This article outlines the growth of internet and email usage in relation to healthcare.
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article found under “related files”
Antonia Dean, BSc, DipOnc, Cert Counselling, is clinical nurse specialist (helpline and ‘ask the nurse’ email service), Breast Cancer Care.
Dean, A. (2008) Communicating with patients using email and the internet. This is an extended version of the article published in Nursing Times; 104: 7, 29-30.
This article outlines the growth of internet and email usage in relation to healthcare. It describes vital considerations for healthcare professionals when using email to communicate with patients, and discusses the advantages and disadvantages. It also outlines practical advice for nurses when using email.
Use of the internet is becoming increasingly common in modern society. Nearly 15 million households in the UK have access to the internet - around 61% of the population (National Statistics, 2007). Many people choose to search the internet for health information; the NHS, the voluntary sector and the private sector have all responded to this demand by creating a range of websites covering almost every aspect of health and disease. Along with this increase in internet usage, the popularity of email as a means of communication has also risen, and healthcare providers are beginning to experiment with its therapeutic potential.
Many charities provide a service that allows clients to email healthcare questions to teams of specially trained nurses or information workers (for example, Breast Cancer Care, Cancerbackup and Asthma UK). NHS Direct also has an email service that will respond to queries about specific health conditions, treatments or NHS services (NHS Direct, 2008). Some healthcare settings are using email as a device to remind patients of appointments, or as a method of reinforcing health promotion advice (Thomas and Shaikh, 2007).
It is not clear how many doctors and nurses working in face-to-face clinical practice are using email to communicate with patients. While research in this area is mainly from the US, evidence suggests that patients would welcome it as a means of communication with healthcare professionals (Sittig et al, 2001). Modern nurses may – either now or in the future – need to develop skills in using email so that they can maximise the benefits and minimise the potential pitfalls of conversing with patients in this way.
Nurses have a duty to protect patients’ confidentiality by avoiding any inappropriate disclosure of patient information (NMC, 2004). Emails from patients should only be accessible to those directly involved either in patient care or in the running of the service itself. Patients’ details held on computer should be as carefully protected as written records, and it is important to ensure that the computer software used offers sufficient security (NMC, 2007). In addition, the email system software itself must be secure to avoid breaches of confidentiality when emails are sent. Practitioners must also ensure that if they choose to communicate via email, they comply with statutory regulations such as the Data Protection Act (1998) when storing emails or using patients’ contact details.
Healthcare professionals should always use a designated work email address rather than their own personal one to both protect confidentiality and maintain appropriate boundaries.
Practitioners are accountable for the information or advice they provide to patients, regardless of the method used to communicate it. To ensure that email content is clinically accurate and evidence-based, many organisations using email as a way of delivering healthcare information have a policy of peer review, which reduces the chance of clients receiving an email that may be misleading. Having clear organisational guidelines about the scope of email communication may also provide clinical staff with additional support and security.
Communicating by email can be time-consuming, and if peer review is also introduced, this increases the use of healthcare professionals’ time even further. Organisations will have to consider their resources before offering patients the opportunity to have email contact. However, as email can give people a permanent, written record, it may reduce repeat queries from patients who have forgotten or felt unsure about previous advice or information.
Advantages and disadvantages of using email
One of the main advantages of using email is the convenience it offers for both patients and practitioners. Emails can be written at any time of the day or night, potentially making it easier for those whose circumstances might make it difficult for them to consult with healthcare professionals during working hours. Those responding to the email can also do so in their own time, giving them space to research any difficult questions or consult with colleagues. However, because there will always be an element of time delay between sending an email and receiving a reply, this is not an appropriate way of dealing with any queries that are urgent or an emergency.
Email can be used by those living in remote communities or by those with a disability that may make attending face-to-face appointments difficult. It therefore has the possibility to increase access to healthcare for certain groups, although it has been noted that internet use is more common in younger people who may be wealthier. Delivering healthcare in this way may therefore widen certain social inequalities (Car and Sheikh, 2004). However, if other methods of reaching practitioners remain accessible, then providing the option of email purely increases patient choice.
The Department of Health’s (2004) white paper Choosing Health: Making Healthy Choices Easier recognised that today’s consumer society demands information from a variety of sources, including the internet. It also cited research on the significant number of adults in the UK lacking basic literacy skills. Communicating by email requires a level of literacy that may exclude some people from using the service. Healthcare professionals regularly involved in writing to patients may benefit from training to improve the ‘readability’ of their emails. It should also be noted that email use requires patients to be confident using computers, and a proportion of people neither possess a computer nor have experience of using email.
