More and more neurologists have Web sites. Designed by physician organizations, medical societies, hospitals, and e-health companies to market and promote our services, they increase our visibility, describe our office policies and locations, publicize our practice focus, and even inform and educate consumers. Patients, using the Internet in increasing numbers to search for medical information and advice, are finding us at these sites. And many of these Web sites are “interactive,” permitting visitors to send e-mail to physicians.
GUIDELINES FOR E-MAIL
How do we best navigate this uncharted area, both professionally and legally? Daniel Z. Sands, MD, Clinical Director for Electronic Patient Records and Communication at Boston's Beth Israel Deaconess Medical Center, suggests adhering to these guidelines when using e-mail (Journal of American Medical Informatics Association (JAMIA) 1998; 5: 104-111):
- Always discuss with patients the rules, risks, and benefits of e-mail communication;
- Inform patients that their questions may require more than just an e-mail exchange; and, if necessary, call them or have them make an appointment;
- Append a block of text at the end of all patient e-mails (a “signature”) containing full contact information and reminders about security and emergency communication;
- Save all e-mails sent and received in an e-mail folder for each patient and ideally in the patient's medical record;
- Never deliver bad news by e-mail;
- When replying to a patient's e-mail, include the full text of the message received;
- If sending e-mail to more than one patient at a time, always use the “BCC” (blind carbon copies) to protect confidentiality.
PROTOCOLS FOR USE
In addition, Dr. Sands gives his patients these guidelines for e-mails, which are printed on the back of his business card:
- Put your name and patient ID number in the subject line.
- Do not use e-mail for emergencies and other time-sensitive issues.
- Do not use e-mail for confidential information.
- 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.
Daniel B. Hoch, MD, PhD, Assistant Professor of Neurology at Harvard, has extensive experience using e-mail with patients and is the principal investigator of the neurology department's Web-based patient resource, PatientWeb. He presented advice on developing site-specific guidelines based on his experience with this site in the article, “Expanding the Guidelines for Electronic Communication with Patients: Application to a Specific Tool” (JAMIA 2001: 8: 344-348).
In the guidelines, Dr. Hoch includes information about security and privacy, and outlines the responsibilities of the patients and health care providers involved in the site. He cites these e-mail exchanges as appropriate: requests for refills of prescriptions; discussions regarding treatment options such as medication choices, side effects, or surgery; instructions on how to take medications; and general questions relating to epilepsy.
E-mail is especially useful, experts say, for enhancing communication between physicians and their patients. For patients, getting through to their doctors' offices by telephone can be a time-consuming and exasperating affair. E-mail can be sent and answered at any time of the day.
For physicians, e-mail communication also solves the frustrations of “phone tag” and is more direct than responding to a message relayed second-hand by a secretary. It reduces the number of pages and telephone interruptions received at inappropriate times during the day. It facilitates sharing of information and allows neurologists to direct patients to reliable resources on the Internet through embedded links. E-mail can also simplify many secretarial tasks, including the handling of referral-related queries, facilitating prescription refill transactions, and clarifying insurance claims issues.
“Every e-mail represents one less phone call interruption to my receptionist, then to me, and then perhaps from me back to the patient,” says John R. Ellis, MD, a neurologist in private practice.
FORM OF DOCUMENTATION
Physicians say they like being able to respond to their patients' questions in a quiet setting as opposed to the hurried, often frantic pace of an office visit. Also, they say, e-mail provides a form of documentation.
Generally, physicians do a poor job of documenting telephone calls; e-mail solves this problem, says Dr. Sands. “Patients remember only about half of what we tell them, so by writing it down, they can refer to it. This can be a comfort for people.”
Dr. Hoch has received a grant from the National Library of Medicine, which, among other objectives, is studying patient satisfaction with health care. “Patients want three things,” he says, “direct access to their doctors, the ability to talk to each other about problems, and doctor-approved or doctor-written content. When these needs are met, satisfaction goes up.” E-mail provides patients with the opportunity to ask questions that they may not feel comfortable bothering the office with by telephone, Dr. Hoch adds.
These benefits notwithstanding, physicians have expressed concerns about security on the Internet. General e-mail is unencrypted and, if it is intercepted, it could be easily read. However, several secure Internet-based networks are available that facilitate e-mail communication between physicians and their patients. In general, these sites use systems that are encrypted and authenticated and grant patients privileges to use them, unlike standard e-mail where messages can be received from anyone.
Messages remain on secure servers and not on computers or networks owned by patients' employers, as standard e-mail often does. Healinx, www.healinx.com, for example, is one secure site where patients can communicate with physician offices regarding a variety of practice issues.
Neurologist Andrew J. Barbash, MD, has overseen the implementation of electronic medical records and e-health strategies at Kaiser Mid-Atlantic over the past six years. He is working with their staff to use Healinx to enable Kaiser patients to request appointments, refill prescriptions, inquire about referrals, and communicate with their physicians via an enhanced triage process.
Several health plans – including Aetna, Cigna, and United Healthcare, for example – are engaged in pilot studies to examine the benefits of e-mail communication between patients and doctors. They are also reimbursing participating physicians for these “e-visits.” This enables patients to access the online consultation service at no cost.
Fifteen technology companies are participating in this project in hopes of reducing absenteeism and lowering employer health costs.
PAYING FOR SERVICE
According to the April 2002 Harris Interactive survey, over one-third of those online would be willing to pay out-of-pocket for the ability to communicate online with their physicians. Medem, www.medem.com, an online service founded by the American Medical Association (AMA) and other specialty societies, is a secure messaging and online consultation (OC) service that allows individual physicians to determine what – if anything – they will charge for an online consultation. The service was launched in June.
Accessed through the physician's Web site, the OC service allows patients to make appointment requests, request prescription refills, get general information, and send e-mail to the practice.
Even those neurologists who are not interested in electronic communication with patients may be forced to deal with it. Hospitals and provider organizations release e-mail addresses, unbeknownst to physicians, which might invite e-mail questions from anonymous visitors.
At a minimum, physicians who have Web sites should post a disclaimer stating that unsolicited patient e-mail may not be answered and is not a substitute for in-person advice from a physician.
Dr. Ellis regularly receives e-mail from strangers on the Internet seeking medical advice – despite warnings on his Web site that he does not respond to these questions. “I tell these people that I can't and don't practice medicine over the Internet, and advise them to see their own physicians about these matters,” he says.
Dr. Sands advises: “If physicians choose to answer e-mail from individuals who are not their patients, they should be very careful not to establish a relationship. If they respond at all, it is best that they address questions in general terms.”
HOW TO RESPOND
Dr. Hoch tells anonymous e-mailers that he cannot provide specific medical advice since he hasn't seen them in person. He recommends that they contact the neurology department at his hospital to find another neurologist who has specific training to deal with their problem.
In addition, he suggests that they call the office or e-mail a staff member who can triage the message appropriately. He also provides them with a list of online organizations that supply medical information.
Neurologists could also simply refuse to respond to e-mails from persons who are not their patients. Astoundingly, however, studies reveal that many physicians are willing to enter into an e-mail dialogue with unknown patients (Journal of American Medical Association 1998; 280(15): 1333-1335).
“E-mail addresses are not secret, and physicians need to be prepared to handle this growing area of practice communication,” Dr. Sands says. However, used wisely, it can be a very good tool and actually help improve interactions with patients. And, as the health care industry is challenged to find more affordable and efficient ways of providing care, Web-based communication between patients and physicians may supply one effective solution.