By Laura Johnson Morasch, MPH

Communication lies at the heart of the physician-patient relationship, and many physicians lament the increasing breakdown of this communication as one of their greatest losses. The compressed office visit sabotages opportunities to truly connect with patients. But the emergence of the Internet and its host of related communication technologies, including e-mail, could be the key to restoring this broken connection.

Today, practices across the country are facing the question of how to incorporate e-mail into patient care—or if they even should. But just as physicians in an earlier era ultimately incorporated telephones into their practices—after intensive debate in the medical community about how and whether to do so—e-mail and other Internet-based communication will certainly become a part of routine practice in time. Thus, the question physicians should probably be asking is not “whether” they should use e-mail with patients, but rather “how and when” to start.

While data on physician-patient e-mail patterns are limited, patients appear eager to e-mail their doctors. Physicians are more reluctant. According to Cyber Dialogue, one of the leading researchers of Internet business trends, 48% of people surveyed in 1999 wanted to communicate with their physicians by e-mail. Perhaps more telling, one-third of those surveyed felt strongly enough about e-mail to consider changing physicians to be able to use it.

Although physicians recognize the importance of e-mail, the vast majority have yet to incorporate it into their practices. For example, 83% of physicians surveyed in 1999 in a University of Michigan study thought that using e-mail to answer patients’ nonurgent questions was a good idea, but only 27% were doing so. In an informal member survey conducted by the California Academy of Family Physicians (CAFP) in January 2000, 28% said they were using e-mail with patients. Several other studies have put physician e-mail use at about 33%. In the CAFP study, of the physicians who weren’t using e-mail, half did not plan to offer this service to their patients.

Physicians are clearly both intrigued and anxious about e-mail. At medical meetings, doctors fill sessions on e-mail use, and the same questions invariably crop up: What are the benefits of using e-mail with patients? Are there unique liability issues I need to be aware of? Can I be reimbursed? What about security? Will I be overwhelmed by a flood of patient mail?

The following overview addresses e-mail-related issues and offers guidelines for introducing e-mail in your practice.

PUTTING E-MAIL INTO PLAY
Daniel Z. Sands, MD, MPH, clinical director of electronic patient records and communication at Beth Israel Deaconess Medical Center in Boston, is a leading proponent (and practitioner) of physician-patient e-mail and coauthor of the widely distributed American Medical Informatics Association e-mail guidelines for doctors. He cites the following key benefits: E-mail

• Reduces nonurgent telephone calls and pages for providers.
• Increases patient satisfaction and participation in care.
• Improves communication, permitting better management of patient health and possible reduced utilization of services.
• Enhances patient education.
• Improves record of communications between patient and provider.
• Improves provider satisfaction as it strengthens provider-patient relationships.

Achieving these benefits requires addressing a number of practical considerations at the outset.

Scope of e-mail usage: The number of patients with whom you exchange e-mail will depend on many factors, primarily the size and volume of your practice, patient demographics, and your intended uses for e-mail. It’s worthwhile to poll patients on their interest. Keep in mind that no matter how many patients want to e-mail your practice today, the number is sure to grow in coming years.

Services offered: E-mail can have both clinical and administrative applications. Your office must decide under which circumstances it wants to correspond with patients via e-mail.

E-mail processes: You will need to establish systems for receipt, triage, and response. You should concentrate on responding to messages that require a high level of clinical decision making, and enlist others to respond to e-mail about such administrative matters as refills, referrals, and scheduling.

Internet access: E-mail communication with patients requires that your staff have Internet access. If your nursing, reception, or back-office staffs do not have Internet access, the practice will not be able to triage messages to them, and vice versa.

E-mail addresses: If more than one staff person is going to respond to patient e-mail, your clinic must decide if it wants to give out one address or assign separate addresses for different functions (appointments@drbob.com, doctor@drbob.com, etc.), as well as who will distribute messages received centrally.

