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is a question-and-answer forum featuring leading practice management experts who may or may not be employed by Physicians Practice. Physicians Practice receives questions from physicians, office managers, office administrators and others. Have a question about the operation of your practice? Visit www.PhysiciansPractice.com. Your question will be answered within three business days.

Q I am creating a "new patient" information form for my office. I am trying to decide whether to have a field where patients can write in an e-mail address. I can foresee that it may be useful to e-mail patients with business news, such as accepting a new payer or adding a new service, but I am concerned that gathering e-mail addresses without a fixed e-mail policy will create more confusion than productivity. I have seen that the Health Insurance Portability and Accountability Act (HIPAA) recommends or requires encrypted e-mail for doctor-patient communication. What kind of policy do you suggest?

A I would ask for e-mail addresses. Sending patients notices about new services and the like does not violate HIPAA since you aren't transmitting protected health information.

That said, you should still put an e-mail policy into place. For now, it's probably sufficient to say that no patient will receive protected health information (anything that identifies anything about a patient's health or payment) via regular e-mail. Also, review the guidelines approved by AMA, AHIMA and AAFP at www.amia.org/mbrcenter/pubs/email_ guidelines.asp.

Finally, consider looking into services that provide secure messaging, such as Medem (www.medem.com) and many others.

Q I am in family practice and just started a solo practice. The practice is picking up, but it is still somewhat slow. (I average six to seven patients per day now.) I do see my patients in the hospital, but I am not sure if the hassle is worth it economically. I much prefer outpatient work, too. Do you have any figures or resources that can help me?

A Run a report on all your inpatient codes. How much revenue have you earned in the past six months and how many visits have you had? This information will help you determine what you earn per visit on average. You can then weigh whether the wear and tear is worth it to you. Also take a hard look at how your balance sheet would read without that revenue.

Do your hospital rounds keep you from filling outpatient appointments — that is, does your scheduler have to turn away potential patients at your office because you're doing rounds when they want to come in? You might try to capture that somehow.

If no one is getting turned away, I'd generally say go to the hospital. You can work with a hospitalist when you are seeing more patients a day and don't need the money quite so much.

Q If I have to fire a patient — say, someone I suspect of narcotics abuse — I follow the advice I've been given and send the patient a letter of dismissal by registered mail. But sometimes when I use registered mail and require the recipient's signature so I have proof that the patient received the letter, the patient refuses to sign it and claims never to have received my correspondence. What should I do to make sure patients do not have a way to claim they did not get my letter?

A With both certified and registered mail, you should be able to confirm delivery even if you don't get a signature. In addition to sending a certified letter, send a letter by "regular" mail. Sometimes patients will not open or sign for a certified letter, but they will get a letter through regular mail. If the letter sent via regular mail is not returned, you can assume it was delivered.

Of course, if the patient does show up at the practice, the manager should bring him into her office and tell him he is being terminated.

Either way, document what you have done and why. You can do only so much.

You should also contact the risk management folks at your malpractice carrier for their advice.