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White Paper
BEVERLEY KANE, MD, AND DANIEL Z. SANDS, MD, MPH, for the AMIA Internet Working Group, Task Force on Guidelines for the Use of Clinic--Patient Electronic Mail.
ABSTRACT
Guidelines regarding patient-provider electronic mail are presented. The intent is to provide guidance concerning computer-based communications between clinicians and patients within a contractual relationship in which the health-care provider has taken on an explicit measure of responsibility for the client's care. The guidelines address two interrelated aspects: effective interaction between the clinician and patient, and observance of medicolegal prudence. Recommendations for site-specific policy formulation are included.
Health care organizations differ in the methods they adopt to communicate with patients. The task force acknowledges that it is not realistic to prescribe a detailed set of practices for universal implementation.
The guidelines that we present are based upon our accumulated experience and the current literature. All recommendations should be adapted to individual circumstances. Ongoing evaluation of the guidelines is needed within a variety of institutions and relationships.
Definition
Patient-provider electronic mail is defined as computer-based communication between clinicians and patients within a contractual relationship in which the health care provider has taken on an explicit measure of responsibility for the client's care. This guideline does not address communication between providers and consumers in which no contractual relationship exists, as in an online discussion group in a public support forum.[1]
Background
Although there is some literature in praise of electronic messaging between providers,[2-5] there is a paucity of published research on the subject of patient-provider e-mail, and no long-term studies of which We are aware.
The Nature of E-Mail
E-mail is a hybrid between letter writing and the spoken word. It is more spontaneous than letter writing and offers more permanence than oral conversations. Words in e-mail can be more carefully chosen than in telephone conversation. While unencrypted electronic messages may, in theory, provide less privacy than postal mail or telephone calls, in practice e-mail replaces and is used more like the telephone but with less urgency. Because of its asynchronous nature (volleying back and forth over hours or days), e-mail helps prevent "telephone tag" and avoids the interruptions associated with telephone calls or electronic pages.
E-mail follow-up allows retention and clarification of advice provided in clinic. Often patients under the duress of illness forget to ask important questions. Selfcare instructions might not be fully understood or retained. E-mail creates a written record that removes doubt as to what information was conveyed.
E-mail is especially useful for information the patient would have to commit to writing if it were given orally. Examples include addresses and telephone numbers of other facilities to which the patient is referred; test results with interpretation and advice; instructions on how to take medications or apply dressings; pre- and postoperative instructions; and other forms of patient education. Some frequently used educational handouts can be ported to an e-mailer template or formatted for the provider's home page on the World Wide Web.
E-mail messages can embed links to educational materials and other resources on the clinic's Web site or on external sites. In some electronic mail applications, clicking on a "live" universal resource locator (URL) link inside a mail message launches a web browser and takes the user directly to the indicated resource.
Clinics can provide lists of URLs on a particular topic, such as pregnancy, and create e-mail reply templates with pointers to frequently used reference sites.
While telephone messages are often overlooked, forgotten, or lost under piles of charts, e-mail messages are less likely to accidentally fall through the cracks of a busy practice. Voice mail systems can be plagued with irksome branching menus, lapses on hold, and the threat of telephone tag. Many callers hang up in frustration. With or without annoying automated systems, telephone messages are typically relayed along the "sneakernet"-a physical chain of human transmission from receptionist, to nurse, to doctor-with many "While you were out ..." slips lost in the process.
In contrast with telephone conversations, e-mail is self-documenting: Copies of e-mail can be printed or attached to the patient's electronic record.
Finally, since many malpractice claims can be traced to faulty communication, good communication is part of good insurance.
E-mail at the Millennium
Technically minded, electronically equipped health care consumers have accelerated the demand for e-mail access to their health care providers.[6] The use of e-mail has dramatically increased from 100,000 users in the late 1970s to about 50 million users in 1997, with over 100 million users predicted by the year 2000.[7] This trend correlates with the advent of low-cost Internet access, mass-marketed online services, and employer-provided e-mail accounts to an estimated 30 to 40 million employees.[8] Thus, 15% of the population of the United States is currently using e-mail, and this number will naturally continue to increase.
Estimates of physician use are not as readily available.
In 1996 one author[9] estimated that over half the physicians in the United States had personal computers, and at least 20% had gone online. A conservative estimate would be that the percentage of e-mail use among physicians is at least that of the overall population. As more health care organizations provide e-mail accounts to physicians, this proportion will rise.
