Several times a day, Dr. Tom Delbanco sits in front of his computer, opens his e-mail and fields questions from his patients.
Electronic communications between doctors and patients, he says, may be the next best thing to a home visit.
People are often more comfortable talking to a computer than they are to a doctor, said Delbanco, a professor of medicine at the Harvard Medical School and the lead author of an article on doctors and e-mail in the current New England Journal of Medicine. In the office, a doctor sits there in a white coat exuding authority, which can be scary. There's evidence that people tend to be more open in front of a computer, especially with tricky stuff like alcohol or sexual behaviors.
In an age of palmtop computers, wireless Internet and instant messaging, more and more doctors are using e-mail to work with patients. Instead of playing phone tag or answering a deluge of less than urgent phone calls throughout the day, some physicians say, they are redirecting minor questions and concerns to their in- boxes.
Although many doctors continue to use conventional e-mail, some hospitals have set up messaging systems on secure Web sites to protect patients' privacy. At the Beth Israel Deaconess Medical Center in Boston, 18,000 patients routinely log on to a protected Web site called PatientSite to request prescription refills, write to their doctors or scan personal medical records.
I mostly write about things that are not extremely urgent, said Bruce Male, 62, a retired business leader who periodically sends e- mail to his doctor at Beth Israel. I'll use it to tell him I need an appointment that is not my annual physical, and he'll write back saying he'd like to see me.
Dr. David Ives, a general internist at Beth Israel Deaconess who receives about 30 e-mail messages a day from his patients, said, Most physicians are afraid they'll be overwhelmed, but it actually replaces telephone calls for me.
About a quarter of practicing doctors, surveys show, have communicated with patients through e-mail. But many doctors feel that it means working for free, and some have begun charging for e- mail consultations. In some cases, patients pay a flat rate from $100 to several hundred dollars a year for such services, said Dr. Daniel Sands, an assistant professor of medicine at the Harvard Medical School.
I think it's reasonable to assume that if lawyers and accountants charge for time, then physicians should, too, said Sands, a co- author of the new journal article.
Some health insurers are experimenting with programs to pay for e- mail contacts. Blue Cross of California has a pilot program that treats e-mail messages like visits to the doctor, with co-payments or a modest fee of no more than $10, said Michael Chee, a spokesman for the company.
Doctors say they are most likely to read e-mail that is straightforward and concise. Patients writing about prescriptions often receive priority. Someone who sends a three-page message or repeatedly asks the same question, Ives said, will most likely get a response along the lines of See me.
Long-winded messages and excessive nagging are rarely a problem, doctors say. Patients tend to write e-mail messages more carefully than they would deliver voice-mail messages. It is hard not to become flustered or ramble when an ominous beep is seconds away, said Dr. Jonathan Wald, director of patient computing at Partners HealthCare of Boston, which runs Patient Gateway.
Patients have told us that with e-mail they can really take their time, and physicians appreciate the more organized and specific messages, Wald said.
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