Email may be the most powerful new communications tool since the telephone. But despite its clear potential in health, the BMA remains sceptical and few British doctors have yet embraced email communications with patients. Stephen Pincock reports on why most doctors remain ‘out of office’ online.

Ask the British Medical Association about its view on the vexed issue of e-mail consulting, and you get yourself a pretty straightforward answer.

"On the whole, it’s not a good idea," says British Medical Association (BMA) spokeswoman Linda Millington. Why? Because with email, unlike a face-to-face consultation, you can’t be certain exactly who you’re communicating with and you don’t have the personal contact that can provide crucial clues in diagnosis, she says. What’s more, the exchange could put patient confidentiality at risk.

That cautious view is reinforced in the BMAs extremely cautious advice to doctors on email consulting (

"The world of medicine is being irrevocably changed by the ‘e-‘ word," it says. "It has become common to hear of new ‘e-health’ web sites or ‘on line consulting’ services, some offering promises of ‘speedy access’ to health professionals. However, the scene remains one of confusion and uncertainty – these new technologies remain largely unproven and their clinical and medico-legal risks are mostly unknown."

So email consulting is dangerous for the patient, and could be risky for the physician too, they say. What happens, for example, if a doctor unwittingly provides medical advice to a patient living in a country where his medical qualifications are not recognised? He could find the General Medical Council getting involved.

In the BMA’s view, the problems are currently just too many to recommend any email consultation with patients, except maybe – providing authentication, security, integrity and other concerns are satisfied – for "general low-level non-clinical communications."

But if the BMA’s position recites all the standard arguments against email consultations – many of which could also be said to apply to telephone consultations – its American counterpart focuses far more on potential benefits.

Official American Medical Association (AMA) guidelines say e-mail "can aid the health care delivery process by allowing written follow-up instructions, test results and dissemination of educational materials for patients, as well as a means for patients to easily reach their physician on routine health matters."

The AMA also cites a survey by Harris Interactive showing that 90% of adults want to communicate online with their physicians, and about 37% say they would pay out of pocket to communicate online with their doctor.

And that in-principle support has recently been turned into concrete action. In June this year, about 1,000 doctors began offering secure, fee-based online consultation service to established patients through an online service operated by Medem, a venture partly owned by the AMA.

Experienced with "e"

If leading national medical associations are in two minds about emailing, so are individual doctors. And those who have dipped their toes into the water have differing experiences.

In the UK, Dr. Liz Miller has had first hand experience of running an email based advice service which hasn’t turned out to be everything she hoped.

Two years ago, she set up, which offers "fast, confidential consultations from doctors who care." For £25 Miller or one of her two doctor colleagues will email with patients about their condition, or for £12 give a 75 word answer to a specific question. So far, uptake has been low.

"It is a highly personal and time consuming service," Miller told E-Health Insider. "I thought it might have had some commercial potential–unfortunately not, but it has other rewards!!"

She thinks there’s a long way to go before email medical communications will be a viable commercial opportunity. "It is about communication, people respond to care and concern about their condition. Unfortunately care and concern do not necessarily produce a financially viable business."

But Miller still believes in the potential of the email to cut to the quick of doctor-patient communication. "It is easier to be much more blunt in an email – although nicely phrased – than in a face to face consultation where a patient need not listen to a word you say!"

Another British GP who’s been a trail-blazer in e-health is Dr. Richard Fitton, from the Hadfield Medical Center in Derbyshire.

For some time now, patients in Dr Fitton’s practice have been using a secure email system for sending in own blood pressure results and blood sugar results, after which they are filed in the GP record.

Email discussions with the 250 or so patients who have been involved in the project have inevitably slid toward the direction of consultations, he said. "They have all said they would like to be able to consult and to order their prescriptions using email. My feeling is that almost everybody would like to be able to do that."

He also thinks there is a fair amount of interest among British GPs. As an example he mentions a local practice he knows has been collecting patient’s email addresses over recent years. "I imagine they must be populating a field within the patient record and they want to consult with patients."

But the big hurdle, other than the knotty issues of security and confidentiality, is a lack of NHS national standards.

"I think at the moment the NHS is taking away your right as a patient to consult by email, because they haven’t actually set standards or allowed any form of standards for email consulting," he said.

Which is also a pity for the UK’s overworked family docs, he says, because email consults have the potential to reduce workload. That potential benefit was aired as long ago as 2001 in the BMJ by Dr. David Mechanic from the Institute for Health, Health Care Policy and Aging Research at the University of New Jersey. BMJ 2001;323:266-268 (4 August)

Dr Mechanic argued that properly structured email communication with patients can help maintain continuity of care, provide opportunities to deal expeditiously with routine matters, and allow more time for meaningful communication.

"Email and the internet potentially provide opportunities to deal with routine information and to reallocate time to more meaningful communication. Combining these technologies with ancillary staff provide the basis for more effective practice designs."

Responding to that article, Dr. Robert Mol from Hoogvliet-Rotterdam in The Netherlands, said he felt the same way. Mol began his own email consultation practice in July 2001 focusing on people in his working area who can’t see a GP. (

His service, which offers 12 Euro e-consultations, prompted large number of positive articles in Dutch newspapers, and a growing response from actual patients.

"Although this new approach of primary care in The Netherlands is still very new, I believe…that e-mail communication with patients allows more time for meaningful communication," he said.

"In my opinion it will save us in the future 1-2 hours a day because of the simple fact that one third of our face-to-face consultations are, in using the e-mail communication, not necessary anymore."

E-Health Insider invites readers views on whether email has an important role to play in doctor-patient commenications. Can it, with the right safegaurds in place, offer valuable benefits?