E-MAIL SECURITY
E-mail is not inherently secure. Messages can pass between hundreds of computers before arriving at their intended destination; thus, there is a risk—albeit remote—of e-mail being intercepted and read by others. According to network security consultant Wes Sonnenreich, free Internet e-mail services such as Yahoo and Hotmail are particularly vulnerable to security and privacy breaches, and should be avoided for e-mail communication with patients.

There are two approaches to making e-mail more secure. You can use encryption software, such as Pretty Good Privacy, which works with your e-mail program to scramble your messages. Users and experts alike offer mixed reports about the user-friendliness of encryption technology. A significant impediment to routine use is the need for both sender and recipient to install the software.

The second option for secure communications is to use secure server messaging such as Healinx. This is a hybrid version of online communication in which messages are hosted on a third party’s server—and are visited and viewed as Web pages—rather than traveling through e-mail servers on the Internet to get from one computer to another. (If you’ve sent or received an Internet greeting card, you’ve used this technology already.) Regular, unencrypted e-mail is used to notify patients and physicians when they have messages waiting for them on the third party’s secure Web site. These messages usually embed the site address so recipients can go right to the site, where they log on with user names and passwords to see the messages. This authentication process, combined with Web browser–based 128-bit encryption, results in a secure, if indirect, route to communicating with patients online.

Security options should be discussed with all patients who plan to exchange e-mail with you. Physicians who are not using security measures should be sure that patients understand that e-mail communications are not secure, and have them sign a document acknowledging this (see sample contract).

The risk of unencrypted e-mail messages being intercepted and read is slim. Perhaps a greater threat to patient privacy is the possibility of sensitive e-mails being printed by office staff and left inadvertently on the printer or a countertop, or simply being left on screens where they’re visible. Advise staff to carefully control e-mail once it arrives at your office, just as they would control other patient information.

E-MAIL GUIDELINES
What follows is adapted from “Guidelines for the Clinical Use of Electronic Mail with Patients,” published in the Journal of the American Medical Informatics Association, volume 5, number 1 (January/February 1998). A full text version of the guidelines is available to subscribers on the AMIA’s Web site, http://www.amia.org/.

Physicians should ask patients how they would like to receive communications. They can then determine a patient’s preference for e-mail, postal mail, telephone, or voice mail at the time of a visit, and document this in the chart. Patients might elect different communication routes at different times for different purposes. A more formal arrangement could include informed consent. Physicians should periodically confirm patients’ preferences.

Time-sensitive issues, such as medical emergencies, should not be communicated via e-mail because hours or days can pass between when a message is sent and when it is received and acted upon. Sensitive and highly confidential subjects should not be discussed on most e-mail systems, because of the potential for the messages to be intercepted or transmitted to unintended recipients.

PATIENT-PROVIDER AGREEMENT
Safe, effective e-mail communication depends on the patient’s clear understanding of use policies, which should address the following issues:

Turnaround time: Determine how often you and your patient retrieve e-mail, and establish a maximum turnaround time for patient-initiated messages. In some messaging cultures, typical turnaround times are one business day for nonurgent phone calls and two to three-business days for e-mail messages. Often, the context of a patient’s message will indicate the expected turnaround time. For example, a patient inquiring about last week’s blood work will probably expect a more prompt reply than a patient checking on her travel immunizations six months before an overseas trip.

Privacy: Tell patients whether the office or nursing staff will triage messages, or whether mail sent to your private e-mail address will be read by you exclusively. Furthermore, establish with whom you may share a patient’s e-mail message and under what circumstances, such as when consulting another physician.

Permissible transactions and content: Especially if other clinic staff will be processing e-mail from patients, establish the extent of actions permitted over e-mail. Common appropriate topics include

• Prescription refills
• Scheduling and confirming appointments
• Release of records
• Selected test results
• Medical advice and information requests
• Follow-up care and clarification of treatment plans
• Reporting of self-care measurements.