In many locales, consumer-driven demand is urging health care providers, both individuals and institutions, to establish a mechanism for e-mail exchanges. Electronic access to a clinic's providers and educational resources is also likely to be a market differentiator in the health care industry.[10]
Clinician-Provider E-mail
Neill et al.[11] surveyed 117 e-mail-equipped patients at a university-based family practice center. Less than one-third of the patients reported that their physicians had an e-mail address, and only about one-third of those (10 patients) had used e-mail to communicate with their physicians. Of those who did not use e-mail with their doctors, half had never considered it, one-third reported no need to do so, one cited confidentiality concerns, and one felt uncomfortable. Almost all who had used e-mail for this purpose felt satisfied.
A significant majority felt that e-mail would be a useful way to communicate with their physicians. They cited speed, convenience, utility for managing simple problems, efficiency, improved documentation, and avoidance of telephone tag as positive characteristics.
In another university-based practice, Fridsma et al.[6] studied patient attitudes toward patient-provider communication. In this Silicon Valley locale, almost half the patients had access to e-mail, most through their workplaces. About one-quarter were already using e-mail to communicate with their providers, and another quarter said they would do so if e-mail were available. The respondents expressed concerns about confidentiality, especially when e-mail access was through their employers.
Table 1
Summary of Communication Guidelines
Other reports are anecdotal. Green[12] described proper use of e-mail and mentioned the more cost-effective management of capitated patients. In an interview with Green and two other physicians who use e-mail to communicate with their patients, Ojalvo[13] discussed the benefits and addressed privacy issues. Some authors also suggest guidelines for use.[14],[15]
Guidelines
Guidelines for using e-mail in a clinical setting address two interrelated aspects: effective interaction between the clinician and patient (Table 1) and the observance of medicolegal prudence (Table 2).
In these times of increasingly impersonal, truncated, and regulated care, clinic time with patients is often compromised. If a provider anticipates a need to contact a patient again soon with regard to test results or other follow-up, he or she should inquire about the patient's communication preferences. Informally, the provider can ascertain preference for e-mail, telephone or voice mail, or postal exchange at the time of the visit, and document it in the chart. A more formal arrangement entails the use of informed consent, discussed below. Patients might elect e-mail, telephone or voice mail, personal meeting, or the postal route at different times for different purposes. The provider should confirm on a periodic basis which route to use for communication.
Prescription refills, lab results, appointment reminders, insurance questions, and routine follow-up inquiries are well suited to e-mail. It also provides the patient with a convenient way to report home health measurements, such as blood pressure and glucose determinations.
Issues of a time-sensitive nature, such as medical emergencies, do not lend themselves to discussion via e-mail, since the time when an e-mail message will be read and acted upon cannot be ascertained. Sensitive and highly confidential subjects should not be discussed through most e-mail systems because of the potential for interception of the messages and the potential for transmission of messages to unintended recipients.
Table 2
Medicolegal and Administrative Guidelines
Patient-Provider Agreement
In general, the use of e-mail depends upon negotiation between patient and provider. Negotiation should focus on the following issues:
Often, the context of the patient's message will indicate the expected turnaround time. A patient who inquires about the results of a routine cervical smear will tolerate a longer messaging interval than one who is experiencing even mild side effects from a medication.
These points should be discussed with the patient and the discussion documented in the record. A more conservative approach would be to commit the agreement to writing. In that case, have the patient sign the document, give a copy to the patient, and place a copy in the patient's chart. A summary of the policies and standards should be available on the clinic's web site.
For example, the Stanford Medical Group's external web page on Electronic Mail Services illustrates how these policies can be conveyed to patients.[16]
Handling of Messages
In addition, out-of-the-office replies should be activated on any e-mail account that will not be serviced by staff or covering physicians during an absence that exceeds the established e-mail response time. Such messages should include the provider's estimated date of return and instructions on whom to contact for immediate assistance.
Some e-mail programs have sophisticated filtering mechanisms that trigger different automated replies for patients, colleagues, and unknown correspondents. At this writing, about half of the 12 most commonly used e-mail applications provide filtered automatic reply capability.[17] The UNIX ".vacation" script affords simple auto-reply but requires UNIX shell privileges, is too cumbersome for the average user, and sends the same message to all parties.
The following steps result in efficient archiving: (1) Include the full text of the patient's query in the email reply. (2) Copy the reply to the sender (provider). When the Internet delivers the provider's copy, which now includes both the original message and the provider's reply, the message should be printed and filed in the chart. Printers must operate in an area that is accessible only to staff and not to other patients.
When sending out group mailings, use the "blind cc:" (blind carbon copy, or blind courtesy copy) software feature to keep recipients invisible to each other. When using this feature, enter the provider's own name in the "To:" field and place the list of recipients in the "bcc:" field.
