Email Consultations
Introduction
Emails have become an essential method of communicating for the last 40 years and ubiquitous for at least the last 10 years. Every business you can think of uses emails. So why is primary care so far behind?
Talking about the service especially to our younger cohort it's become clear that there is an expectation for us to be able to communicate this way with lots of patients being pleasantly surprised or just saying why we didn't do it sooner.
The problem is patients ring their GP surgery which is invariably engaged in the morning just to get on the queue for us to ring them back. Then when the GP rings back, and the patient isn't available and you can play a frustrating game of phone tennis. If you miss them, they ring back just to get on the queue again. Very frustrating and you can end up with a non contact thus missing a diagnosis or the patient going to other health care providers eg A+E to get their health worries addressed.
In our surgery, we've been piloting a system to allow patients to have direct contact with their GP via email without using online consultations for the last 4 months. This Blog is initial thoughts and the pros and cons of using this system.
Information Governance
The biggest question myself and I'm sure you would be asking is around information governance and confidentiality of the email sent and received. We've worked with our local GDPR representative on the back end of an email they sent explaining the current stance around communication via unsecure email with your patients and visa versa.
This is a quote from this email from Miles Dagnall (thank you Miles), our independent Sutton Data Protection Officer
"In situations where there is a conflict between the principles of providing care and controlling data, the provision of care must take priority. Having said that, the practice needs to minimise the risk to data and systems integrity wherever practically possible.
Practices can do this by telling patients about the system and begin to make this the norm for communicating with the patient, explaining that this keeps their data secure.
If decrypting the email remains impractical when communicating with patients, practices should preferably respond to an email received from the patient within the practice e-mail system. If that is not available then the practice should check with the patient verbally where possible that the e-mail details on the patient record are correct and to use those."
The bottom line is that so long as you are sure the email you are sending will be sent to the expected individual, provision of care is the over ridding principle. In our system, we wait for the patient to contact us so we know that the reply will go to the correct inbox.
BTW if you did want to send a secure email to a patient, it's easy: just type the word [secure] in the 1st word of the header of the email and it will send the email securely asking for the recipient to log into a secure web page location to retrieve this.
We offer secure emails to patients but not one has taken us up on this offer so far!
So we work on an implied consent model. We text the patient to show them the link explaining the system and when they have read it (based on trust) and are happy they can use the email service. Our standard text message is as follows
By receiving this text you are happy to send/receive emails and have read the information on our webpage link which is: http://www.parkroadcentre.co.uk/?page_id=317 This service will only be monitored from 8 am to 12.30pm weekdays. If it is more urgent please contact us directly on 0208-647-4485 or dial 111 outside our normal working hours of 8am-6.30pm. If your condition is very urgent or life threatening dial 999. This email is not for prescriptions or appointments. You can email us on mysurgerysemail@nhs.net
Workflow
Below is a self explanatory flow diagram of the current model. We state to patients that we will reply for the next working day from 8am-12pm to manage expectations but we tend to reply when we have the time. We are also clear in saying that we do not manage urgent conditions and they need to contact us directly or ring 111 for this.
The above is a workflow example of how to manage communication when the patient rings. However once the patients has the email, they don't need to go through this system and they can email us directly.
Once the email thread is complete the GP either copies and pastes or types up a summary of the email consultation in the notes. We also add the code 9N3B (E-mail received from patient) in the consultation. BTW, in the consultations tab of EMIS there is an option called CR Config. From here you can add a Consultation Type and name it "Email Consultation".
Microsoft Outlook
We use outlook as the operational software to manage messages. Since this is normally installed in each users machine, installation was not a problem. Otherwise a few points
Each doctor has a category (Categorize in the Home Tab) which is colour coded. Once an email has been allocated, their name is tagged in the category and their colour appears next to their email. In our surgery the most senior clinician does this but in larger surgeries there is no reason why this can’t be taken over by a senior administrator.
We work on a Zero Inbox policy so as soon as a message is completed we move the email trail to Archive. This way we are aware of outstanding emails.
Occasionally we found a few emails in the Junk mail so look out for this. You can disable Junk Filtering by right clicking on the junk folder and choose junk mail options
You need to sort out the email via conversation and also group them with the newest on top them otherwise the email thread may appear as separate entries which can be confusing. See this screenshot
online TRIAGE SERVICES
This Blog isn't about comparing this method to Online consultations such as DrLink, AskmyGP or eConsult and at the moment we don't have the data to see if email consultations actually improve access. In our workflow we have provisions for online consultation document which points to the surgery email to be triaged accordingly.
I can imagine though it can be frustrating for patients who want to talk to a real person having to go through an algorithm to achieve this, similar to us trying to talk to a big company on the phone for support and having go through reams of options on the number keypad before being told they have to talk to a real person or being pointed to a web page to manage the problem themselves.
Managing different sources
One concern raised is that you are introducing yet another form of communication with the patient. I've put together a table around initial thoughts of each method.
It's a matter of fitting the right consultation in the right place and more importantly trying to avoid overlap which creates inefficiencies eg an email consultation leading to a telephone consultation which leads to a face to face taking up "3 slots" when it could have been managed with one.
