Email may be the preferred communication method with clients in many industries, but many health care clinics are still relying on phone and fax to connect with patients. Only about 11% of Canadian primary care doctors communicate with their patients through email. In comparison, 35% of doctors email patients in the United States and United Kingdom, and in Switzerland, 68% communicate electronically with patients. Some countries, such as Denmark, even have national mandates that all individuals have the ability to email their primary care physician.
Currently, the regulations and professional recommendations around email communications are contradictory. On top of this, secured email software is expensive and difficult to implement. As a result, many doctors and patients are left emailing over unsecured platforms — with little legal guidance — or simply not emailing at all.
Email has “potential to improve patient care”
One of the advantages of email is that it can allow for “more efficient communication,” says Patrick Ceresia of the Canadian Medical Protection Agency (CMPA), the organization that helps Canadian doctors with legal protection costs and provides legal advice. With the right software, emails can also be archived and stored as part of a patient’s medical record, saving clinicians from having to document their telephone conversations.
Patients and caregivers are interested in communicating with their doctors over email. For some patients who frequently change phone numbers or mailing addresses, email may be the most reliable option, while others simply prefer to communicate electronically rather than through phone or face to face appointments. Furthermore, studies have shown that some patients are more likely to communicate sensitive health-related information to their clinicians over email than by phone or in person.
“Emails have the potential to improve the quality of patient care,” says Sabrina Sullivan, a patient in Calgary who has used email to communicate with her doctor. Sullivan says emailing lets her take an active role in her health care and build rapport with her doctor. Doreen Rabi, an endocrinologist at the University of Calgary and a researcher in this field, agrees that email makes it easier for her patients to “check in” with their medical team about simple questions. And email communication may help fill a gap for the 37% of older adults with chronic conditions in Ontario who are not able to easily contact their health care team between appointments.
It is not yet clear from the evidence, however, whether email is superior to more traditional communication methods. A Cochrane systematic review of studies evaluating email for clinical communication noted that the evidence to date contains “variable results and missing data,” and that a clear conclusion about the clinical value of email communication could not be reached with the evidence to date.
While email communication has a number of potential advantages, the ability to maintain patient privacy remains a fundamental concern, says Donna Call, senior communications advisor at the College of Physicians and Surgeons of Alberta (CPSA). And this concern is not limited to Alberta. In Canada, health information custodians, such as hospitals and clinicians, are responsible for ensuring the secure transfer of personal health information.
In Alberta, the Privacy Commissioner’s Office (PCO) recommends that all email communication take place within an encrypted and secure portal. However, the personal email services most often used, such as Gmail, do not meet these security standards, because they are not encrypted and do not communicate through a secure portal.
While it recommends secured, encrypted communication, the Alberta PCO does allow for the use of unsecure channels in circumstances where only limited personal health information will be shared. What constitutes limited data is up to the doctor to assess, states Brian Hamilton, director of compliance and special investigations at the Alberta PCO. Generally, however, it’s acceptable to email information such as clinic announcements, even though the fact that an individual is a patient in a specific clinic is considered personal health information. But it’s generally not acceptable to email details about a patient’s care.
In Ontario, the PCO recommends secure, encrypted email communication but, if that’s not possible, the PCO suggests doctors obtain explicit consent from patients to use unsecure email. Both parties involved need to be aware that there is no fail-safe way to control who has access to information that is shared across unsecured networks, says Debra Grant of Ontario’s PCO.
Grant explains that even if patients send an unsecure email to their doctor directly, consent to this communication cannot be implied. She says that before responding by email, physicians are obligated to discuss the potential risks of email communication with their patients in person or over the phone. Once the patient understands the risks and has provided informed consent, a doctor may communicate with them via email, but should still minimize the amount of personal health information contained in those emails.
Interestingly, in Alberta, patients cannot consent to using unsecure email channels to discuss details about their care, according to Hamilton.
The CMPA’s position on unsecure email has evolved over the past several years and is now similar to Ontario’s PCO recommendations. The CMPA advises doctors to use secure communication methods, but says those who choose to use unsecure email should take steps to minimize the associated risk, such as obtaining patient consent.
Both the CPSA and College of Physicians and Surgeons of Ontario (CPSO), take a firmer stance on this issue. They recommend that doctors only use secure and encrypted emails to communicate with their patients and avoid other unsecure methods of electronic communication altogether.
As a matter of best practice, the CMPA and the Canadian Medical Association (CMA) recommend that doctors get patient consent for email communication, regardless of whether the network used is secure or not. To aid this process, the CMPA has developed template consent forms. In addition, both the CMA and CMPA advise physicians to set expectations about response times and what content is appropriate to discuss over email. Furthermore, doctors are responsible to assess if email is the most appropriate method of providing care to that patient in a given circumstance, according to Andrea Foti, Manager of Policy and Privacy Officer at the CPSO. Patients should also be aware of who will have access to their email, such as receptionists or other medical staff.
Cost and workload concerns
Currently, not all doctors have access to secure portals to communicate with their patients. This is especially true for doctors working outside of hospital settings and in the community. Some provinces, such as Alberta, have begun taking steps to integrate secure electronic communication into their health care system. These programs, however, are in their infancy, according to Ceresia.
Meanwhile, there are private communication companies, such as Wellx, which doctors can use to set up secure email portals. Rajesh Girdhari, a family doctor in Toronto and partner at Wellx says that for most clinical teams such technology works well and improves patient satisfaction.
For some doctors, however, the financial burden and complexity associated with technologies like Wellx’s makes them difficult to implement.
And solutions like these are not always easy for patients. As one patient told us, they often forget their password to their doctor’s secure portal and find the process of using it time consuming, compared to regular email. As a result, some clinicians consciously choose to use unsecure email due to the added efficiency it provides, even though they are aware of the privacy risks associated with its use.
Both patients and doctors also describe concerns regarding the “rules of engagement” for emailing. In a unpublished recent study, Rabi found that doctors would be more accepting of engaging in email communication with their patients if there were clear guidance about when and where this communication method is appropriate. These concerns are often compounded by the legal implications of providing medical advice over email and the associated increased workload.
The workload concern may be smaller than doctors think, however. Most email requests received by physicians are non-urgent and relate to simple medical questions, following up on medical advice, subspecialist referral information and medical prescription renewal. In fact, one study found that far less than 1% of all emails reviewed required immediate attention. Patients are also mindful of overwhelming doctors with too many or inappropriate emails, says Girdhari. Studies have shown that most emails only address one problem and are used to communicate straightforward information. In some clinical practices, however, the use of email has resulted in increased workload for the health care team, and does not always decrease telephone call volume or doctor visits. However, the results are generally inconclusive across many small studies.
Finally, for a busy clinician, the lack of reimbursement for email communications may serve as a deterrent for its widespread adoption. Currently, only British Columbia has payment for certain specialists who email their patients.
Will Canada’s health system embrace email?
Despite the many perceived barriers associated with email communication, email is already being used by some doctors to communicate with patients and has the potential to transform the way patients receive care. But it remains to be seen whether the system and policymakers support this transition in a manner that protects both patients and their health care teams.