“Can you just text it to me?”
My patient was awaiting the results of her urinalysis, but couldn’t stay in the emergency department any longer; she needed to pick up her kids. I had offered to send the results to her doctor, but she wanted them immediately and directly. I hesitated, conflicted.
The request was both reasonable and, from my perspective as a busy emergency department (ED) physician, persuasive. Many tests I order—such as those looking for strep throat, flu, STDs, or, as with this patient, UTIs—can take hours to come back, are often perfectly normal, and if abnormal, may only necessitate a prescription that can be called in to a pharmacy just as well as handed over in person. Sending a patient home to await results is more comfortable and convenient for them, and allows me to open up an ED bed and see other patients in the meantime.
When I was a medical student rotating in a busy urban ED, things ground to a halt overnight. Attending physicians would leisurely conduct teaching rounds or, occasionally, even slip away for a nap. By the time I became an attending myself in the same ED, there was constant bustle, with the waiting room rarely empty, day or night—a trend that is mirrored nationally. And it’s not just EDs that are busier than ever, in the primary care setting, office appointments are jam-packed with “recommended” actions: simply completing preventive care would occupy seven hours of a physician’s workday, and that doesn’t count the time it takes to address why patients came in to begin with. Here, too, digital communication offers a way to increase efficiency and maximize the office visit.
But if communicating the outcome of routine medical tests seems relatively straightforward, offering results about serious or even terminal diseases via digital technologies is an altogether different proposition. Such diagnoses must be accompanied by reassurance, prognostic information and a treatment plan. If the news is that weighty or complex, however, shouldn’t the whole conversation be had in person? Or have we arrived at an age when everything—even professional sympathy and support—can be conveyed electronically? I’m SO sorry, but your HIV test came back positive. TTYL.
Digital communication also raises issues about safety and privacy. If my patient is feeling suicidal or experiencing severe violence, this information has no business sitting unread in an email inbox. Yet we have few safeguards in place to ensure that urgent messages are not left to languish if I’m on vacation, sleeping or, God forbid, simply behind on my email. And although “secure messaging” and “encryption” are reassuring terms, privacy concerns are not solved by technology. Many computers store histories of websites and automatically fill in passwords. And routine text messaging (i.e., without a third party program to provide extra security) generally does not meet requirements for Health Insurance Portability and Accountability Act (HIPAA)-compliant electronic communications (ultimately why I did not text my patient her urinalysis results). Who, if anyone, is teaching patients—or, for that matter, their healthcare providers—how to keep health information secure?
People want greater contact with their doctors, and doctors pine for the kind of unpressured, face-to-face time that used to characterize healthcare visits. But patients and physicians are driven apart by a wedge of productivity demands, administrative obligations, and regulatory requirements. Technology-based communication is a tantalizing solution to this human divide. Patients are increasingly being offered online portals where they can look up their own lab results, request prescription refills, schedule future appointments, ask questions of their doctor, and otherwise virtually extend their healthcare visits.
However, digital communication may not improve the deficit in patient-physician interaction, and might even worsen it if just piled on to the workload. Mandates for healthcare improvements like better communication rarely come with the increased workforce, equipment, or funds to fully support them; thus, tasks required of physicians have the tendency to exceed the time needed to complete them in real life without neglecting something. A friend recently told me about her first colonoscopy. When she was wheeled into the room, she found the gastroenterologist sitting at a computer, absorbed in email. Perhaps he was answering messages to other patients, my friend thought, feeling magnanimous. But as the minutes stretched on and she lay unacknowledged on the cold stretcher, she began to suspect that other patients’ needs were superseding her own.
My own wariness about digital health comes from the way it has disrupted (in the negative sense) the tidy compartments of my work and home life. My ED shifts might be 10 hours without food or bathroom breaks, but afterward I used to be able to switch my attention completely to my family. Now I can pull up medical charts on my laptop and finish my notes on patient care at home for hours after my shift is technically over. And it’s not just the extra time; it’s the lack of privacy and personal space. For a while, I maintained two cell phones and three email accounts to separate the personal and professional. Chaos ensued, forcing me to abandon the practice.
Although the bugs remain to be worked out, what is clear is that digital communication is becoming a standard feature of the healthcare landscape: a recent study showed that a fifth of patients in a large health system enrolled in an online portal, with emails between patients and physicians tripling over the 10-year study period. Emails and web portals have been shown to improve control of chronic diseases, adherence to medical advice, and patient satisfaction with their care. When e-health works, it works well, and meaningfully.
During my last pregnancy, my obstetrician gave me her email so I could contact her directly. I found myself scrambling to find it when a routine third trimester ultrasound showed that one of my twins’ estimated birth weight had slipped below the tenth percentile. My head spinning with what this might mean (insufficient blood flow to the placenta) and the worst potential outcome (fetal demise), I had forgotten to ask a practical and pressing question: Was it safe to continue working? I shot off a message. Later that evening, she wrote back: “You can still keep up a moderate level of activity. Let’s not get overly worried until your next visit. If you still want to talk, I’m in the office Tuesday.” Timely information, quick reassurance, a route back to see her in person. It was digital communication at its best: a tool used to enhance, rather than replace, compassionate patient care.