More than 80 percent of physicians actively use online services, according to a 2002 survey of physicians by the American Medical Association. A 2002 Harris Poll of consumers found that 90 percent would like to use e-mail to communicate with their physicians. Not all that many years ago, the telephone was invented. Telephones found their way into both private homes and clinical offices, after which only a short time passed before a clinician and patient used the telephone to communicate. I doubt anyone polled the public to determine whether they wanted to talk to their doctor in this manner. No laws were imposed regarding the use of the new technology for this purpose. Privacy was minimal; until the late 1940s, callers generally had to go through a local operator to make a call, and as recently as the 1980s, there were still quite a few party lines left in the country. Times have changed, and now to develop a comparable mode of communication into something useful seems to require all kinds of investigational studies.

Let’s take a look at the direction one company has taken, partially in response to the surveys and statistical results. Medem, which describes itself as “the nation’s premier physician-patient communications network” and ConnectiCare, a managed care company, made an announcement on August 27 of “a new service that will, for the first time, allow insured patients with diabetes to send their glucose readings to their own doctors securely via the Internet.” The usual publicity statements alleging excitement, a focus on quality care, and big steps forward were exclaimed. As I read the press release, I could hardly restrain myself, but my feelings didn’t include one of excitement. I could imagine endocrinologists receiving an onslaught of highly secure e-mails that look like this:

180, 124, 140, 56, 211, 175

Maybe I’m just too cynical, but I don’t believe there is anything new or remotely “first time” about that. Or isn’t that the issue? Perhaps the excitement is over the word “securely” in the original press release. While patients are concerned with privacy, the media has served its purpose by making the limitations of e-mail privacy known to the public. Medem’s service of providing secure e-mail is essentially the equivalent of scrambler service on a telephone line, scrambling at my end as I speak, then descrambling at the other end for the listener. I’ve never had a patient request scrambler service for our telephone conversations despite the ease with which phone conversations can be picked up by third parties if desired.

I have a basic question as to the need and desire for secure e-mail beyond the security that e-mail naturally provides. Medem has been busy writing policy and position papers, the latest of which is titled, as of this writing, “Improving Healthcare Quality and Efficiency Through the Use of Online Communications, A National Initiative.” Their goal, of course, as a for-profit venture, is to encourage legislative bodies to require the use of services such as those offered by Medem. The first step in that process is to push organizational bodies to recommend the use of these services to their members. Once this happens, clinicians everywhere worry that they’ll be next on the stand listening to, “So tell me, Dr. X, weren’t you aware that <insert name of august medical organization here> recommends that all clinicians use only secure e-mail to correspond with their patients?”

Medem believes that the use of secure e-mail between patient and clinician can improve healthcare access, quality, and efficiency. Versus what? If we’re comparing secure e-mail to standard e-mail, there isn’t any improvement in efficiency — if anything, the process takes more time — nor is there improvement in access since clinicians who receive secure e-mail can also receive standard e-mail. Whether there is an improvement in quality is the only real question, one for which I have yet to find a convincing argument.

But I digress. Let’s return to the new exciting diabetes service. ConnectiCare’s part of the announcement is that clinicians who provide specific online diabetes services will be compensated for their time. That is something new, and Medem has long argued that clinicians should be reimbursed for their time consulting with patients online. Of course, Medem has an investment in the technological underpinnings that will allow such reimbursement to take place. Is this the direction we want to go? I for one am not sure that I want patients to think of their billfold prior to contacting me by e-mail. If they want to contact me, they should contact me; it is up to me to determine the extent to which I’m willing to spend time on the phone to deal with an issue versus asking them to come into my office for a discussion. Medem, of course, is not saying that we have to accept reimbursement; they are simply offering the carrot of potential reimbursement as an incentive for us to use the rest of their offerings.

One final point in Medem’s executive summary to highlight: “Actions should be taken quickly to expand the use of secure online communication and automated patient reminders as a new and higher standard of care, to improve healthcare quality and efficiency.” Which would you rather receive from your own doctor? A faceless e-mail generated by a computer reminding you to come in for a checkup, or a postcard obviously signed by the office administrator that you’ve come to know over the years? Which do you think represents a higher level of interpersonal communications? Which one is more likely to get you to come in? New and higher standard of care? Neither, I think.

Agree? Disagree? Annoyed because this has nothing to do with addictive disease?

Stuart Gitlow, MD, MPH, is the author of Substance Use Disorders: A Practical Guide, from Lippincott Williams & Wilkins. He spoke at the Psychiatric Congress in Orlando in November 2003 on e-mail and the psychiatric patient.

This article is published in Counselor,The Magazine for Addiction Professionals, December 2003, v.4, n.6, pp. 70-71.

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