of high quality, safe, and efficient care, including the role of email.

Center for Health Information Technology American Academy of Family Physicians Leawood, KS swaldren{at}aafp.org

Center for Health Information Technology American Academy of Family Physicians, Physicians' EHR Coalition Chapel Hill, NC dkibbe{at}aafp.org

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Information in practice pp 533, 538

Competing interests: None declared.

References

1. Landro, L. The doctor is online: secure messaging boosts the use of Web consultations. Wall Street Journal 2004: September 2.
2. Martin JC, Avant RF, Bowman MA, Bucholtz JR, Dickinson JR, Evans KL, et al. The future of family medicine: a collaborative project of the family medicine community. Ann Fam Med 2004;(2 suppl 1): S3-S32.[Abstract/Free Full Text]

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This article has been cited by other articles:

• Stalberg, P., Yeh, M., Ketteridge, G., Delbridge, H., Delbridge, L. (2008). E-mail Access and Improved Communication Between Patient and Surgeon. Arch Surg 143: 164-168 [Abstract] [Full text]