You may also want to exclude certain subjects from e-mail discussions. Stanford University Medical Clinic, for example, forbids discussion of HIV status, mental illness, and workers’ compensation claims via e-mail.

Categorical subject headers: To facilitate message triage, ask patients to specify a transaction type in the subject field, such as “prescription,” “appointment,” “medical advice,” or “billing question.”

Discreet subject headers: Physicians and their staff should use discretion in their outgoing message titles. Patients may share an e-mail address with a family member or have fewer safeguards on their desktops than are necessary to ensure privacy. “About Your Pregnancy Test” is not an acceptable subject header.

Patient ID: Ask patients to put their name and patient identification number in the body of the message.

Documentation: E-mail policies should be reviewed with the patient; the discussion should be documented in the record, or the patient should sign a contract (see sample contract). In the latter case, have the patient sign the document, give a copy to the patient, and place a copy in the patient’s chart. E-mail policies should be conspicuously posted.

HANDLING MESSAGES
Automatically replying to incoming messages: E-mail software should be configured to respond to all incoming messages from patients with an automatic reply such as this: “Your message has been received by Dr. [name], who will attempt to process your request within [time frame]. If your question is urgent, do not rely on e-mail for a response. For immediate assistance, please call the office at [phone number].”

In addition, the out-of-the-office reply feature should be activated on any e-mail account that will not be checked by staff or covering physicians within the established e-mail response time. These automatic replies should include the provider’s estimated date of return and whom to contact for immediate assistance. Because e-mail is simply another form of communication with the office, you may wish to have your e-mail messages forwarded to your covering physician just as you would phone calls and other queries.

Archiving e-mail transactions: E-mail exchanges about follow-up care or other clinical issues constitute a kind of progress note. Unless you are using an electronic patient record that allows you to include e-mail messages, each message should be printed out and placed in the patient’s paper record. When e-mailing a reply message, include the full text of the patient’s query and copy the reply to yourself. When the Internet delivers your copy, which now includes the original message and your reply, the message should be printed and filed in the chart.

Confirming action taken on the patient’s request: A new reply message should be sent after completion of the patient’s request for a transaction (e.g., prescription refill).

Acknowledging messages: When e-mail contains important medical advice, patients should be instructed to acknowledge messages by sending a brief reply. When you are expecting an acknowledgment, the printed (chart) copy should not be filed until this confirmation is received. In the absence of confirmation, it cannot be assumed that the patient has received, much less read, important instructions. When in doubt, confirm delivery by telephone.

Levels of communication: E-mail from providers should include a footer (signature file) that invites patients to call or come in for an office visit should they feel that e-mail is insufficient. The footer should give the appropriate contact information. Providers should actively discourage the use of e-mail as a substitute for clinical examination (see sample footer).

Using an address book and group mailings: Providers should maintain a list of patients who communicate with them electronically. The address book feature available with nearly all e-mail software makes this easy. If it is necessary to notify the general patient population about something (e.g., new clinic services), the clinic will have a ready-made mailing list. However, never use group addressing, where those in the group see each other’s names, to broadcast e-mail to patients. When sending out group mailings, use the “blind cc” software feature to keep recipients invisible to each other. When using this feature, enter the provider’s own name in the “To” field and place the list of recipients in the “Bcc” field. Patient e-mail addresses should not be used in marketing schemes or given to third parties for any reason.

SITE-SPECIFIC POLICIES
Health care institutions and medical practices should develop written policies to address communication, technical, and medicolegal issues. Questions that must be answered include:

• Who will triage e-mail, and what will be the response time?
• Who will print messages and place them in patients’ charts?
• Will each provider have his or her own account, or will there be category accounts for billing questions, medical questions, scheduling questions, and the like?
• Should all patients be given the provider’s e-mail address, or should the provider give it out selectively?
• How is e-mail archived, backed up, and cleared from the server? Does it stay on the provider’s local machine or on the clinic’s or Internet service provider’s mail server, or both? How are both repositories archived and cleared? How long should e-mail be stored on backup systems? How will messages be indexed for retrieval?
• How will the efficacy of e-mail with patients be evaluated? Will it be possible to determine utility based on a monetary cost-benefit analysis, patient satisfaction, provider perception, or clinical outcomes?

