You've Got Mail

Getting the Most From Physician-Patient Email

By Joanne Tetrault
Joanne Tetrault is the managing editor of Physicians Practice

Patient-to-physician communication via e-mail is beginning to gain a foothold, as practices begin to dabble on the Web. Some physicians are praising e-mail for its efficiency — it eliminates phone tag, provides easy documentation of the correspondence in an electronic medical record and allows the physician to answer patients during free time or even when out of the office.

"We have six or seven patients who now use e-mail with us — and they love it. We are trying to educate more patients about it," said Scarlett Young, R.N., office manager for Cecil Bourne, M.D., of Corpus Christi.

But the enthusiasm is tempered with realism. Young says that physicians are concerned about maintaining privacy in e-mail communications, among other issues. Her observations are confirmed by physicians on a national level, as well as industry experts.

While various surveys indicate that physicians are steadily integrating computers into their practices, patient e-mail proponents are still in the minority. Based on data collected from more than 1,000 physicians from June to September 2001, the American Medical Association (AMA) estimates that only about one in four doctors uses e-mail to communicate with patients. The findings indicate that, while physicians accept using online administrative functions, they are somewhat less eager to embrace online communications with patients. But that will likely change as demand from patients grows.

Barry Hibb, research director of the Gartner Group, a research and consulting firm for information technology services, agrees that there are still a few hurdles to overcome. "Until it can be proven that e-mailing saves time and money and improves care, doctors won't be convinced," he says. "In addition, there is no malpractice law governing e-mail so what happens if a doctor gives advice on the Web and it goes bad?"

Health systems, physicians and legal experts agree that, before you hit the "reply" button on a patient e-mail message, it's critical to give patients clearly defined ground rules to avoid possible problems down the road.

Establishing e-mail policies

"You should not just open up this channel of communication without thinking very carefully about what your policies are going to be," says Reece Hirsch, who co-chairs the practice group on health care and the Internet for the law firm Davis Wright Tremaine in San Francisco.

Key considerations include:

• Who will answer patient e-mails — and how quickly?
• How will sensitive or urgent medical situations be handled?
• What needs to be done to ensure compliance with Health Insurance Portability and Accountability Act (HIPAA) security rules?

Responding effectively

Does offering e-mail privileges to patients mean physicians will be chained to their computers answering messages? Not if other qualified staff members are involved in reviewing e-mail requests and responding when appropriate.

"It makes sense to arrange the office information flow so that e-mail messages go through triage just like phone calls do," agrees Eric Knight, M.D., a family practitioner in New Hampshire. "For fairly routine exchanges, such as referral and refill requests and many lab results, the triage person might be able to respond perfectly well, saving the more complex questions for the physician."

Hirsch adds, "Usually there is an understanding that other members of the staff will have access to patient records to a reasonable extent." Still, you should establish guidelines that specify exactly how incoming e-mails will be processed once they reach your office. "Just because a patient is sending an e-mail to 'drsmith.com' doesn't mean Dr. Smith is going to be the only person who reads it," he says.

At Bourne's practice, office manager Young reviews all incoming e-mails and forwards them to the physician as appropriate. They are also printed out and attached to the patient's chart. Young also believes that e-mail can be a timesaver in communicating with patients. She estimates she spends only about 30 minutes a week reading and responding to patients' electronic messages.

David Donnell, M.D., a Dallas-based internist, also praises e-mail for its efficiency — it eliminates phone tag, allowing him to answer patients when he has free time and provides easy documentation of the correspondence in an electronic medical record. He can also read or respond to e-mails when he is out of the office.

The expected response time should be shared with patients in advance; a good rule of thumb is to respond within two business days.

"Patients are more efficient about what they say in an e-mail, which also eliminates the time-consuming dialogue of a phone call," adds Daniel Griffin, a Colorado internist.

Not for urgent care

Physicians should also provide patients with guidelines for what types of medical situations are appropriate for e-mail. Focus on nonurgent care and clarification of advice offered during an office visit.

For instance, one of Donnell's patients e-mailed about an ineffective allergy medication; Donnell changed the prescription. On the other hand, another patient explained via e-mail that she had been losing weight; Donnell recommended an office visit.

Young says e-mail is appropriate "if it's something we can address within 24 hours." Her office provides an informational brochure that tells patients they should call the office or 911 in case of an emergency or the need for urgent medical care.

Some physician e-mail systems include even more specific information as to what types of issues are appropriate for e-mail. For example, one university-based medical center's site reads: "Because e-mail is best suited for nonurgent issues, you should use it for prescription refills, request or cancellation of appointments or simple medical questions. Sensitive issues, such as the results of HIV testing, substance abuse or mental health, will not be addressed by e-mail."

Promoting privacy

One of the concerns surrounding e-mails is the ability to authenticate or confirm the exchange. The looming Health Insurance Portability and Accountability Act is putting pressure on the health care industry to formulate some consistent measures.

As of last July, the Centers for Medicare and Medicaid Services (CMS) modified its policy to allow CMS data to be transmitted via the Internet, stipulating that "an acceptable method of encryption must be used and authentication or identification procedures must be employed," according to the organization's Internet security policy.

Most practices are complying with these regulations anyway, as they move toward compliance with the security rules of HIPAA.

Bourne's office uses the Healinx secure server, which encrypts all messages and "maintains the highest level of security available," according to the brochure given to patients.

"In the proposed HIPAA security rule, a covered entity like a health care provider can't send protected health information over an open network like the Internet without encryption," adds Hirsch. "Any physician who is communicating with patients via the Internet and transmitting protected health information or any form of medical information should be encrypting it."

Getting paid?

A recent Deloitte Research/Fulcrum Analytics survey of 1,200 physicians revealed that 54 percent said reimbursement for e-mail would be the "leading driver" for them to adopt e-mail with patients in the future. Only 9 percent of respondents said they did not expect reimbursement for time spent e-mailing patients.

Donnell, for one, says he has never considered charging his patients for e-mail. "It is such a cost saver in terms of efficiency that I am happy to pick up the cost," he says.

"Basically," Knight adds, "e-mail is better for transmitting clear and detailed information than a verbal exchange. Some patients love it and will change to — or stay with — a particular physician just to be able to use it."

Joanne Tetrault can be reached at jtetrault@physicianspractice.com.