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The clinical email explosion. (Health Care Meets E-Commerce).

KEY CONCEPTS

* Clinical Email

* Physician-Patient Communication

* Changing Physician-Patient Relationship

* Legal and Ethical Considerations

* Patient Confidentiality

* Informed Consent

SUCCESSFUL COMMUNICATION between patients and physicians is a key factor in providing quality health care and increasing patient compliance with therapeutic recommendations and interventions. (1) In recent years. it has become apparent that successful patient-physician communication is not limited to face-to-face contact. Fifteen percent of all ambulatory medical contacts are made by telephone. (2) Moreover, about 70 percent of medical problem-related telephone calls can be adequately managed on the telephone without the physician seeing the patient. (3)

The computer, like the telephone, is transforming patient-physician communication. Electronic mail (email) is a relatively new form of communication that uses computers to relay messages nearly instantaneously from sender to receiver. Despite its infancy, physicians have already found use for it in physician-to-physician consultation, medical journal dissemination, and hospital-physician communication. (4)

Kane (5) defines patient-provider electronic mail as a 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 client's care. This does not include communication between providers and consumers in which no contractual relationship exists, as in an online discussion group in a public support forum.

Communications in health care

With Internet access increasing to upward of 60 million people, its use in the health care context cannot be ignored. Technically minded, electronically equipped health care consumers have accelerated the demand for email to their health care providers. (6) The use of email has dramatically increased from 100,000 users in the late 1970s to about 50 million users in 1997 with more than 100 million users predicted this year. (7) This trend correlates with the advent of low-cost Internet access, mass-marketed online services, and employer-provider email accounts to an estimated 30 to 40 million employees.

Fridsma et al. (8) have suggested that many patients who go online are increasingly interested in exchanging email with their physicians. In their study at Stanford University, they documented that 46 percent of patients used email and of those 51 percent were interested in using it to communicate with the clinic. Mold documents that between 80 and 90 percent of people in Oklahoma would like to use email for communication with their family physicians. (8) In a 1996 survey, Brown found that patients ranked "information from my own doctor's office" as the type of online health information they desired most. (9) Katz reported that 70 percent of email users and nonusers said they would like to communicate with their health care provider via email. (10)

These trends reflect the experience of other professions and industries, where dramatic new consumer demand for electronic services has been viewed as a valuable market opportunity. Online brokers are competing successfully with traditional financial houses. Amazon.com and Barnes&Nobles.com are competing with brick-and-mortar booksellers. Email has become a ubiquitous tool for communicating with business associates, friends, and family. There should be little surprise that Net-savvy patients would like greater digital access to their physicians. Spielberg suggests that patients may turn to the Internet because there is something inherent in traditional office-based medical practice that leaves them "wanting more." (11)

Increasingly aware of patients' interest in electronic communication, most hospitals and insurers and some physician practices have established websites, many of which allow direct electronic contact with their offices. Yet in contrast to other industries, the medical profession has been slow to embrace email and the Internet as communication tools. (11) A 1998 survey indicated that 80 percent of physicians own a computer and 44 percent have accessed the Internet. Among physicians who have not yet accessed the Internet, two-thirds intend to do so soon. The overall result? More than 90 percent of physicians in the United States are online or intend to be online In the near future. (12)

However, in 1997 only about 1 to 2 percent of physicians offered patients this option to communicate with them. (13) A survey of 10,000 physicians released in May 1999 by Healtheon found that 33 percent had used email at some point to communicate with patients, a 200 percent jump over the year before. The share of doctors who use email with patients routinely is thought to be significantly smaller, and it certainly pales next to the 63 percent of doctors who use email on a daily basis for collegial consultation and business affairs. (14)

Unless you are contemplating imminent retirement, communicating via email with your patients is not a matter of if but when.

Nature of email communication

Email is a hybrid between letter writing and the spoken word. It is more spontaneous than letter writing and offers more permanence than conversations. Words in email can be more carefully chosen than in telephone conversations. While unencrypted electronic messages may, in theory, provide less privacy than postal mail or telephone calls, in practice email replaces and is used more like the telephone but with less urgency. Because of its asynchronous nature (volleying back and forth over hours or days), email helps prevent "telephone tag" and avoids the interruptions associated with telephone calls or electronic pages.

