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MedEconomics: E-consulting 'will be normal practice'

Patients do not always have to be physically present to be treated, says Jane Feinman.

Mr A wants reassurance that persistent symptoms caused by 'a bad pint' could safely be treated with Imodium. Miss B is seeking an assessment of her risk of breast cancer after a great aunt has been diagnosed with the disease, while Mrs C needs to discuss the pros and cons of a proposed laser treatment for 'glare' in her eye.

Scenarios like these, from research into email consultations at Edinburgh University, are all part of the rich tapestry of a day's consulting for the average GP. But in the cyber-age, do these, and hundreds of thousands of people like them, really have to be physically present at the surgery?

Like everyone else, many GPs use the internet for banking, buying on line and personal and business correspondence. They habitually talk to their colleagues, their practice staff and hospital specialists using email.

Email consultations

While most GPs are aware of the potential benefits of the NHS 'electronic highway' for safe, effective communication throughout the NHS, there is less enthusiasm for advising patients by email.

The e-consultation has been around for nearly 10 years and is widely used in the US, Australia and Europe. Yet it still causes deep anxiety within the profession in the UK. The BMA issued extremely cautious guidance on the subject four years ago and has not returned to the subject since.

The RCGP recommends that GPs persist with face-to-face consultations because they provide all-important non-verbal cues. There are concerns about confidentiality, security and exclusion of those who are IT illiterate.

Hand in hand with this is a general acknowledgement that email consultations might have to happen at some point but that, when they do, they will add rather than subtract from workload.

Yet evidence to support these concerns is lacking. The first double blind randomised trial of e-consulting is receiving final approval at Edinburgh University's eHealth Research Network. However, studies suggest clear benefits in email consultations particularly for following up chronic problems and for providing reassurance.

Patient satisfaction

While many patients prefer to see a doctor, that is less true of the young, the healthy and the better educated.

Out of 150 patients aged between 20 and 85, who accepted an offer of an email consultation at Westgate Health Centre, near Edinburgh, all reported satisfaction with the service they received.

Dr Ron Neville, a GP at the practice and lead author of the study, which was published in Informatics in Primary Care in December 2004, reported three main types of email requests. The first two were administrative, which take only a few seconds to deal with, and medication-related that can be dealt with equally swiftly but 'can be tedious if dealt with by telephone'.

The third category, clinical enquiries, 'the most interesting to deal with', varied from fears about cancer to advice on how to self-medicate.

Overall, the study found that e-consultations saved time, taking two minutes on average. This finding has been replicated elsewhere. There are estimates that e-consulting could save GPs one to two hours every day as one in three consultations would no longer be necessary.

Reducing pressures

'Considering the time they save patients, there will be relentless pressure on practices to respond to patient demand for email access for booking appointments, ordering prescriptions and asking for advice,' says Dr Neville.

Where e-consultations are routine, they appear to work safely and effectively.

Some private doctors are already predicting that the 'bedside manner' is on the way out.

'Unless there is a need for a physical examination, there's no real benefit in doctor and patient being in the same room,' says Dr Julian Eden of e-med.co.uk. The online 'doctor's surgery' charges £20 joining fee and £15 per consul- tation, including emailing a prescription to a local chemist and claims to have performed over half a million e-consultations since it was set up four years ago.

So far, however, there is little public demand or GP enthusiasm within the NHS. EMIS, the primary care computing company, already offers free software that allows patients to make appointments and order repeat prescriptions online, using a PIN number and, where necessary, an extra 'strong authentication' with a key-ring token, with plans for secure e-consultation software in the pipeline.

However, only 500 of their 5,000 subscribers have so far taken up the offer and with only another 50 or so signing up each month, 'it will be at least five years before e-consulting becomes routine,' says Dr David Stables, medical director of EMIS. 'But it will happen.'

- To contact Edinburgh ehealth Research Network, email claudia.pagliari@ed.ac.uk

CASE STUDY - 'E-consultations work'

Dr Richard Fitton, of the Hadfield Medical Centre in Glossop, Derbyshire, said it was becoming commonplace for patients to test their own blood pressure and blood sugar.

Patients enter the results on to their own records that they access at home. They then decide whether and how they wish to consult their GP.

'We give volunteers access to their own records on the internet. Nearly all our chronic patients have expressed an interest in consulting by email and I don't think they're unusual,' he says.

Dr Fitton acknowledges that security and confidentiality constitute a hurdle for e-consultations - but only because NHS national standards have not been set.

'As retail and banking have shown, it's not difficult to make email secure,' he said. 'My concern is that confidentiality is being used as a sword against patients for the convenience of doctors. There is no need for patients to be physically present and it's often more useful for them to be able to consult me and their records from the comfort of their homes.'



- Allows an exact record of the dialogue between doctor and patient to be kept.

- Might save time for doctor and certainly saves time for patient.

- Allows doctors to consult with colleagues or textbooks to provide a more considered response along with attachments and web-links that can be used to disseminate information.

- Means that patients are less likely to consult irresponsible or inaccurate internet sites.


- Prevents the doctor from seeing body language and other non-verbal cues.

- Potentially allows someone other than the patient to make the consultation.

- Difficult to authenticate the email address.

- Might provide extra work for the GP, which might not attract a fee.

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