Patient E-mails Guidelines help avoid mishaps

by David Orenstein freelance writer

Most physicians have had at least a few patients who just won’t cooperate with a beneficial treatment. Such patients’ refusal to help themselves is frustrating. A similar frustration is inspired among technologists when they see how few doctors use electronic mail to communicate with patients.

For example, a Harris Interactive poll earlier this year of more than 800 physicians found that 55 percent of physicians use e-mail to communicate with each other and 33 percent exchange e-mails with their staff, but only 13 percent e-mail with patients. Many are understandably concerned about the privacy and security of e-mails, which could contain sensitive test results or treatment recommendations. But even if security were guaranteed, the Harris poll found, 40 percent of respondents say they still wouldn’t e-mail clinical information.

That’s too bad because e-mail can save physicians time and money, and can increase patient satisfaction and continuity, say researchers who study the effect of e-mail on medical practice. The literature still is evolving, but e-mail, when properly handled, appears to be a real benefit to the doctors who use it. Under the right conditions, e-mail is perfect for confirming appointments, fielding patient questions, reporting test results, and following up on office visits with treatment instructions. It also gives patients a way to report glucose levels or other routine health data.

E-mail is a quick, painless way to take care of something simple and mundane, such as an appointment confirmation or a billing reminder. But e-mail also can be ideal for difficult and complicated messages to patients. Because e-mails are written, legible, and easy to find, they can ensure that physicians and patients have a clear, durable record of what has been said. Patients are prone to forget complicated instructions if they hear them only once, but they can refer repeatedly to an e-mail describing a complicated treatment regimen. E-mail not only saves time, but also gets information into an easily referenced document. And, they can be attached to electronic medical records or filed within paper ones.

But then, there are those e-mail caveats—“…when properly handled…” and “…under the right conditions….” Like paper documents, telephone calls, or in-person meetings, e-mails can be insecure and indiscreet. Fortunately, strong guidelines that can help practices avoid e-mail mishaps have been available for years. In a 1998 article in the Journal of the American Medical Informatics Association, Drs Beverly Kane and Daniel Sands outlined a strategy that makes physician-patient e-mail a little more onerous, but a lot less problematic.

The recommendations emphasize two themes: courteous communication and diligent discretion. (I am drastically summarizing the paper.) [For more details, see below.*] Courteous communication means establishing up-front the amount of time a physician generally will take before getting back to the patient. It also means generating an automatic response to patients that acknowledges receipt of their e-mails. Drs Kane and Sands recommend that doctors assure patients that they retain the option to call or schedule an appointment. Diligent discretion means disclosing whether staff will send or read messages, using discreet subject lines, stating at the top of each e-mail that it is a confidential medical document, and, perhaps banning sensitive information—such as HIV diagnoses—from e-mail.

For legal purposes and to manage expectations, Drs Kane and Sands say, a physician might want to ask patients to sign a document indicating they agree to the doctor’s e-mail rules. The researchers also recommend encrypting e-mails and signing them with a digital signature. Those steps can be somewhat complicated to implement, however.

E-mail has been the most popular benefit of the Internet for years because it combines some of the speed and ease of leaving a phone message with the durability and clarity of a written message. People will send at least 610 billion e-mails this year. No wonder technologists scratch their heads that so few of those messages move between physicians and patients.

*The full text of the article, “Guidelines for the Clinical Use of Electronic Mail with Patients,” published in the Journal of the American Medical Informatics Association (1998;5:104-111), is available for $5 at www.j-amia.org/cgi/content/full/5/1/104?jkey=mFmCJ6A9Eqsh.

David Orenstein is a technology and business writer in Silicon Valley. If you'd like to learn more about a certain computer topic, e-mail him at davealli@home.com.