Unique advantages of email in the clinical setting include:

1. Routine transactions and patient education

Clinical email is ideal for simple and non-urgent problems, such as making appointments and managed care referrals, refilling prescriptions, and providing patient information. Patients can receive test results with interpretation and advice, information on how to take medications or apply dressings, pre- and post-operative instructions, as well as addresses and telephone numbers of facilities to which they are referred. Frequently used educational handouts can be ported to an emailer template or formatted for the provider's home page on the World Wide Web. (5)

Email messages can embed links to educational materials and other resources on the clinic's website or on external sites. In some electronic mail applications, clicking on a "live" universal resource locator (URL) link inside a mail message launches a web browser and takes the user directly to the indicated resource. Clinics can provide lists of URLs on a particular topic, such as pregnancy, and create email reply templates with pointers to frequently used reference sites. (5)

2. Increased efficiency

Email provides greater efficiency in the patient-physician communication. While telephone messages are often overlooked, forgotten, or lost under piles of charts, emails are less likely to fall through the cracks of a busy practice. Proponents praise email as an efficient means of communication that actually decreases time spent answering patient's questions by telephone." Practitioners who use email do not report a deluge of messages: rather, they appreciate the chance to respond to messages at their convenience and, in turn, report a greater sense of control of their time. Daniel Sands, MD, an internist in Boston and co-author of the AMIA guidelines on clinical email, says he averages about one patient-generated email per day on a patient load of 500. (15) One study indicated that patient-physician communication via email was perceived to increase speed, convenience, and access to medical care. (4)

Patients also value the time savings with clinical email. Roemer reports that patients find waiting for a return call from physicians to be particularly irksome. The patient may, in fact, be busier and harder to reach than their physician who usually is in only one or two places during the day and has staff to take messages. Many patients move around in their jobs, do not have access to telephone, have no privacy at work, or have no one to take messages. Those who have responsibility for the care of family members undoubtedly would find it useful to communicate with physicians via email. (16)

3. Self-documenting

Email is self-documenting--copies can be printed or attached to the patient's record (a paper copy for charts or electronically to electronic medical records). Some physicians point out that electronic communication enriches the medical record. Specifically, one physician notes that she has "documentation of the interaction.... that's often very difficult when you're taking calls on the fly." (17) The self-documenting nature of email should make it relatively easier for doctors to bill insurers for online consults. (15)

4. Cost-effective

Cost-effectiveness has also been advanced as a compelling incentive to use email. Not only might it save patients office visit time and co-payment cost, but it may also enable physicians to better manage their patients out of the office, filling additional time with more patients. Physicians may eventually be permitted to charge and be reimbursed for time spent attending to email consultations.

An increased use of email is predicted in the managed care setting, with the high volume of required referrals and approvals. Proper use of email provides more cost-effective management of capitated patients. (18) Email should have the most potential in capitated situations, where clear communication, timely intervention, and abundant information is often the key to preventing an expensive office visit or hospitalization. (15)

There is growing evidence to suggest that electronic resources, both email and Web-based self-help documents, will result in substantial cost savings to clinics. (5) Savings will result from a reduction in telephone tag and repetitious instructions. Many clinics, especially those with capitated plans, anticipate replacing inappropriate office visits with online support, including teleconferencing.

Consumer-driven demand is urging health care providers, both individuals and institutions, to establish a mechanism for email exchanges. Electronic access to a clinic's providers and educational resources is likely to be a market differentiator in the health care industry.

5. Clinical extender

Email is an ideal clinical extender. A widening gap is developing between the crucial need for transmitting more information and the relatively few and often brief face-to-face opportunities for communication between physicians and patients. Fax machines, voice mail, and email extends physicians' availability to their patients. Green, an academic family physician, noted that he sees patients 20 to 25 hours per week and with the use of email he is able to address many of his patients concerns without needing to see them. (18)

Unlike telephone conversations, which require both parties to be available at the same time, email, like voice mail and facsimile, is an asynchronous mode of communication, essentially creating continuous access to the health care system. By increasing opportunities for communication before and after visits, email might help optimize the value of personal encounters. (19)

Legal and ethical considerations

1. Confidentiality

Email, like other technologies such as fax machines and voice mail, can be misdirected, printed, intercepted, rerouted, and read by unintended recipients. Most importantly, it may be stored indefinitely, even after its user deletes a message.