Since email provides clients with a written response, it allows them the opportunity of re-reading any information given. Numerous studies have looked at patient satisfaction and information needs following medical consultations. Hogbin and Fallowfield (1989) identified various reasons why patients may have unmet needs following hospital appointments. These included lack of time, poor communication skills by medical professionals and patients’ difficulty in remembering all the information. It can be difficult to absorb large amounts of information during a face-to-face consultation or phone call. Times of high emotional stress, such as receiving a diagnosis or bad news, might further reduce people’s capacity to retain information. Having an email to read in their own time and at their own pace may help patients to better understand aspects of their diagnosis or treatment. The opportunity for email contact may also allow patients to ask questions they may have forgotten or that only occur to them later as information about their condition is gradually assimilated.
When seeking information about a particular condition or health-related matter, many patients will now turn to the internet. While this can be both informative and empowering, the internet is a largely unregulated resource that has the potential to mislead people.
A recent study of patients attending outpatient departments at Nottingham City Hospital found that a large proportion used the internet for health matters, but over 80% of those with internet access would value internet information that had been validated (Ayantunde et al, 2007).
Anonymity of email
As will be discussed later, emails allow healthcare professionals to direct their patients to sources of information on the internet that they feel might be helpful and they judge to be accurate and appropriate.
One of the advantages of email is the potential for anonymous contact. While this may not be feasible for all healthcare settings, many voluntary sector organisations such as The Samaritans invite email contact from clients who are not required to supply their name or any personal details that might identify them apart from their email address. People often have personal or private concerns that they may feel uncomfortable about discussing in a face-to-face consultation. Email can be a ‘safe’ way of talking to someone about such concerns.
It might also give people the confidence to seek help about something they were previously unwilling to ask about, perhaps due to embarrassment that they may be ‘wasting the doctor’s time’. A recent large-scale study looking at erectile dysfunction in men found that providing written information increased the likelihood that participants would seek help from a doctor (G et al, 2007).
There is evidence to suggest that email might fulfil a similar function. A survey of Breast Cancer Care’s email service found that a significant number of participants (16%) reported using the service when deciding whether or not to consult a doctor about a breast problem, seeking validation for their concerns (Leadbeater, 2005). This suggests that email contact with healthcare professionals may also empower people to take positive steps in managing their own health.
Communicating remotely does mean that physical examination is not possible. Inherently, there may therefore be some questions raised by patients that are impossible to answer fully. However, an email in reply to such questions, encouraging clients to arrange a face-to-face consultation, might reinforce the need to have certain symptoms diagnosed and possibly treated.
Communication skills using email
There is very little published guidance to help healthcare professionals develop skills in using email to communicate with patients. As previously mentioned, NHS Direct and the many charitable organisations that offer a helpline service also now have an email service. The Telephone Helplines Association, which sets standards for good helpline practice, has also published directions for organisations using email and text services, although this is not specific to a healthcare setting (THA, 2006).
While the tone and style of the email may vary depending on its purpose (for example, an email reminder to attend an appointment compared with an email providing emotional support), there are some style and language considerations that remain consistent. It is important to use language that is easy to understand and does not contain inappropriate medical jargon, abbreviations or acronyms that the recipient may not be aware of (Redfern Jones, 2006). Since it can be difficult to read from a computer screen, it may also be helpful to keep sentences and paragraphs as short as possible.
To help patients feel that their concerns have been understood and addressed, it is possible to apply some basic counselling skills to email communication. This can include acknowledging their concerns by reflecting any emotions patients express. It can be difficult to communicate warmth and empathy via email. Unlike face-to-face communication, tone of voice, eye contact, facial expression, touch and gestures cannot be used to convey emotion, so language – and the way it is used – becomes especially important. As email is often used as a brief, more informal method of communication, it is easy for the response to a patient’s question to come across as stark or uncaring. It is therefore crucial to ensure that phrasing is as sensitive as possible, and that patients are aware of where further support might be obtained. It can be helpful to avoid making assumptions by matching language to the client, using words of a similar weight. For example, if a patient says they are ‘enraged’ by their circumstances, acknowledge that they are ‘very angry’. If they said they were ‘annoyed’ about something, nurses might want to acknowledge their ‘frustration’.