All policy decisions regarding electronic mail should be placed in the institution’s policies and procedures manual, given to all staff in paper form, and be made available in electronic form on individual workstations or the clinic’s Web site, or both.

ENHANCED RELATIONSHIPS
While the practical benefits of e-mail with patients are clear, it’s hard to measure what may be its most important quality: the potential to enhance physicians’ relationships with their patients.

Physicians who routinely share e-mail with patients often describe the warm “e-relationships” that develop and the positive feedback that they get from patients—feedback that is often sorely missing in the compressed office visit. Doctors describe e-mails that end “The prescription worked. Slept great last night!” or “Thanks for getting back to me so fast”—encouraging comments that can be very satisfying at the end of a long day.

David Ives, MD, an actively e-mailing internist in Lexington, MA, notes that e-mail improves patients’ confidence that they can reach you when they need to. He cites the following exchange with one patient who hadn’t heard back from him in a few days. “The patient wrote, ‘David, you haven’t answered my last couple of e-mails. Are you still out there?’ I answered ‘Yes.’ He responded ‘Good.’” That was, says Dr. Ives, “one more satisfied, reassured patient, with one typed word. Not bad.”

Here are a few scenarios that illustrate ways of setting up your practice to handle e-mail:

• Dr. Simms works in a solo rural practice. She is the only person with e-mail in the practice. She gives her e-mail address out to all of her patients, about 85 of whom have access to e-mail. She encourages patients in remote areas to adopt e-mail, hoping to occasionally save them a trip into town or an office visit. Dr. Simms has asked her patients not to use e-mail for appointment scheduling or business matters, preferring to use it only for clinical issues. Any clerical requests are printed, forwarded to the receptionist for a response, and filed in the patient’s chart, along with confirmation of the receptionist’s response. Dr. Simms also uses e-mail for consultations with the nearest teaching hospital, more than 100 miles away.
  
  
• Dr. Jones works in a busy academic setting. He exchanges e-mail with several hundred patients and receives e-mail concerning both clinical and administrative matters. All staff members at the family health center have university-based e-mail accounts, so Dr. Jones has set up e-mail filters to automatically forward messages to the appropriate people. Requests for appointments go to the receptionist, and those for prescription refills and charts go to his nurse. He keeps and responds personally to all follow-up inquiries, lab-test questions, referral requests, and self-care inquiries. Dr. Jones and his staff print all responses to patients’ e-mail, including the original question or request, and copies are filed by the office file clerk.
  
  
• Dr. Jacobs works in a high-volume managed care setting. A year ago, his group made the decision to incorporate Web-based e-mail into the practice structure. Each provider in the group has his or her own e-mail account that is triaged by a nurse, who reads all e-mail and then distributes it as necessary. Front office staff also have e-mail accounts. About 700 patients, or one-fifth of his panel, currently use e-mail with the practice—although only about 25 clinical messages a day are forwarded to him for response. The remainder of the requests are triaged to appointment scheduling, the practice’s health educator, the business office, and the like. The number of phone messages he has to respond to has been cut in half, and the practice expects to eventually reduce unnecessary office visits by 15%.

The following correspondences between Joseph Scherger, MD, and his patients illustrate the range of issues that can be addressed via e-mail. These e-mails are reprinted with permission. Identifying details have been changed to protect privacy.

From: Scherger, Joe
Subject: Good Test Results

Susan,
Good news. Your Pap test and all your lab work came back normal and healthy. Your cholesterol is only 147 with an excellent ratio of good to bad. Keep up the good work and I’ll see you next year.
Joe

To: Scherger, Joe
Subject: Antibiotic for congestion?