Physicians must take reasonable precautions to avoid exposing patient-related email to unauthorized entities, Moreover, physicians should caution patients against using email for matters that they would not wish to be available to payers, employers, and others. Since physicians hold an exclusive duty to protect the confidentiality of patient information known only to them, patients may still reveal confidences in person "off the record. (11)

To ensure that patients' information is not accidentally exposed, physicians should use encryption when communicating with or about a patient by email, unless that option has been explicitly waived. Encryption authenticates the messages so there is no doubt over who the sender and recipient are. (11) Mandl outlines recommended procedures for encryption to authenticate the user's identity and to encrypt stored or communicated data to prevent unauthorized access. Although electronic communication must be protected from unauthorized interlopers, he notes most violations are committed by authenticated persons. (19) Physicians and health care providers should take precautions to avoid inadvertent forwarding, copying, and printing of email that would otherwise further endanger patient confidence.

2. Informed consent

Patients should be informed of the potential risks and benefits of using email. Although no law specifically addresses this, informed consent has been proposed for other aspects of telemedicine. Physicians need to discuss preferred communication methods with patients. (5) The consent form should reflect a variety of options. Patients should understand who in the office has access to the physician's email and be assured that all communication will be from that address.

Electronic communication should not compromise a physician's judgement about what Information is necessary to render an opinion or give advice. (11) just as practice standards evolved for telephone consultation, clinical email will be governed by evolving norms, particularly regarding expected response time, since a physician can be found negligent for failing to return a patient's telephone call within a reasonable amount of time. Physicians who are not prepared to respond to email regularly may decide not to offer it to their patients.

3. Licensing and jurisdictional issues

In the United States, a patient-physician relationship is established when a physician exercises independent medical judgement on the patient's behalf, whether explicitly or implicitly. One legal test of the relationship is embodied in the question of reliance: did the patient reasonably rely on the physician's judgement. Keeping in mind these precepts, physicians have the capacity to establish patient-physician relationships using email. (20)

Just as with telephone's introduction into medical practice, electronic communication raises a series of jurisdictional and licensing issues. When physicians transmit email messages across state lines to render medical advice, they may be unwittingly practicing medicine without a license. (21) Interstate consultation between physicians by email may not fall within this category, however many states require licensure before an out-of-state physician may render care to patients electronically.

Several recent legal cases have established that electronic communication is sufficient to establish jurisdiction. (22) However, this issue can get complicated. In a hypothetical case, Sabbatini and Kuppersmith described a psychiatrist in Canada counseling a patient in California by email. Suppose the patient commits suicide and the family wishes to sue the treating physician. Suppose the physician's mail server is located in Brazil and the patient's mail server is located in Indiana. Which locale has jurisdiction? Should the case be tried in California, Indiana, Canada, or Brazil? If the physician lives in Canada, he or she would have to incur significant expenses and opportunity costs to defend a case in a distant city. (22)

4. Medical websites

Physician practice websites not only provide information and communication linkages but also advertise services. They are more than simple business cards or practice brochures and may be construed as a form of advertising, subject to regulation. While physician advertising is regulated by state licensing agencies, maintaining a website may implicate other legal authorities, relating to interstate practice, misrepresentation, negligence, and even antikickback statutes." To protect the privacy of the unknown parties, websites should use secure servers that encrypt any messages transmitted from the site itself. Likewise, any sites that offer email addresses should contain a statement regarding security risks for visitors who might choose to use email at another time over another server. They should also delineate all potential uses of information collected about site visitors. (11)

Guidelines

The American Medical Informatics Association recently published guidelines for physician-patient email in the context of an established relationship. (5) Guidelines for using email in a clinical setting address two interrelated aspects: effective interaction between the clinician and patient and observing medicolegal prudence.