Other counselling and listening skills used in face-to-face encounters, such as paraphrasing and summarising, can be used with email. These skills are helpful in demonstrating understanding, providing focus and giving a framework to the email, while dealing with patients’ concerns in a systematic way. When dealing with an email that is lengthy and descriptive, it may be possible to condense the issues and deal with them in a more structured manner.
It is also possible to take cues from patients’ emails about the best way to respond. If the email is full of medical detail and displays a high level of knowledge, then it seems reasonable to infer that they would prefer a reply containing a similar level of detail. Another patient’s email may display less understanding or a level of confusion that would suggest that a simpler reply might be more appropriate.
Uniform resource locator (URL) links to other sources of information on the internet can be provided. This is a useful way of allowing patients to choose if they would like additional detail on a particular subject. It is also helpful for signposting clients to other services or organisations they may benefit from. It is worth bearing in mind, however, that the content of a webpage may be altered from time to time, so it is good practice to check that any links remain relevant and up-to-date.
Patients’ expectations of the service can be managed from the start by informing them of how long they may have to wait for a reply. If a swift response is not possible, it might be useful to provide patients with an alternative method of contact. The charity Breast Cancer Care’s ‘Ask the nurse’ email service informs people via an automated response that their email has been received and will be answered in the next five working days. It also provides details of their freephone helpline in case clients would prefer to have their question addressed earlier (Breast Cancer Care, 2008).
Implications for practice
- As the popularity of the internet and email grows, patients may increasingly expect to use this as a method of communication with healthcare professionals;
- Using email has implications for confidentiality, resources and accountability which need to be carefully considered when designing email services for healthcare settings;
- Patients may benefit from the convenience and accessibility of email, which may ultimately empower them in terms of their own health;
- A range of methods for communicating with healthcare professionals must always be available to meet the needs of patients who lack access to computers or computer skills or general literacy;
- Training may be beneficial before communicating with patients by email in order to develop a style of writing which is clear, easy to read, informative and empathetic.
Communicating with patients using email has many advantages, including the flexibility it offers people who may otherwise find it difficult to discuss health matters during office hours. While other methods of contacting healthcare professionals must be made available to meet the public’s varying needs, email may provide a valuable tool for many people seeking to understand more about their health, illness or treatment. There are many considerations when offering email as an option to clients, such as staff training, choosing appropriate software and policies to support staff and ensure patients receive a high-quality service.
Ayantunde, A.A. et al (2007) A survey of patient satisfaction and use of the internet for health information. International Journal of Clinical Practice; 61: 3, 458–462.
Breast Cancer Care (2008) Support for You: Ask the Nurse Email Service. www.breastcancercare.org.uk/content.php?page_id=119
Car, J., Sheikh, A. (2004) Email consultations in health care: 1 - scope and effectiveness. British Medical Journal; 329: 435–438.
Data Protection Act (1998) London: Office of Public Sector Information. www.opsi.gov.uk/acts/acts1998/19980029.htm
Department of Health (2004) Choosing Health: Making Healthy Choices Easier. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4094550
G, C. et al (2007) Can written information material help to increase treatment motivation in patients with erectile dysfunction? A survey of 1188 men. International Journal of Impotence Research; 19: 3, 330–335.
Hogbin, B., Fallowfield, L.J. (1989) Getting it taped: The ‘bad news’ consultation with cancer patients. British Journal of Hospital Medicine; 41: 4, 330–333.
Leadbeater, M. (2005) A nurse-led email service for breast cancer information. Nursing Times; 101: 39, 38–40.
National Statistics (2007) Internet Access. www.statistics.gov.uk/CCI/nugget.asp?ID=8&Pos=&ColRank=1&Rank=374
NHS Direct (2008) Send a Health Enquiry. www.nhsdirect.nhs.uk/enquiry/?WT.svl=nav
NMC (2007) NMC Record Keeping Guidance. www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=3170
NMC (2004) Code of Professional Conduct: Standards for Conduct, Performance and Ethics. www.nmc-uk.org/aDisplayDocument.aspx?DocumentID=201
Redfern Jones, J. (2006) Sending the right message. Nursing Standard; 20: 41, 72.
Sittig, D.F. et al (2001) A survey of patient provider e-mail communication: what do patients think? International Journal of Medical Information; 61: 71–80.
Telephone Helplines Association (2006) Telephone Helplines - Using Email and Text Services: Guidelines for good practice. London: THA.
Thomas, J.R., Shaikh, U. (2007) Electronic communication with patients for breastfeeding support. Journal of Human Lactation; 23: 3, 275–279.