We've found that with email, replying back to change the type of communication is as simple as "see me in clinic". With a telephone triage it can take as long as a face to face to achieve the same result.
The other issue is having direct contact with the GP which is lovely for the patient but potentially an issue as systems are in place normally to protect this so GPs can make appropriate use of their time. Reception normally manages the telephone and a triage GP manages face to face.
Here is a summary of my thoughts about each form of communication
Face to Face
Pros - Human Interaction | Examination
Cons - Patient Travel | F2F often not required
Telephone
Pros - Most Convenient Method
Cons - Unable to Examine | Missed Contact
Pros - Contact not missed | Convenient
Cons - Unable to Examine | Direct GP Access
Every day your patient population generates work passively by contacting you and actively by your surgery recall. Your job is to ensure you have the capacity to manage this to maintain the health of your population. My hope is that email with help manage this rather than generate more passive work!
What we can't do
We encourage patients not to use this service to get an appointment or for a repeat prescription and if emailed about this we direct them to other apps which can do this or ring at reception. It's actually more obvious that you would realise around what needs to be seen face to face. I've had patients who have asked me to look at a skin lesion and one patient asked for an alcohol detox via email! I kindly directed them to book an appointment for a face to face.
Worry of Litigation
We discussed the concept of emails consultations in a small group discussion recently with other GPs and the worry about ligation came up. I remember the time when we shunned telephone consultations and the medico-legal issues this would create but now it's accepted as the norm. I believe this is the way emails are travelling in as a communication form.
One could argue that emails are better as documenting conversations than face to face or telephone as frequently we have to interpret patients communication which can lead to disputes between what the patient thought of the consultation vs what the GP typed. With email it's black and white and in theory would be safer so long as you have the appropriate safety netting.
Dr Google and EMail length
The dreaded Dr Google and this now famous meme which I think is very arrogant.
I actually don't mind patients looking up their condition and coming to us about it and am the first to say I don't know. As GPs we can't expect to know everything and from how I've approached this method, patients do understand. But what Dr Google does show is that patients have a vested interested in their condition so it's easier to work with them to find a treatment but more importantly compliance goes up.
Where I do have an issue with Dr Google is in educating the patient on, in essence, what we learn with experience and that is
Common things are common!
Just like a junior med student it's important to go through common causes of their symptoms first before exploring the exotic which tends to come on the top of search results or the diagnoses they worry the most about.
So why mention Dr Google? I've found the quality of the conversation between myself and the patient is exponentially better than face to face or telephone where the patient has to reply on the fly as do you. With emails they can compose their thoughts and write to you clearly. You can then compose your thoughts and write back to them. Both can use Dr Google or NICE guidance to check up on, which just isn't possible face to face or on telephone. So in my opinion.
The quality of the communication improves with email.
We frequently get emails of epic proportions which was another potential issue with were worried about. From my experience you can quickly scan these emails to their essence and also have lots of text to look back to if you need to get a recap on their symptoms. As we are so busy my patients appreciate that our replies are short and to the point. We don't have to and actually can't reply back in length.
Scalable?
Our surgery is 4300 so it's not a big surgery. The question is if it is scalable to larger sites. I'm afraid I don't know the answer to this but am currently proposing this method to local surgeries who have a larger population based on the above workflow.
Does it ACtually Improve Access?
The million dollar question.
With regard to access. We haven't as yet promoted this feature to all our patients and have just been trialling it in our surgery on an ad hoc basis for the last few months which is in the region of 40-50. Anecdotally it seems to improve access at the moment but need to do proper analysis to see if it helps with face to face once we release it to all our population and promote it. Will feed back findings here.
Where it has without doubt improved is in patient care. Patients who use the service love it and get their issues resolved quicker and better from their point of view.
Some quotes from our survey although this population is probably rather biased!
No the service is brilliant! Very Happy!
No. It’s beyond perfect!
Nothing at the moment. I am impressed by the response time
One offset we also have is that where a patient would normally try to work out how to manage themselves if they have easy access to GPs via emails they might overuse the system. So far we have had a small number of emails where we've wondered why they emailed us but to be honest these are the easiest to reply to!
Summary
Email consultations have the potential of transforming how we communicate with the patient. There is no doubt it is patient-centric and panders to their needs but will it be a win also for the GP to help access?
At the moment I believe it will help access and improve efficiency but instead of having 10 minute face to face consultations, we will have shorter more rapid dialogues with patients. The ultimate aim is to prevent overlap of communication as mentioned above. Overlap introduces inefficiencies in the surgery appointment workflow where we spend 20 minutes with a patient who we phone and see rather than just 10 minutes face to face.
Enclosed are my summary of pros and cons
Pros
Extremely Patient-Centric. Younger patients have an expectation to want to be able to contact their GP this way
Might pick up on patients who wouldn't normally contact their GP via other methods
Will help patient population health and won't miss as many missed contacts
Quality of the conversation improves
Has potential to help access and reduce inefficiencies.
Cons
Extra avenue of contact to manage in our regular workflow
Will it increase workload?
Will need buy in from all the GPs for the system to work
Direct access to GPs might open up the system being overused by patients for matters they can easily manage themselves
Watch this space!