Email consultations in health care: 1—scope and effectiveness
http://www.100md.com
《英国医生杂志》
1 Department of Primary Care and Social Medicine, Imperial College London, London W6 8RP, 2 Division of Community Health Sciences: GP Section, University of Edinburgh, Edinburgh EH8 9DX
Correspondence to: A Sheikh aziz.sheikh@ed.ac.uk
Electronic communication promises to revolutionise the delivery of health care. In the first of two articles considering the potential for email consultations, Car and Sheikh summarise the evidence about their use for preventive health care, health education, and managing non-urgent conditions
Introduction
We used established systematic review methods to identify systematic reviews and original research studies evaluating the role of email communication in health care.w1 We searched the Cochrane Library, Embase, and Medline (from 1980 to 2003) and scrutinised bibliographies of identified articles in order to identify additional published material. We searched the internet using general and specialised search engines to identify "grey" literature from sources such as industry reports, legal and strategic documents, and official government healthcare websites. We also searched the National Research Register to identify commissioned research in progress.
Wherever possible, we refer to findings from controlled trials for drawing conclusions about the clinical effectiveness of email delivered care. We have used case reports and case series to help understand recent developments and inform safety considerations.
Improving access to health care and health information
There is little empirical evidence about the effectiveness of email in helping management of acute and chronic disorders. However, the few studies so far undertaken suggest great potential for email.
Professional-patient communication
Most interventions studied to date combined use of email and the internet. Randomised controlled trials of weight loss programmes conducted via the internet found that adding email counselling to internet intervention significantly improved their effectiveness.10 w14 In these studies neither patient nor counsellor had any previous knowledge of or relationship with each other and communicated only by email. Other conditions for which combined use of email and internet has been favourably evaluated are treatment of depression, recurrent headache, panic disorder, and distress associated with tinnitus.11 w15-w18 High dropout rates and delays in completing treatment are common in studies of email based treatment, but these limitations should be weighed against the potential cost effectiveness of the intervention.w15 w16 w19
In a case series of patients with anorexia nervosa email contact offered a useful adjunct to treatment, had emotional value, and was highly acceptable to patients. Patients reported that emails increased their sense of being in touch with and looked after by the clinician and, furthermore, required them to be more attentive to therapeutic tasks. Clinicians also gave positive views, indicating that reading and responding to emails was not unduly time consuming.12
Several studies have shown the benefit of computerised communication in diabetes care.13 Adding email communication to these interventions can reduce the number of face to face visits, improve quality of care, and improve quality of life.w20
Concordance and follow up
Email provides a new avenue for reporting, monitoring, and feedback of patient self care assignments. It can be used to enhance patient involvement in treatment and strengthen therapeutic alliances. Email reminders (automated, two way) can encourage adherence, remind, educate, and solicit responses about side effects and self reported adherence to medication.14
In one UK survey most patients undergoing day surgery (varicose vain surgery, inguinal hernia repair, or vasectomy) believed that they would not benefit from an outpatient appointment after surgery.w21 w22 Email follow up consultation may be a middle course between the extremes of face to face review or no review consultation at all.w22 Obtaining postoperative (or preoperative) information electronically may seem impersonal, even if efficient. However, several surveys consistently found that respondents were more honest in reporting sensitive information when responses were obtained by electronic questionnaire rather than by an interviewer.w23 w24
Communication by email may not always be the optimal strategy, however, as shown by a recent study of email follow up after emergency department visits, which found it to be less efficient than telephone communication.15
Directions for future research
Healthcare systems are evolving throughout the world and are now embracing the concepts of patient-clinician partnership and patient self-management. In this context, email consultations provide exciting possibilities to augment and facilitate healthcare delivery.
Extra references (w1-w24) are listed on bmj.com
We thank Professors Azeem Majeed, George K Freeman and Martyn R Partridge for their critical comments on an earlier draft of this manuscript.
Contributors: AS and JC conceived the idea for this review. JC conducted the searches, evaluated the study quality, analysed the data. AS contributed to the search design, quality evaluation, data analysis and interpretation. JC wrote the first draft of the paper; both authors jointly wrote the paper subsequently. Both authors are guarantors for the paper.
Funding: JC is supported by research awards from the Ministry of Education, Science and Sport, Slovenia, Ad Futura Foundation, and Universities UK (ORS award).
Competing interests: None declared.
References
Committee on Quality Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001.
Moyer CA, Stern DT, Katz SJ, Fendrick AM. `We got mail': electronic communication between physicians and patients. Am J Manag Care 1999;5: 1513-22.