Summary of Communication Guidelines

* Discuss explicitly the use of email

* Establish turnaround time expectations for messages

* Inform patients about each person who may see the messages

* Discuss policies for managing messages at off-hour and vacation times

* Use an auto-reply feature and encourage patients to do the same

* Tell patients to avoid email for urgent matters

* Establish the types of transactions for which email may be used (for example, scheduling appointments and refilling prescriptions)

* Remind patients to identify themselves explicitly in the message body

* Print all messages and include them in the patient's chart

American Medical Informatics Association

Medicoleqal and Administrative Guidelines

* Obtain patient's informed consent for use of email

* Use password-protected screen savers for all desktop workstations in the office, hospital, and at home

* Don't share an email address or forward a message without explicit consent

* Use encryption for all messages when this technology becomes widely available, user friendly, and practical

* Double-check all 'To:" fields prior to sending messages

* Commit policy decision to writing and electronic form

American Medical Informatics Association

Implementation strategies

The Healtheon survey showed doctors' chief concerns or perceived limitations about email were divided into four compelling reasons: the shaky confidentiality of the medium, fear of additional work, unspecified liability concerns, and a general lack of patients' access to the technology."

Sands provides recommendations for beginners in clinical email, He notes that consent and understanding are at the core of the guidelines. First, you need to understand appropriate and inappropriate uses of email and come to an agreement with your patients up front. Sands implemented email by putting his email address on his business card along with six rules the patients agree to follow in their electronic communication, The cards act like an informal contract. Among the rules: Don't use email for emergencies, be concise, keep copies of email. (15)

The Stanford Medical Group in Palo Alto, California, which has had email access since 1994, opted for a hub-and-spoke system to control workload after patients started sending unsolicited email to doctors, The practice set up a triage system, in which a clerical worker or nurse routes email to the appropriate person. Physicians can and do give out their personal email address to selected patients with whom they want to keep in close touch. (15)

Don't accept email from patients until the key support individuals in your office (for example, nurses and scheduling and billing personnel) are also online. A high percentage of emails from patients are administrative rather than medical and typically concern matters that have not traditionally required physician's direct involvement. (23)

Email correspondence does not come clipped to the front of the patient's medical record, Unless physicians remember the patient well enough to make an intelligent reply, someone has to pull the record before responding. This will be unnecessary when electronic medical records are installed. Responding to email when away from the office resources, particularly medical records, can be difficult. One suggestion is to create a template reply for patients, with instructions for whom to call in your absence. (23)

Be prepared to receive medical inquiries from individuals who are not your patients. Many patients send their medical histories by email, seeking opinions from as many practitioners as they can reach, This is especially true if your practice maintains an informational website. Such inquiries are usually best handled by offering the patient an appointment (if appropriate) or by suggesting a referral to a qualified practitioner in the patient's geographic region. Be careful about giving advice based on sketchy clinical information. In particular, avoid giving advice to individuals in another state where you do not have a license to practice medicine. (23)

Regarding unsolicited emails, a patient-physician relationship with all its legal and liability implications is established if a physician replies to an unsolicited email. (24) Most ethical guidelines for telemedicine would explicitly discourage giving any concrete advice under such circumstances of limited information. Given the enormous patient demand for "teleadvice," we need to develop appropriate guidelines, which do not prohibit any patient-physician interaction by email but set standards for proper cyberconsultations, One template for such guidelines could be the American Medical Association recommendations for 'Physician Advisory or Referral Services by Telecommunications. (25)

Conclusion

Clinical competence and sensitivity to the needs and preferences of patients have always been physicians' most prized qualities. 'Just as the most caring, competent, and sensitive physician of today would be hard-pressed to build a successful practice without a telephone, those who choose not to communicate electronically with patients may soon find themselves at a similar disadvantage." (26) There is a pressing need for dialogue within the profession to understand how communication and information technologies will affect health care delivery.

References

(1.) Bertakis. K.D. The communication of information from physician to patient: a method for increasing patient retention and satisfaction. J Fam Pract. 1977:5:217-222.

(2.) National center for health statistics. Ries P. Physician contacts by sociodemographic and health characteristics, United States, 1982-93. Vital Health stat., 10. 1987; No, 161.

(3.) Curtis, P. The practice of medicine on the telephone. J. Gen. Intern Med. 1988: 3:294-296.

(4.) Neil, R.A., Mainous. A.G., Clark, Jr.. Hagen, M.D. The utility of electronic mail as a medium for patient-physician communication. Arch. Fam. A'(ed. 3 (3): 268-71.