Clinicians should be aware that e-mail messages are typically stored for months or years on backup tapes. Pressing the delete button on the keyboards doesn't necessarily erase the message from the system. Such "deleted" messages containing disparaging, flippant, or incriminating remarks have come back to haunt physicians.
Medicolegal Issues
Aspects of electronic messaging of particular interest to risk management and legal departments concern data security and liability for advice. Medicolegal anxiety, however, should not be allowed to disable open communication as the basis for a healthy provider-patient relationship.
The most wary, not necessarily the best, approach dictates that patients be asked to sign printed guidelines by way of informed consent at the time an electronic relationship is established. In addition to the points detailed above, electronic messaging agreements should include, in nontechnical language:
Additional Recommendations
This is a CONFIDENTIAL medical communication.
Many commercial e-mail programs allow creation of stationery templates. Even simple UNIX-based mail programs such as pine can be scripted to create headers and footers.
In March 1997 the Committee on Maintaining Privacy and Security in Health Care Applications of the National Information Infrastructure, under the National Research Council, released a comprehensive preliminary report on the privacy and security of health information.[20] Although the authors did not specifically address e-mail as a separate entity for security purposes, all their findings and recommendations are germane to this topic.
With regard to encryption the authors state: "...
[S]ecurity tools based on cryptography are still largely undeployed anywhere in the public computing industry, much less in health care. In the sites visited, the committee found almost no use of encryption technologies except in a few localized experimental settings...." Of additional interest is that the Committee acknowledges the tension that will always exist between the need for access and free flow of information and the need for security. Providers should be prepared to encounter patients who are sophisticated Internet users, aware of its privacy limitations, who nevertheless initiate unencrypted e-mail discussions of a surprisingly intimate medical nature. Wireless communications should never be used to transmit unencrypted patient data.
Site-specific Policy Formulation
There is growing evidence to suggest that electronic resources, both e-mail and Web-based self-help documents, will result in substantial cost savings to clinics. Savings of time spent on the telephone will result from a reduction in telephone tag and a reduction of repetitious instructions. Many clinics, especially those with capitated plans, anticipate replacing inappropriate office visits with online support, including teleconferencing.
Health care institutions will need to develop written policies to address communication, technical, and medicolegal issues. Questions that must be answered include:
A survey or focus group conducted among both staff and patients before instituting an e-mail policy will reveal important additional considerations innate to each venue. Seeking buy-in from all users and stakeholders will foster maximal cooperation with the new directives.
All policy decisions regarding electronic mail should be placed in the institution's policies and procedures manual, given to all staff in paper form, and be available in electronic form on individual workstations or on the clinic's internal Web site.
E-mail storage and retrieval must eventually be integrated with a comprehensive electronic medical record (EMR) and with patient education resources, some of them Web-based. EMRs over secure internal Internet sites, called intranets, seen destined to be the future of clinical computing services, and they will subsume e-mail functions. E-mail and other computer-based resources are not an entirely satisfactory substitute for face-to-face clinical evaluation, however.
Ultimately, quality-of-care outcome assessments of adjunctive forms of communication must be benchmarked against physical contact.
The Task Force thanks the following people for comments, encouragement, and assistance: Ramsey D. Badawi, William M. Detmer, Valerie Florance, Douglas B. Fridsma, Carole Gassert, Sharon Jadrnak, Nancy M. Lorenzi, Gary Malet, Anna Mancini, Kathleen A. McCormick, Alexa McCray, Bruce C. McKenzie, Adrian K. Midgley, Jeanne Nevin, Thomas C. Rindfleisch, Edward K. Shultz, and Jonathan Teich.
References
1. Ferguson T. Health Online: How to Find Health Information, Support Groups, and Self-Help Communities in Cyberspace. Reading, MA: Addison-Wesley, 1996. See also: Ferguson T. A guided tour of self-help cyberspace. 1996.
(http://www.healthy.net/selfcare).
These guidelines were endorsed by the Board of Directors of AMIA in June 1997. Members of the task force are: Beverley Kane, MD, Chair; Ted Cooper, MD, Tom Ferguson, MD, Joseph Kannry, MD, Tim Kieschnick, Gretchen Murphy, Edward Anthony Oppenheimer, MD, Thomas Payne, MD, Larry Pfisterer, and Daniel Z. Sands, MD, MPH.
Affiliation of the authors: American Medical Informatics Association, Bethesda, MD.
Correspondence and reprints: Beverley Kane, MD, Philips Multimedia Center, 1070 Arastradero, Palo Alto, CA 94304. e-mail: (bkaneQpmc.philips.com).
Received for publication: 7/28/97; accepted for publication: 9/22/97.
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