Hamilton W, Round A, Sharp D. Effect on hospital attendance rates of giving patients a copy of their referral letter: randomised controlled trial. BMJ 1999;318: 1392-5.
Campbell JR, Szilagyi PG, Rodewald LE, Doane C, Roghmann KJ. Patient-specific reminder letters and pediatric well-child-care show rates. Clin Pediatr (Phila) 1994;33: 268-72.
Car J, Sheikh A. Telephone consultations. BMJ 2003;326: 966-9.
Katz SJ, Moyer CA, Cox DT, Stern DT. Effect of a triage-based e-mail system on clinic resource use and patient and physician satisfaction in primary care. A randomized controlled trial. J Gen Intern Med 2003;18: 736-44.
Stone EG, Morton SC, Hulscher ME, Maglione MA, Roth EA, Grimshaw JM, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med 2002;136: 641-51.
Harrison RV, Janz NK, Wolfe RA, Tedeschi PJ, Chernew M, Stross JK, et al. Personalized targeted mailing increases mammography among long-term noncompliant Medicare beneficiaries: a randomized trial. Med Care 2003;41: 375-85.
Eysenbach G, Diepgen TL. Patients looking for information on the internet and seeking teleadvice: motivation, expectations, and misconceptions as expressed in e-mails sent to physicians. Arch Dermatol 1999;135: 151-6.
Tate DF, Wing RR, Winett RA. Using internet technology to deliver a behavioral weight loss program. JAMA 2001;285: 1172-7.
Christensen H, Griffiths KM, Jorm AF. Delivering interventions for depression by using the internet: randomised controlled trial. BMJ 2004;328: 265.
Yager J. E-mail as a therapeutic adjunct in the outpatient treatment of anorexia nervosa: illustrative case material and discussion of the issues. Int J Eat Disord 2001;29: 125-38.
Balas EA, Jaffrey F, Kuperman GJ, Boren SA, Brown GD, Pinciroli F, et al. Electronic communication with patients. Evaluation of distance medicine technology. JAMA 1997;278: 152-9.
Dunbar PJ, Madigan D, Grohskopf LA, Revere D, Woodward J, Minstrell J, et al. A two-way messaging system to enhance antiretroviral adherence. J Am Med Inform Assoc 2003;10: 11-5.
Ezenkwele UA, Sites FD, Shofer FS, Pritchett EN, Hollander JE. A randomized study of electronic mail versus telephone follow-up after emergency department visit. J Emerg Med 2003;24: 125-30.(Josip Car, doctoral stude)
Correspondence to: A Sheikh aziz.sheikh@ed.ac.uk
Electronic communication promises to revolutionise the delivery of health care. In the first of two articles considering the potential for email consultations, Car and Sheikh summarise the evidence about their use for preventive health care, health education, and managing non-urgent conditions
Introduction
We used established systematic review methods to identify systematic reviews and original research studies evaluating the role of email communication in health care.w1 We searched the Cochrane Library, Embase, and Medline (from 1980 to 2003) and scrutinised bibliographies of identified articles in order to identify additional published material. We searched the internet using general and specialised search engines to identify "grey" literature from sources such as industry reports, legal and strategic documents, and official government healthcare websites. We also searched the National Research Register to identify commissioned research in progress.
Wherever possible, we refer to findings from controlled trials for drawing conclusions about the clinical effectiveness of email delivered care. We have used case reports and case series to help understand recent developments and inform safety considerations.
Improving access to health care and health information
There is little empirical evidence about the effectiveness of email in helping management of acute and chronic disorders. However, the few studies so far undertaken suggest great potential for email.
