Using E-mail in Clinical Care:
A Practical Approach Combining the best of high tech and high touch

So you're thinking of beginning to use e-mail in your practice? Did you decide on your own or are your patients or colleagues goading you into it? You're not alone. A 1999 survey conducted by Healtheon/WebMD showed that although only 3% of physicians surveyed were regularly e-mailing their patients, another 9% described their use of e-mail as growing and an additional 22% had done so at some point. These numbers had all grown substantially from the prior year's survey.

So what should you think about as you enter this brave new world of electronic patient centered communication? What are some strategies you should employ so this technology improves your efficiency and satisfaction rather than detracts from it?

First, let's dispel some myths:

Myth #1: Hackers could read my patient's confidential messages

It is true that, in general, people tend to use unencrypted e-mail, and that e-mail is transmitted from computer to computer across an open network. It is also true that it is possible to intercept these messages. However give the incredible volume of e-mail (hundreds of millions per year) it is extremely unlikely that a given e-mail will be intercepted. More common are:

• misaddressing of messages
• misrouting of messages
• forgetting to log off of an e-mail system or inadvertently allowing others to read your messages

In addition, messages that are misaddressed (or sent to inactive e-mail addresses) may be intercepted and possibly read by system administrators for troubleshooting. Also, the courts have upheld an employer's right to read e-mail messages that are sent on an employer-owned e-mail system.

All this means that, at worse, e-mail is as secure as sending a postcard. In practice it is much safer than that when used appropriately.

Myth #2: It will take more time from my day and I won't get reimbursed for it

The time you use answering e-mail messages from patients will be offset by time you won't spend on the phone with them. At least with e-mail, messages are more concise, they can be answered anytime of day or night, and patients won't forget what you tell them. You may want to set up a system of e-mail triage, where all messages from patients initially get sent to a triage nurse who involves you as needed.

We aren't reimbursed for time spent on the telephone, either. If you have a large population of capitated patients, any time you spend communicating with your patients to prevent unnecessary utilization of health care services is time well spent.

Myth #3: If I allow patients to e-mail me I will receive a flood of e-mail messages

This has not been the experience of those who have tried it. In general, patients respect your time and will not contact you constantly. Physicians who give out their page numbers to patients often find this to be the case. I have heard from physicians who give their e-mail address to patients with multiple somatic complaints and have found symptom reduction over time with regular e-mail exchanges!

Myth #4: Patients will ramble

Again, this has not been the experience of those who adopt this communication medium in their practices. Unlike talking, either in person or over the telephone, typing offers a certain barrier to rambling. In addition, it is important to explain to patients ahead of time that their messages should be concise. When they are not, you can let them know that the long discussions are better suited to other means of communication or a face-to-face discussion.

Myth #5: I may get sued and a lawyer will discover my e-mail messages

You are likely to be named in a malpractice suit whether or not you use e-mail. Because e-mail exchanges, when stored and filed in the patient's record, provide a self-documenting paper trail, they are more likely to come to your defense in a malpractice suit. Contrast this with the poor documentation that usually accompanies telephone transactions.

Rules of the Road

If you would like to use e-mail, how should you go about it? Here are some tips that I have used and shared with many physicians.

• You may choose to offer this to all of your patients, some of your patients, or none of them.
• You may choose to have a triage nurse accept all e-mails for your practice and then forward them to you, as necessary.
• Always discuss guidelines for appropriate use. The major points can be summarized on a sticker, which you may place on the back of your business card. Your discussion with your patient about the use of e-mail is an informed consent discussion, and as such the discussion and the patient's assertion of their understanding should be documented in the patient's record, for example "We discussed the risks, benefits, and appropriate uses of e-mail for our communications. The patient expresses an understanding of the risks and agreement to our standard guidelines. Her e-mail address is: …"
  
  
• The guidelines I give to patients are:
  • Use alternative forms of communication for:
    • emergencies and other time-sensitive issues
    • sensitive information (do not assume e-mail is confidential)
    • situations in which my response is delayed (I may be away)
  • Be concise
  • Put your name and hospital number in the subject line
  • Keep copies of e-mail you receive from me
  • I may save e-mail I send and receive in your record
  • I may share your messages with my office staff or with consultants (if necessary)
• Additional points worth mentioning:
• E-mail sent using an employer's e-mail system could legally be read by the employer. An alternative is to sign up for a personal e-mail account.
• E-mail is sent across an open computer network and is generally unencrypted. It is thus accessible to prying eyes much as a postcard is.
• The biggest threat to the confidentiality of e-mail is not hackers intercepting messages, but:
  • messages that are misaddressed
  • messages containing confidential information that are inadvertently forwarded to others
  • messages read using shared e-mail accounts
  • messages left on computer screens when one forgets to log off
• Always quote the full text of the e-mail that is being sent to you when responding (to provide the context for your replies).
• Append a standard block of text to the end of all your e-mail messages to patients, which contains your full name, contact information, and reminders about security and importance of alternate forms of communication for emergencies. An example is at the following website (http://clinical.caregroup.org/ePCC/).
• Save all e-mails that you send and receive in a folder for each patient. Ideally you should print these out and sent to Medical Records for filing (or you may cut and paste or electronically transfer to electronic patient record notes).
• Record your patient's e-mail addresses in your address book and in their patient record. See if you can arrange to have a field in the registration system that you can use for this.
• In general, be careful about sending e-mail messages to more than one patient at a time, since they will see the other recipients' e-mail addresses (or worse). If you wish to send group mailings, do the following:
  • Address the message to yourself.
  • Use the "bcc" field to list each of the intended recipients. This way your patients will not be able to see who else received the message (other than you).
• You may maintain a policy of only replying but never initiating e-mail messages.
• Do not deliver bad news via e-mail.
• When e-mail messages get long or the volley is prolonged, tell the patient you'd like them to come in to discuss (or call them).
• Remind patients when they do not adhere to the guidelines.
• For repeat offenders, it is acceptable to terminate the e-mail relationship.

Forms of computer-based communication are likely to be important to your patients and to your practice within the next few years. E-mail is one way of doing this, as we've discussed. Another is using a system of secure web-pages to communicate with your patients. These systems are available for little or no money and provide a nice way of managing your practice communications, including an integrated practice web page which can help promote your practice.

When used properly, you will find that electronic patient-centered communication will be satisfying for you, your office staff, and your patients.

For more information, I've set up a web site devoted to this subject at http://clinical.caregroup.org/ePCC/.

You can also see another provider's opinion at:

E-mail is just what the doctor ordered describing Eugenia Marcus, M.D., a kindly pediatrician, wise in the ways of primary care and exuberant about kids.

© 2000 Dean F. Sittig

The Informatics Review > Thoughts - Using E-mail in Clinical Care

dfs 2/16/00