Physicians, patients must work together on new electronic relationships

BOSTON – The "office visit" of the future will likely involve patient and physician sitting in front of cameras mounted atop computer terminals, the doctor examining a rash or monitoring a symptom diary while the two converse verbally or electronically, two Beth Israel Deaconess Medical Center (BIDMC) primary care physicians write in the New England Journal of Medicine.

This new dynamic will lead patients and health care professionals to work together to ensure a transparent system that enables them to share knowledge, responsibility and decision-making more equally, Tom Delbanco, M.D., and Daniel Z. Sands, M.D., M.P.H. write in the April 22 edition.

"Patients will soon have full and continuous access to all notes in their personal, electronic medical record offering them the opportunity to suggest amendments, to disagree with their doctors' views, and to point out and correct errors," says Delbanco. "This should enhance patient safety and promote both patient responsibility and shared decision-making."

The growth of electronic communication options presents both opportunities and challenges. E-mail and secure web-based portals offer patients better access both to their physician and to applications where they can review their medications and correct errors, request prescription refills, make appointments, retrieve laboratory results and view radiology images. PatientSiteTM, BIDMC's secure portal, can be found at https://patientsite.bidmc.harvard.edu.

But surveys find physicians are less enthusiastic about electronic communication than are their patients, with only about a quarter of practicing physicians reporting they had conducted e-mail conversations with patients – and few encourage the practice as a matter of course.

Despite early experiences that suggest e-mail interchanges can offset costs incurred by telephone calls, missed or avoidable appointments, medication errors and requests for prescriptions, doctors remain unconvinced about the tradeoffs.

"For doctors, at a time of disquiet, fatigue and bombardment by paper and electronic 'noise,' even if e-mail improves the quality of communications with patients it threatens to break the camel's back," Delbanco and Sands write.

A chief concern too is the lack of compensation for time spent handling e-mail inquiries. Surveys found two-thirds of physicians would use e-mail if they were paid for the time involved, and the authors note than insurers and health plans – at the urging of the American Medical Association and the American College of Physicians – are looking for payment methods, whether by the message, the episode of illness, or through an annual per-patient or global practice fee.

But that, they say, is only one piece of the solution. Equally important is a joint effort between patients and health care professionals to create and evaluate new portals, record systems and practice guidelines that delineate shared expectations. They also recommend that the medical community learn from online merchants, auctioneers and bankers who have created systems that can make individuals feel valued, while handling vast numbers of interactions without free text e-mail exchanges.

The bottom line is that electronic communications offer a change to truly enhance the doctor-patient relationship.

"E-mail gives doctors and patients more time to think. Doctors and patients move closer together and trust grows strikingly. Interchange becomes more personal and office visits seem more efficient and less emotionally charged," they write.

"And with time 'off-line' to reflect and learn, patients appear better able to grasp information that is central to their care. Indeed, as one of our patients told us: 'Exchanges by e-mail are the next best thing to a house call.'"

Delbanco is the Richard A. and Florence Koplow-James L. Tullis Professor of General Medicine and Primary Care at Harvard Medical School. Sands is an Assistant Professor of Medicine at Harvard Medical School and Clinical Systems Integration Architect at BIDMC. Both are physicians in BIDMC's Health Care Associates practice and members of the Division of General Medicine and Primary Care.

Beth Israel Deaconess Medical Center is a major patient care, teaching and research affiliate of Harvard Medical School, and ranks third in National Institutes of Health funding among independent hospitals nationwide. BIDMC is clinically affiliated with the Joslin Diabetes Center and is a founding member of the Dana-Farber/Harvard Cancer Center. BIDMC is the official hospital of the Boston Red Sox. For more information, visit http://www.bidmc.harvard.edu.

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