Professional-patient communication
Most interventions studied to date combined use of email and the internet. Randomised controlled trials of weight loss programmes conducted via the internet found that adding email counselling to internet intervention significantly improved their effectiveness.10 w14 In these studies neither patient nor counsellor had any previous knowledge of or relationship with each other and communicated only by email. Other conditions for which combined use of email and internet has been favourably evaluated are treatment of depression, recurrent headache, panic disorder, and distress associated with tinnitus.11 w15-w18 High dropout rates and delays in completing treatment are common in studies of email based treatment, but these limitations should be weighed against the potential cost effectiveness of the intervention.w15 w16 w19
In a case series of patients with anorexia nervosa email contact offered a useful adjunct to treatment, had emotional value, and was highly acceptable to patients. Patients reported that emails increased their sense of being in touch with and looked after by the clinician and, furthermore, required them to be more attentive to therapeutic tasks. Clinicians also gave positive views, indicating that reading and responding to emails was not unduly time consuming.12
Several studies have shown the benefit of computerised communication in diabetes care.13 Adding email communication to these interventions can reduce the number of face to face visits, improve quality of care, and improve quality of life.w20
Concordance and follow up
Email provides a new avenue for reporting, monitoring, and feedback of patient self care assignments. It can be used to enhance patient involvement in treatment and strengthen therapeutic alliances. Email reminders (automated, two way) can encourage adherence, remind, educate, and solicit responses about side effects and self reported adherence to medication.14
In one UK survey most patients undergoing day surgery (varicose vain surgery, inguinal hernia repair, or vasectomy) believed that they would not benefit from an outpatient appointment after surgery.w21 w22 Email follow up consultation may be a middle course between the extremes of face to face review or no review consultation at all.w22 Obtaining postoperative (or preoperative) information electronically may seem impersonal, even if efficient. However, several surveys consistently found that respondents were more honest in reporting sensitive information when responses were obtained by electronic questionnaire rather than by an interviewer.w23 w24
Communication by email may not always be the optimal strategy, however, as shown by a recent study of email follow up after emergency department visits, which found it to be less efficient than telephone communication.15
Directions for future research
Healthcare systems are evolving throughout the world and are now embracing the concepts of patient-clinician partnership and patient self-management. In this context, email consultations provide exciting possibilities to augment and facilitate healthcare delivery.
Extra references (w1-w24) are listed on bmj.com
We thank Professors Azeem Majeed, George K Freeman and Martyn R Partridge for their critical comments on an earlier draft of this manuscript.
Contributors: AS and JC conceived the idea for this review. JC conducted the searches, evaluated the study quality, analysed the data. AS contributed to the search design, quality evaluation, data analysis and interpretation. JC wrote the first draft of the paper; both authors jointly wrote the paper subsequently. Both authors are guarantors for the paper.
Funding: JC is supported by research awards from the Ministry of Education, Science and Sport, Slovenia, Ad Futura Foundation, and Universities UK (ORS award).
Competing interests: None declared.
References
Committee on Quality Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001.
Moyer CA, Stern DT, Katz SJ, Fendrick AM. `We got mail': electronic communication between physicians and patients. Am J Manag Care 1999;5: 1513-22.
Hamilton W, Round A, Sharp D. Effect on hospital attendance rates of giving patients a copy of their referral letter: randomised controlled trial. BMJ 1999;318: 1392-5.
Campbell JR, Szilagyi PG, Rodewald LE, Doane C, Roghmann KJ. Patient-specific reminder letters and pediatric well-child-care show rates. Clin Pediatr (Phila) 1994;33: 268-72.
Car J, Sheikh A. Telephone consultations. BMJ 2003;326: 966-9.
Katz SJ, Moyer CA, Cox DT, Stern DT. Effect of a triage-based e-mail system on clinic resource use and patient and physician satisfaction in primary care. A randomized controlled trial. J Gen Intern Med 2003;18: 736-44.
Stone EG, Morton SC, Hulscher ME, Maglione MA, Roth EA, Grimshaw JM, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med 2002;136: 641-51.
Harrison RV, Janz NK, Wolfe RA, Tedeschi PJ, Chernew M, Stross JK, et al. Personalized targeted mailing increases mammography among long-term noncompliant Medicare beneficiaries: a randomized trial. Med Care 2003;41: 375-85.
Eysenbach G, Diepgen TL. Patients looking for information on the internet and seeking teleadvice: motivation, expectations, and misconceptions as expressed in e-mails sent to physicians. Arch Dermatol 1999;135: 151-6.
Tate DF, Wing RR, Winett RA. Using internet technology to deliver a behavioral weight loss program. JAMA 2001;285: 1172-7.
Christensen H, Griffiths KM, Jorm AF. Delivering interventions for depression by using the internet: randomised controlled trial. BMJ 2004;328: 265.
Yager J. E-mail as a therapeutic adjunct in the outpatient treatment of anorexia nervosa: illustrative case material and discussion of the issues. Int J Eat Disord 2001;29: 125-38.
Balas EA, Jaffrey F, Kuperman GJ, Boren SA, Brown GD, Pinciroli F, et al. Electronic communication with patients. Evaluation of distance medicine technology. JAMA 1997;278: 152-9.
Dunbar PJ, Madigan D, Grohskopf LA, Revere D, Woodward J, Minstrell J, et al. A two-way messaging system to enhance antiretroviral adherence. J Am Med Inform Assoc 2003;10: 11-5.
Ezenkwele UA, Sites FD, Shofer FS, Pritchett EN, Hollander JE. A randomized study of electronic mail versus telephone follow-up after emergency department visit. J Emerg Med 2003;24: 125-30.(Josip Car, doctoral stude)