(5.) Kane, B., Sans, D.Z, for the AMIA task force to develop guidelines for clinical use of electronic mail and the world wide web. "Guidelines for clinical use of electronic mail with patients." J. Amer. Med. In form Assoc, 1998;5:104-111.

(6.) Fridsma, D.B,, Ford. P., and Altman. R. A Survey of patient access to electronic mali: attitudes, barriers and opportunities. Proc. Annu. Symp. Comput. App. Med. Care 1994: 15-9.

(7.) Forrester Research, Inc. The email explosion. January 7, 1997.

(8.) Mold, J. Patient-physician email communication, J. Oklahoma State Med. Assoc. Vol. 91, No. 6. Sept. 1998.

(9.) Brown, M. Consumer Health and Medical Information on the Internet. New York. New York:) Emerging Technologies Research Group. FIND/SVP Inc. 1996;46.

(10.) Katz, Steven. Physician email system is evaluated. Reuters Health. October 13th, 1999.

(11.) Spielberg. J.D. Sociohistorical. legal, and ethical Implications of email for the patient-physician relationship. JAMA. 1998:280:1353-1359.

(12.) Informatics Review, All Bets are on: Physicians are using and accepting the Internet] www.informaticsreview.com/thoughts/physicians, html.

(13.) Hoffman. A. Take two, and email me in the morning: doctors consult patients electronically. The New York Times-Cyber/T "lines. June 3. 1997.

(14.) Healtheon News. May 6,1999. www.healtheon.com/news/pr_5_06a_99.html.

(15.) Havighursi, Craig. Unlocking the mailbox. Doctors are granting patient demands for email access, but they want a few ground rules. AMNews. Sept. 13, 1999.

(16.) Roemer, L. Doctor, you've got email. JAMA. 1999;282(8):729:discussioin 730.

(17.) Saltus, R. Take two aspirins and email me in the morning. Boston Globe Magazine. Jan. 18, 1998.

(18.) Green, L. A better way to keep in touch with patients. Medical Economics. October 28. 1996. Pg. i53-56.

(19.) Mandl, K.D. Electronic patient-physician communication: problems and promise. Ann Intern Med. 1998:129:495-500.

(20.) Richards EP, Rathbun K.C. Law and die Physician: A practical guide. Massachusetts: Little Brown: 1993.

(21.) Granade. P.F. Medical malpractice issues related to the use of telemedicine: an analysis of the ways in which telecommunications affects the principles of medical malpractice. North Dakota Law Rev. 1997:73:65-91.

(22.) Kuppersmith, R.B. Is email an effective medium for physician-patient interaction? Arch Otolarygol Head Neck Surg. 1999 Apr; 125(4):468-70.

(23.) Jackler, R.K. Brave new world. Arch Otolarygol Head Neck Surg. Vol. 125 No. 4 April 1999.

(24.) Eysenbach. G, Dlepgen, T.L. Responses to unsolicited patient email requests for medical advice on the World Wide Web. JAMA. 1998:280:1333-1335.

(25.) AMA Current Opinions of the Council of Ethical and Judicial Affairs. Chicago, Ill: American Medical Association: 1998. E-5.025 Physician Advisory or Referral by Telecommunications.

(27.) Ferguson, T. Digital doctoring-opportunities and challenges in electronic patient-physician communication. JAMA. 1998:280:1361-1362.

RELATED ARTICLE: UNIQUE ADVANTAGES OF EMAIL IN THE CLINICAL SETTING

1. Routine transactions and patient education

2. Increased efficiency

3. Self-documenting

4. Cost-effective

5. Clinical extender

LEGAL AND EHTICAL CONSIDERATIONS

1. Confidentiality

2. Informed consent

3. Licensing and jurisdictional issues

4. Medical websites

Kevin M. Taylor, MD, is Director of Managed Care Services at Mercy Primary Care, a 70-physician group practice in Southeastern Michigan. He is in his final year of study at the University of Wisconsin Masters in Administrative Medicine Program. He can be reached by calling 734/712-5558 or via email at km_taylor@email.msn.com.

If you are interested in further discussing this article with Kevin Taylor, M.D, please email him at km_taylor@email.msn.com.
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Date:Jan 1, 2000
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