Pediatricians are more likely than other medical generalists to use e-mail for patient consultations, despite special concerns stemming from the nature of their practices. About 31 percent of all practicing pediatricians use e-mail to communicate with their patients' parents, according to figures projected by Manhattan Research, a marketing information firm.
But while e-mail use in clinical practices continues to rise, little is known about what, precisely, those messages contain.
A new study in the journal Pediatrics, billed as the first to look solely at the content of e-mails exchanged in pediatric practices, offers some answers. The study involved 54 parents who were permitted to exchange e-mail, free of charge, with their children's pediatricians over a six-week period.
Researchers were concerned that people would e-mail the doctors over matters better addressed by nurses or other office staff, said the study's lead author, Shikha G. Anand, a fellow in the division of general pediatrics at Boston Medical Center. But they found that "the vast majority of e-mails were simply to ask a medical question," Anand said. "Parents were very aware of the privilege of direct contact with their physicians . . . and therefore limited their questions." In one of the e-mails examined, a parent expressed concern about her toddler's reaction to a new mixture of milk and formula: "I started [the new mixture] this Saturday and today he woke up with a dirty diaper, loose bowel movements and a bad rash," the parent wrote. "I feel so badly because he gets such a bad rash and screams when I change him because of how much it hurts."
The pediatrician e-mailed back the next night that he doubted the child had a milk allergy but may simply have been unable to tolerate so much milk at once. "I would keep him [only] on the formula for now and we can try again in about [six to 12] months, even longer," he wrote.
An estimated 20,000 U.S. pediatricians use e-mail to communicate with patients, according to Mark Bard, president of Manhattan Research, which released results of a nationwide telephone survey of 1,200 doctors in April. Many say they don't charge for e-mail correspondence, and few insurance plans pay for such services.
Bard said his firm's sample size of pediatricians in the mid-Atlantic region was too small to estimate e-mail usage for pediatricians in the Washington area. But he said that 32 percent of all physicians in Virginia, Maryland and the District reported using e-mail with their patients.
Children's Medical Associates of Northern Virginia, with locations in Alexandria and Fairfax, uses e-mail selectively with parents of patients, avoiding practice-wide use because of reimbursement and time management concerns. Ghassan Atiyeh, one of the office's seven doctors, said he communicates via e-mail with parents of his patients only about five to 10 times a year, mostly if "they are out of town . . . or if there has been an ongoing issue with their child."
The Pediatrics study examined 81 e-mail exchanges between two suburban Massachusetts pediatricians and their patients' parents, most of whom were college-educated. The pediatricians spent about 30 minutes per day on e-mails; the study did not report their feelings about the experience. But 80 percent of parents said they "felt that all pediatricians should use e-mail to communicate with parents"; 65 percent said they'd be more likely to select a pediatrician in the future based on the doctor's use of e-mail. But most said they wouldn't pay for that access.
The exchanges resulted in nine appointments, 21 phone calls, four subspecialty referrals, 34 prescriptions or recommendations for over-the-counter drugs, 11 administrative tasks and one X-ray, found the study.
Robert Gerstle, who sits on the council on computers and information technology of the American Academy of Pediatrics (AAP) and was the lead author of an AAP report addressing e-mail use in pediatric offices, cautioned that the findings should not be generalized to populations beyond the mostly white, upper-middle-class, parents who participated. In the study, parents e-mailed their doctors directly, but Gerstle advises handling patient e-mail on a triage system, where a nurse or some other intermediary reads and filters messages first.
"I don't want to see billing [and] appointment questions," he said. "Parents then have to understand that e-mails sent to me may be seen or touched by other individuals."
In the April survey by Manhattan Research, a large majority of the practicing pediatricians who reported using e-mail said they use it to "discuss clinical questions/symptoms" and 53 percent reported using it for "requests for specialist referrals," Bard said. But he said pediatricians were less likely to use e-mail to communicate lab test results or prescription requests.
An additional e-mail concern for pediatric practices is how to quickly identify messages dealing with patient care. Because parents are usually e-mailing on behalf of their children, doctors and nurses often don't see the patient's name in the return address field. In addition, pediatric offices need to establish the age at which patients are considered mature enough to e-mail doctors themselves, according to a report last year from the AAP.
American Medical Association guidelines updated in 2002 for physician-patient e-mail communication include these recommendations: Doctors should establish a turnaround time for replies, make it clear who might intercept messages at the office and add a standard note reminding the patient of security concerns and the importance of other forms of communication.
The AAP surveyed 1,616 of its active U.S. members about their e-mail use between October 2001 and February 2002. At that time, 14 percent reported using e-mail to communicate with patients. Fifty-four percent used it for prescription refills, 41 percent for test results and 37 percent for appointment scheduling.
Gerstle, assistant professor of pediatrics at Tufts University School of Medicine, who sees patients at Baystate Medical Center Children's Hospital in Massachusetts, said he's hopeful the study will lead to further exploration of e-mail issues.
"What I hope that they follow up on is: What are the kinds of medical problems that people actually use e-mail for . . . [for example] behavior problems, getting my child to sleep [and] diet concerns," he said.