Email consultations in health care: 1—scope and effectiveness
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7463.435 (Published 19 August 2004) Cite this as: BMJ 2004;329:435All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Sir,
Car and Sheikh correctly report that although telephone and mailed
reminders can reduce missed appointments, there is currently a lack of
evidence on the effectiveness of email reminders on patient nonattendance
in outpatient clinics. We recently completed a retrospective evaluation
of email reminders sent out to employee patients three days prior to their
scheduled appointments in the Division of Preventive and Occupational
Medicine at Mayo Clinic, Rochester. We compared the mean nonattendance
rate of patients who received the email reminders with non-employee
patients, who formed the control group, three months before and after the
intervention.
There were a total of 5,974 appointments during the study period. We
found a 35% decrease in the mean nonattendance rate for patients who
received the email reminders (from 9.7% to 6.3%, p = 0.002) compared to no
change in the mean nonattendance rate in the control group (from 5.3% to
4.7%, p = 0.8).
Our study demonstrated that email reminders significantly reduced the
patient nonattendance rate in an academic outpatient clinic. Prospective
studies are in progress to confirm the effectiveness of email and
automated telephone reminders on clinic nonattendance.
Competing interests:
None declared
Competing interests: No competing interests
The authors of the article are absolutely correct in the assumption
that email consultation would exclude many patients. A considerable
number of the patients in the surgery of my GP have problems with the
basic skills, with simple memory tasks and using the telephone, let alone
the Internet. It is completely out of the question.
However, I must make the comment that I have used email to contact
my GP twice in the past year - once to pass on a query about a blood test
and once to ask about medication. I have no doubt that in both of these
instances it was considerably easy for the GP to answer my simple
questions than for me to go through the formal, and sometimes difficult,
task of making an appointment and taking up ten minutes of my GP's time.
The use of email, from the patients' point of view, is probably a
retrograde step. The face-to-face appointment is obviously the ideal -
even if it is becoming increasingly difficult. Secondly, many patients
feel comforted if they can speak to the doctor's surgery on the telephone.
A trained nurse on the telephone could do much to decrease the fears of
patients, reassure them, and act as a triage filter for the busy GP.
Finally, my local surgery has started a system where the patient
rings the surgery in the morning and his or her GP rings them back to
discuss the problem. This is an immense saving of the GP's time and I
feel confident that the GP will be able to discriminate between routine
and more complicate cases.
There is a caveat, of course. After a very few telephone calls the
patient must be seen in person.
Competing interests:
None declared
Competing interests: No competing interests
This paper of Car is a problematic one. Of course, on-line and other
methods of consultation could be helpful in certain cases. The prototype
is the old story of first-time mother calling their pediatricians in the
middle of the night because of a mild fever, cough or something like that.
However, the spread of this kind of "consultation" is highly dangerous. The
basic Ethics and Bioethics principles avoid with huge points the medical
conduct without the actual examination of the patient. The procedure
described is not only unethical, but leaves patients in danger, without a clear risk-benefit conclusion.
In other words, the phone consultation, useful in certain conditions,
can send not only Medical Ethics, but also patients to the grave.
Competing interests:
None declared
Competing interests: No competing interests
Sir,
In the recent BMJ issue Car et al highlighted the effectiveness,
acceptability and safety of E-mail consultations between patients and
practitioners.1,2 We agree with the importance of new technology
facilitating the communication in healthcare and welcome their
contribution. However, in their literature search the researchers failed
to identify our series of surveys in which we assessed the quality and
safety of health advice given by practitioners of complementary and
alternative medicine (CAM) via e-mail to a fictitious patient as opposed
to researchers when presented with a vignette of various health problems.
3-7 In all surveys, one group of practitioners received an E-mail from a
fictitious patient and was informed about nature of study after the
collection of data when the responder was given the option to withdraw.
The second group of practitioners received the same information as part of
a research project. CAM practitioners were presented with a mother asking
about three specific herbs for morning sickness (medial herbalists)4, an
asthma patient who has been on steroids for a few years asking for
chiropractic treatment (chiropractors)5, a patient with a pacemaker asking
for electroacupuncture treatment for smoking cessation (acupuncturists)3,
a patient with abdominal pain asking whether reflexologists can diagnose
and ‘make him better’(reflexologists)7 and finally, we asked homeopaths,
chiropractors and general practitioners for advice regarding MMR
vaccination6.
We found that response rates and recommendations varied between groups,
that E-mail advice given by CAM practitioners was often not evidence-based
and frequently had the potential to put patients at risk. The response
rate of GPs regarding MMR vaccination advice was nil. In total, our series
of studies suggest that E-mail consultations in the realm of CAM have the
potential to do more harm than good.
Katja Schmidt
Pilkington research fellow, Peninsula Medial School, Exeter
Edzard Ernst
Director of Complementary Medicine, Peninsula Medical School, Exeter
1. Car J, Sheikh A. Email consultations in health care: 1—scope and
effectiveness. BMJ 2004;329:435-8.
2. Car J, Sheikh A. Email consultations in health care:
2—acceptability and safe application. BMJ 2004;329:439-42.
3. Schmidt K, Ernst E. Internet advice by acupuncturists - a risk
factor for cardiovascular patients? Perfusion 2002;15:44-50.
4. Ernst E, Schmidt K. Health risks over the Internet: Advice offered
by 'medical herbalists' to a pregnant woman. Wien Med Wschr 2002;152:190-
92.
5. Schmidt K, Ernst E. Are asthma sufferers at risk when consulting
chiropractors over the Internet? Respir Med 2002;97:104-5.
6. Schmidt K, Ernst E. MMR vaccination advice over the Internet.
Vaccine 2003; 21:1044-7.
7. Schmidt K, White A, Ernst E. Reflexologists’ responses to a
patient with abdominal pain – Internet advice. Complement Ther Med
2003;11:98-102.
Competing interests:
None declared
Competing interests: No competing interests
We need not only the address of the patient,but also his e-mail address ?
EDITOR--It was interesting to read the paper of Car and Sheikh, Email
Consultation in health care: 1.Scope and effectiveness [BMJ 2004;329:435-8]. My comment:
1.We ought to take the email address of the patient,as about 60% of the
population of UK have access to the internet.
2.We can and the patient also can cancel his appointment, we can use it as
a reminder for the attendance of outpatient clinic, MDT meetings, appointments, etc.
3.Patients can report side effects of their medication, or even any new
symptoms in regard to their illness and recieve advice.
4.If the patient travels abroad for e.g a holiday, she/he will feel more
confident that he can contact his doctor for e.g in UK, and enquire about things which are worrying her/him.
5.We can send certain informations to the patient, e.g about the
dangers of the abuse of illicit drugs, excessive drinking of
alcohol, smoking..etc.
6.Patients with suicidal ideas might use it as another way of
informing the services when their thoughts become active.
7.We can use it to instruct the patient for e.g to stop certain
drugs, change their dose or change the medication of the patient.
8.Patients ought to be supplied with email address to contact if they
have any problem,
AK.Al-Sheikhli
Competing interests:
None declared
Competing interests: No competing interests