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E-MAIL: OPPORTUNITIES & RISKS FOR PHYSICIAN-PATIENT COMMUNICATION
by Vincent Gualtieri, MD*
Urologist, Sherman Oaks, CA
Member, CAP Board of Directors

Logging onto the Internet to check for my e-mail messages, at least daily, has become a part of my normal routine. The convenience and economic benefits of e-mail have facilitated its popularity and rapid acceptance. Hence, integrating use of e-mail into my office practice hardly seemed novel or risky. But, I still have some misgivings about using e-mail for physician-patient communications. This article is intended to share some information about using e-mail that I found helpful.

Benefits: Itemizing the many benefits of e-mail is more challenging than one might guess. Perhaps one of its significant advantages over my telephone is the "asynchronous" nature of e-mail. The message-sender need not worry whether the intended recipient is available. Certainly, the opportunity to avoid playing endless "telephone tag" is appealing. Also, printed e-mails appear to be more permanent and reliable than telephone message slips that often vanish.

E-mail lends itself to such routine tasks as writing prescriptions, approving refills, and making, changing and confirming office appointments. Sending test results and patient information by e-mail, among medical professionals, tends to be both efficient and cost-effective. E-mail messages can be "self-documenting," merely by means of a mouse-click. E-mail creates its own record and avoids the "failed attempts" at telephone contact. Also, e-mail may even enhance the quality and quantity of physician-patient communications. For example, reiterating your follow-up instructions by e-mail conserves scarce time during office visits, and provides a permanent, readable copy for patients, family members or caregivers.

Risks: Many of the same characteristics that make e-mail so popular tend to create substantial risks. Everyone agrees that use of "asynchronous" e-mail for emergency or urgent messages can be dangerous. When e-mailing, a message-sender seldom can confirm that the message was received, much less by whom. Patients predictably will provide more information and details via e-mail, but may not realize that a new symptom or complaint, e.g., chest or abdominal pain, merits immediate verbal communication with their physicians.

Privacy of sensitive information is another concern. When e-mailing test-results or treatment instructions to your patient's electronic mail box, can a doctor rest assured that only the intended message-receiver has access? Does the doctor even know whether the message is going to the patient's home, as opposed to an office or work place? Regrettably, the answer is "No." Practically speaking, it is impossible to guarantee the security of e-mail.

Because of the convenience and low-cost of e-mail, the number of messages to read and answer will probably increase. Not only is reading and responding to e-mail time consuming, but also, allowing e-mail messages to accumulate in your in-box poses risk. In our litigious society, an untimely response to e-mail may appear negligent, when a bad outcome prompts re-examination using 20:20 hindsight. Also, any physician-patient e-mail messages (even those you thought you "deleted") probably will be evidence, subject to a subpoena, in a subsequent lawsuit for malpractice.

Practical Advice: Maximizing the opportunities posed by e-mail, while taking into account all the new risks, requires careful planning. Any physician would be ill advised to simply begin communicating with patients via e-mail without setting some reasonable ground rules. Here are some recommendations1 :

• Be selective regarding which patients get your e-mail address. Limit use of e-mail to current patients only; i.e., those patients who have regular office visits or on-going treatment or therapy.
  
• Develop guidelines in a patient handout, and provide your handout to those patients who ask to use e-mail:
  
• Include examples of the type of messages that are appropriate for e-mail, e.g., report on effectiveness of new prescription.
  
• Give examples of time-sensitive issues and situations when patients will still need to contact you directly for, e.g., drug reactions, chest pain.
  
• Disclose who in your office will have access to your e-mail (staff, or physician, only).
  
• Educate your staff that certain types of messages are "off limits" for e-mail and that staff should advise patients to contact you about these subjects.
  
• Use the "auto-response" features available from most e-mail providers to request confirmation of receipt, and to notify patients when you are away.
  
• Before you send off that e-mail:
  
• Refer to the purpose of your e-mail message in the subject line, e.g., "Please make an appointment about your medication.".
  
• Include both the patient's name and identification number in the body of every e-mail message (important for subsequent filing in medical records).
  
• Proof read all e-mail messages for accuracy and clarity of instructions, and print an office copy to be filed, before sending them to patients.
  
• Avoid sending e-mail messages when you're angry or irritated. Rather, save and re-read the message later, and tone it down, if necessary.
  
• If sending e-mail messages to more than one patient, be sure that you do not reveal the identities of other patients to the message-recipient.
  
• File a copy of EVERY e-mail, both TO and FROM patients, in the medical record as documentation of patient communication.
  
  

1 For more detailed information, see: (1) Kane B, Sands DZ, Guidelines for the clinical use of electronic mail with patients, Journal of the American Medical Informatics Association, 1998; 5:104-111; and (2) Guidelines for physician-patient electronic mail communications, published by the A.M.A. Board of Trustees (Resolution 810 [A-99]), available at: www.ama-assn.org.

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