Friday, August 22, 2008

All-Access Pass

Since my last post, I've continued my trial of's secure messaging system. I've signed up 27 patients and receive 1-2 messages per day. Several patients have written that they think this is a great way to communicate. My impression is that all the questions I've received would have warranted phone calls or office visits if electronic messaging was not available.

I like the option for asynchronous, or time-shifted, communication. If I have calls to return, I either make the call before I leave the office, or it waits until the next day. With electronic communication, I can leave the office on time to see my son's soccer game, and then deal with emails later in the evening.

I currently have a patient who had to travel very soon after having a biopsy done. I'm planning to use electronic messaging to let him know about his results. Playing phone tag with someone on a different continent would be very frustrating.

It's also easy to cut-and-paste the messages from into our electronic chart, so I don't have to make additional notes, like I would for a phone call.

There are some negative aspects to electronic messaging. There's no way to pick up on the sometimes-subtle emotional cues you get over the phone.  I wouldn't want to break bad news this way.

Some of the exchanges I've had could have been dealt with better on the phone. The site already has a notice telling patients to call their doctor for emergencies. Also, some complicated discussions about multiple treatment options are more appropriately handled with a live conversation.

There are plenty of people who don't have internet access, or who are just not comfortable with communicating this way. I wouldn't force this option on them.

Screening messages is a practical concern. My staff will assess incoming phone calls where a patient is asking to speak with me. If the matter is administrative (when is my surgery booked, how long will the procedure take, where is your office, etc.) then they deal with that. I never see that call. I haven't yet had any electronic questions that I think my staff would have screened out, but it could happen. Perhaps the site could add an option for physicians to send a standard message back to patients under those circumstances. Rather than having to type in "My office staff will be pleased to answer any questions about appointment times. Please contact them at XXX-XXXX" or "This concern would be better dealt with in person. Please contact my staff for an appointment," there would be a list of standard responses the physician can click on to redirect the patient's inquiry.

If you can't type well, I don't think you'll be happy with this system. You'll just be wasting time if you hunt-and-peck. Having said that, technology may be the answer here, too. I'm planning to try a voice-recognition system for office use. This may make electronic messaging easier, even for those of use who are comfortable with the keyboard.

Several colleagues have told me that their main concern is with allowing unfettered access to patients who may "abuse" that access. Doctors are worried that they'll be bombarded with time-consuming questions. I can imagine the occasional "cyberchondriac" who might do that. I suspect that would be more a problem for family physicians, whose patients could seek advice about virtually any health concern. For specialists, patients' questions will be limited to that specialty area.

I think that truly time-wasting, neurotic questioners are few and far between. It's a shame to discount a potentially useful avenue of communication because we're worried about the rare instance of abuse. If it did happen, I would tell the patient that I couldn't continue to provide that service to them and, if they wished to discuss their condition, I would make an office appointment to talk in person.

Perhaps raising the cyberchondriac issue is a red herring. If, as I suggested, it's easy to deal with someone who's "abusing" electronic communication, then maybe there's another issue to consider. Perhaps doctors are worried about being swamped not by "recreational" questions, but by questions that are legitimate and important to our patients' well-being.

Maybe we're currently seeing tip-of-the-iceberg questions. Maybe our patients quietly dismiss a lot of their questions because they "don't want to bother the doctor" or find it too difficult to access their physician on the phone, or have to wait so long to get an office appointment. How many valid questions go unanswered due to the barriers we've put up for our patients? If we removed those barriers, would the number of questions balloon? If so, that could be good for patients. They might be more satisfied with their doctor and better informed about their health.

Not so good for doctors, though. Where will we find the time to answer all these new questions? Doggone it; we might need to change the way we do business! Like posting frequently asked questions (and answers) on our website, along with links to further information. Or making written material available to complement the explanations we give during office discussions. Or rethinking the way we present information to patients so that it is better assimilated. Or being more attentive to patients during discussions to be sure they've understood what we've said.

I often hear from colleagues (and sometimes feel it myself) that we're overwhelmed with the daily demands of medical practice. Our days are full and long. How can we be expected to make ourselves even more available to our patients?

Why do we draw a distinction between these 2 different forms of access? Our Advanced Access project focuses on physical access to doctors. Why is that physical access is considered more valuable than "intellectual access"? For a first contact, a face-to-face meeting is desirable. I want to establish a personal contact and will likely need to perform a physical examination. After that initial visit, many exchanges can be conducted without physical contact.

But there is another big difference between physical and intellectual access: I get paid to see people in person. I can't bill Sask Health for phone calls or emails. Our fee-for-service arrangement requires that I see patients in person. I understand the potential for abuse of the billing system if physicians were allowed to bill government insurance for phone calls, etc. But is the current fee-for-service arrangement the best one for patients? Does it affect the decision to recall a patient to the office rather than calling someone with their test results? It certainly affects my decision. I could spend much of my day making phone calls about test results and asking about patient's progress, but I have to generate billings. This is how I earn my living.

Do you expect me to behave any differently? That's just the way our system is designed.

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