Hey Joe,
Hope you are doing well. I am better . . . meaning I can breathe, but still have some congestion and discharge. Don’t know if this means this is viral, allergies or I need a longer course or different type of antibiotics. I am leaving for the East Coast again on Thursday. What do you think?
Regards,
Bill

Bill,
I would not extend your antibiotics unless things turn worse, such as darker drainage, more pain or fever. I suspect the congestion is a virus or allergy and will run its course slowly. Keep in touch.
Joe

From: Scherger, Joe
Subject: Prep for Appointment

John,
I still have you scheduled for a vasectomy on Friday at 11 am. You should arrive at 10:30 and bring your health insurance card for registration. Remember to follow carefully the preoperative instructions, including shaving the hair off your scrotum the night before. I’ll see you Friday. Send me an e-mail if you have any questions.

Doctor,
I will be there at 10:30, shaved, with my insurance card. If I need to do any other preparation, please let me know. Thanks

John,
Thanks for being such a good sport today. Everything went very well and I hope you are not too sore. Let me know if you have any problems.

Doctor,
I hope you’re well. I am feeling much less tender and getting along well. I still have some swelling and a very large bruise. This is not a concern to me. However two of the incisions seem to remain slightly open. They do not bleed so much as leak a clear but partially red fluid. Should I be concerned and if so how shall I proceed? Feel free to page me. Thank you.

Hi John,
It sounds like you are doing well. Just keep the openings clean and they should heal fine.
(Editor’s note: They did.)

From: Scherger, Joe
Subject: Lab Results

Fred,
I wanted to let you know that, as we discussed they might, your lab results show that your cholesterol and other lipids are outside the healthy range. I want to be sure that you will see me in the next few weeks to review this in detail. To give you some numbers, your cholesterol is 290 (should be less than 200), triglyceride is 241 (should be less than 160) and your “good cholesterol” is only 34 (should be over 40). We have some work to do! As we discussed at your recent visit you must begin to think of losing considerable weight and getting on a very low fat diet. I do not want to overly alarm you now, but to get you started with this news. Please focus on reducing fat in your diet and make sure to set up an appointment with me.
Joe

To: Scherger, Joe
Subject: Prescription refill

Dr. Scherger,
My son needs to refill his Singulair 10 mg medicine. Would you please phone the pharmacy at [phone number]? By the way, his condition hasn’t changed at all.
Thank you, Randy

From: Scherger, Joe
Subject: Test results

Hi Bob,
Your lab test which measures the control of your diabetes over 3 months came back even higher than March—9.4 now, compared to 8.4. This should be below 7.0. This means that despite all that you are doing, your disease has progressed. I am glad we have gotten you started on medication. Keep up what you are doing and let me know how your blood sugars are doing.
Joe

Laura Johnson Morasch is director of Medical Practice Affairs, California Academy of Family Physicians, San Francisco. She can be reached at lmorasch@familydocs.org.

Selected References

Kane B, Sands DZ. Guidelines for the clinical use of electronic mail with patients. J Am Med Inform Assoc. 1998;5:104-11.

Reents S. Impacts of the Internet on the doctor-patient relationship: the rise of the Internet health consumer. Cyber Dialogue. 1999. Available at: www.cyberdialogue.com/pdfs/wp/wp-cch-1999-doctors.pdf. Accessed October 17, 2000.

Sands DZ. Guidelines for the use of patient-centered email. Massachusetts Health Data Consortium. 1999. Available at: http://www.mahealthdata.org/. Accessed October 17, 2000.

Spicer J. Getting patients off hold and online. Family Practice Management. [serial online]. January, 1999. Available at: http://www.aafp.org/fpm/990100fm/34.html. Accessed October 17, 2000.

Spielberg AR. On call and online: sociohistorical, legal, and ethical implications of e-mail for the patient-physician relationship. JAMA. 1998;280:1353-9.

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