E-Mail Between Physicians and Patients: Current Concepts and a Review of the Guidelines
Keeping in touch with patients using e-mail can be a powerful health care tool, but be aware of confidentiality issues.
By Michael A. Becker, DO, MS
Health care policymakers have called on the health care community to improve the quality of care of our United States citizens with chronic medical conditions. In 2001, the Institutes of Medicine (IOM), highlighted its vision for quality improvements in Crossing the Quality Chasm.(1) In the report, the IOM wrote that enhanced patient and clinician communications was one of five key areas in the way information technology could contribute to an improved health care delivery system, and specifically stated that access to care should be provided over the Internet, by telephone and via e-mail communication.(4)
The IOM further identified such needs in its report of 2003, titled Priority Areas for National Action.(1) As the U.S. population ages, it is imperative that new approaches toward care of patients with chronic conditions, rather than acute episodic care, are taken. The Chronic Care Model (CCM) of Wagner, et al, is the most widely-accepted model for such a transformed approach.(1)
Six elements comprise the CCM:
Better functional and clinical outcomes can be supported by effective interactions between proactive practice teams and informed, activated patients by using the six elements of CCM.(1) Electronic mail (e-mail) between physician and patient can be a major factor in communication improvements. Thus, e-mail may facilitate improved approaches toward patients having chronic diseases.
The E-Mail Phenomenon
The Miniwatts Marketing Group, of Bogota, Columbia reported that approximately 205 million U.S. citizens, or 68 percent of all Americans, were Internet users as of March 31, 2006. The U.S. Internet use is listed at the top of all countries globally; 20.1 percent of all world-wide Internet use is produced in
our country.(12) One study stated
that 85 percent of its sample physicians had high-speed Internet access, and this finding was similar to other U.S. surveys.(5)
While e-mail has exploded as a prime vehicle of human communication in the 21st century, electronic mail within the doctor-patient relationship has been slowly adopted.(6) Brooks and Menachemi described the current climate for e-mail between physician and patient to be “…on the uphill slope of the adoption curve.”(5)
Ray Tomlinson is credited for the first e-mail message, sent in October 1971. He was the engineer who first used the “@” symbol, and also wrote the software to produce e-mail.(14, 15) The American Medical Informatics Association (AMIA) has defined patient-provider electronic mail as computer-based communication between clinicians and patients within a contractual relationship, in which the health care provider has taken on an explicit measure of responsibility for the patient’s care.(8)
E-mail, however, is not the only way patients and physicians can communicate electronically. Communicating through a secure Web site, rather than via e-mail, is said to be becoming more popular, and will likely replace e-mail in health care.(9) This second form of electronic communication is frequently seen in online banking and shopping sites.(3, 9)
With Web-based messaging, the patient enters a secure Web site of the medical practice and sends a message using an electronic form that the practice has developed.(9) The physician and staff managing the secure Web site are notified in their regular e-mail of messages on their Web site, and then post a reply on a site that can only be accessed by that patient.(9) The patient is notified of the practice’s message in his or her personal e-mail, and is directed toward a secure Web site to find the physician’s reply.
E-mail has been described as the oldest and still most common form of electronic communication between patients and physicians or their office staff.(9) A hybrid of letter writing and the spoken word, e-mail is more spontaneous than letter writing, and offers more permanence than oral conversations.(8) It has many advantages for both patients and the physicians. The two main advantages of regular e-mail for patients are its simple use and its cost-effectiveness.(9) The unstructured format of e-mail allows patients to freely express themselves, affording them the free expression to reveal an important health matter that they may fear to discuss directly with the physician.(9)
Patients also appreciate the efficiency in communicating with physicians and their office staffs via e-mail. E-mail prevents the “telephone tag” quandary, and assists in preventing lost messages to doctors by their front desk staff.(7, 8) E-mail is especially useful for providing a written record of much information that physicians traditionally give orally.(10) The benefits for patients using e-mail include:
Primary care patients who had Internet access were surveyed in one study, and more than 80 percent of those responding wanted to communicate with their physicians via e-mail. Despite their desire, however, only six percent of those patients in the study had ever used e-mail to communicate with their health care provider.(7)
Advantages and Barriers
in Using E-Mail
There are many advantages
for physicians in using e-mail to communicate with their patients.
E-mail use by physicians allows for follow-up patient care and clarification of the verbal advice that was given to patients in the office setting. Instructions on how to apply dressings, or even pre- and post-operative instructions, can be given to patients via e-mail.(10)
Electronic communication can lead to increased practice efficiency, lower overhead, better patient satisfaction and improved quality of care.(9) By embedding “live” universal resources locator (URL) links within e-mail messages, physicians can enhance the education of patients regarding their disease or treatment.(10)
The literature reports many barriers for physicians in using electronic communication with their patients. One common barrier is time demands.(4, 5, 6, 7, 9, 11, 13) Using valuable patient time to answer e-mail messages can be frustrating and wasteful, especially if other communication modes, such as telephone calls and postal mail, aren’t eliminated. Family physicians are continually challenged with productivity issues; one more task may decrease the number of patient visits on a spreadsheet.
Reimbursement concerns are also described in the literature.(3, 4, 6, 9)
Like telephone calls, physicians are generally not reimbursed by insurance companies for e-mail replies. While there have been a few reports of some doctors receiving $25 per “episode” of e-mail (an “episode” can involve more than one e-mail from a patient),(11) physicians resent more “free work.”
Another barrier to utilizing e-mail in physician – patient communication is cost. The purchase and maintenance of encryption software can add staggering expenses for practices, already burdened by increasing overhead and diminishing insurance reimbursement.(5, 7, 9)
Although e-mail communication is not prohibited by the Health Insurance Portability and Accountability Act (HIPAA), physicians worry about privacy and security issues with e-mail.(5, 9) Another significant barrier is the legal and quality concerns involving inappropriate or urgent content issues by patients.(5, 7) A subgroup of one study demonstrated that 21 percent of patients used e-mail to communicate urgent matters such as chest pain or suicidal ideations to their physicians.(7) Physicians may not check their e-mail for days, and those patients inappropriately using e-mail for urgent or significant conditions would not have these issues effectively managed in a timely manner. Serious morbidity and mortality could occur.
Physicians are also concerned regarding the potential of overuse of e-mails by patients.(7) Lastly, the uncertainty of involving other office staff within the electronic communication between patient and physician is a potential barrier to use of e-mail.(7)
Some of these barriers can be overcome by physicians utilizing published guidelines for electronic communication between physician and patient. The purpose of the guidelines, first published by the AMIA in 1998, and last updated in December 2004 by the American Medical Association (AMA), was to guide clinicians in the use of e-mail so that it would enhance the value of the physician-patient relationship (Chart 1).(8) Two sets of guidelines have been published by both the AMIA and AMA: Communication Guidelines, and Medicolegal and Administrative Guidelines. It must be noted that these guidelines do not address electronic communication between physicians and consumers in which no ongoing professional relationship exists, such as an online discussion group or a public support forum.(8, 10)
Physician/Patient E-Mail Agreements
There are 15 medicolegal and administrative guidelines which have been proposed by both the AMIA and the AMA. First, a physician-patient agreement must be developed for an informed consent in the use of e-mail. As in all informed consents, patients should have the opportunity
to discuss the agreement with their physicians. Following complete understanding of this agreement, both patients and physicians should sign and date the document, and the agreement should be mentioned within the medical record. One copy should be given to patients for their use, while another copy should be included within the medical record.
The physician-patient agreement should contain the following:
If any patients desire to not have their e-mail exchanges encrypted, a waiver may be given by the practice. Security measures should be discussed with patients and listed within the patient-physician agreement.
Recommendations for security mechanisms include using a password-protected screen saver for all desktop workstations in every location that e-mail can be viewed, such as the office, hospital or home. E-mails should not to be forwarded to any third party without the patient’s expressed permission. Patients’ e-mail accounts must never be used in any marketing schemes, nor be shared with physicians’ family members.
Any patient’s identifiable information, social security numbers or birthdates must only be sent via encryption if the communication is wireless. Physicians should always double-check all “To” fields before sending any e-mail message. E-mail backups must be performed weekly onto long-term storage. Electronic long-term storage is equivalent to the same amount of time applicable to that of paper medical records. Policies for both medicolegal and administrative guidelines should be committed to a written document, and available in the practice’s policy and procedure manual.(8, 10)
Unfortunately, physicians have been very slow to adopt and use the published guidelines.(5) In the Brooks and Menachemi study, the e-mail patterns of more than 10,000 primary care physicians were examined. In this study, only seven percent of physicians were using the guidelines, and 1.6 percent had required their patients to abide by the guiding principles.(5)
In the same study, 6.7 percent of the physicians sampled required their patients to use at least one-half of the guidelines.(5) The patients were informed of the privacy issues involving their e-mails by 36.3 percent of the responding physicians,(5) and adherence to any one of the guideline items occurred in fewer than 25 percent of respondents. Most importantly, only 48 percent of the physicians using e-mail to communicate with their patients printed the e-mail and placed the communication into the medical chart.(5)
Conclusion
Despite many barriers, e-mail between physicians and patients is clearly here to stay. Electronic communication over a secure Web site may eventually replace physician-patient telephone communication in the future. The many advantages of e-mail improve the quality of care of all patients.
E-mail is potentially positioned to greatly advance the care for those patients with chronic conditions. With strict adherence to published guidelines by the AMA and AMIA, osteopathic family physicians will be better able to safely and effectively utilize e-mail to serve their patients long into the 21st century.
Michael A. Becker, DO, MS, is Residency Program Director at Mercy Suburban Hospital in Norristown, Pennsylvania.
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