Special Report
MIEC Claims Alert
Number 24A
Revised January 2004

Using e-mail to communicate with patients and other health professionals: What are the pros and cons?

• Opinions vary
• MIEC recommends
• Additional reading
• To reach MIEC
• Figure 1: For our patients
• Figure 2: Our agreement

Electronic mail (email) is a popular choice for com-municating with friends, relatives, and businesses; however, physicians and patients alike have been slow to embrace this medium for the exchange of healthcare information. Studies have been conducted to determine how frequently and under what circumstances physicians and their patients interact via email, or why they do not. Numerous resources are available to physicians interested in email that outline the benefits and liability risks affiliated with electronic communication.

As with all aspects of a physician's practice, MIEC encourages policyholders to consider the pros and cons of any new policy and procedure, technology, or system, before its implementation. Email can be a valuable time-saving communication tool, but if started in haste may create liability problems for physicians. Before you use email in your practice, and especially before you encourage patients to communicate online with your office, consider these advantages and disadvantages.

Opinions vary

Pros: According to many articles that have been written to delineate the positive and negative features of email, opinions vary greatly among physicians and their patients. Benefits discussed by physicians who advocate the use of online communication include, in part:

(A) Electronic communication may enhance patient compliance with treatment recommendations. In one publication, a contributing internist used as an example his patients who engage in frequent business travel, for whom it is difficult to return frequently to the physician's practice, but who require close monitoring (e.g., Coumadin patients and prothrombin times; Statin patients and liver function tests). These patients can be reminded by email that follow-up lab work is needed and, once the diagnostic test has been completed and returned, the results can be emailed to the patients.

(B) Email improves efficiency when scheduling appointments and processing non-narcotic medication refills requested by established patients. One family practice physician reported that his staff can schedule an appointment in two minutes online compared to 10-12 minutes over the phone.

(C) Email allows physicians to use time more effectively when answering patients' routine medical questions. One doctor said that he is able to answer three or four routine online messages in far less time than it takes to make three or four phone calls, and he feels less rushed.

(D) Documentation of electronic communication is better than telephone-based encounters. Email documentation reflects exactly what the patient asked and what the health care provider advised, unlike documentation of phone calls that is often quite abbreviated, inadequate, or altogether nonexistent. Of note: Physicians and staff members who communicate with patients via email should be aware that "deleted" email is never truly deleted. As "electronic discovery" becomes more common in malpractice litigation, any information stored on a hard drive or on back-up tapes can be retrieved, whether or not the data has been "deleted."

Cons: Physicians who resist using email to communicate with patients give two primary reasons for their avoidance of the electronic medium: 

(A) Physicians question the security of protected health information transmitted via email. To minimize these concerns, some physicians use secured online services such as:

• RelayHealth  based in Emeryville, California; 
• Medem, a company owned in part by the AMA; 
• Healthyemail  or 
• MyDocOnline Inc., an organization owned by Aventis Pharmaceuticals. 

Health care providers who offer online consultations charge patients a fee for the service. For example, many physicians in the Medem network charge $25 per consultation; Medem withholds a $2.50 usage fee per transaction, but only if the doctor charges the patient. (Please note: MIEC does not endorse any of the products, services, or third-party payers mentioned in this newsletter.)

(B) Health care plans do not reimburse physicians for time spent online consulting with patients. An exception is Blue Shield of California. Its network physicians may be paid $20 per email consultation for minor, non-urgent matters if they use RelayHealth's secured system.

MIEC recommends

MIEC welcomes all technologies that enhance a medical practice. We recommend that physicians decide for themselves which technologies would benefit their practice and their patients, and make informed decisions when purchasing and using computer software, hardware and consulting services. Consider these loss prevention recommendations as you develop your email policies:

Educate yourself and your staff about the software and hardware aspects of your email system. 

Investigate the reliability and the capacity of your Internet service provider (ISP). Ask if there is a limit on the number of messages or size of messages your individual email in-box can handle. What happens if the capacity is exceeded? (Some ISPs delete older, and possibly unread, messages when a user's in-box is full while others reject new messages until the old ones have been read.) Be sure you know what your ISP will do and be sure that your staff checks e-mail often enough to make sure nothing, new or old, is lost or rejected.

Decide how you will use email in your office. 

Establish a written policy and procedure in your practice that defines how you and your staff will handle email. To avoid being overwhelmed with email messages that require in-depth and/or immediate responses: 

(1) Communicate via email only with established patients;

(2) Limit the types of communication to which you will respond (e.g., to: schedule appointments, request non-narcotic prescription refills, report normal diagnostic test results, give medical advice for non-urgent medical concerns); 

(3) Avoid using email to discuss highly-sensitive issues (e.g., HIV test results, STD test results, mental health information, questions of a sexual nature); 

(4) Do not use email to report abnormal test results - a physician should report these to patients in person or by phone, to ensure the patient receives and understands the significance of the information, can ask questions, and is able to obtain the doctor's follow-up advice; 

(5) Determine who in your practice will respond to different categories of messages (e.g., appointments by scheduling staff; medication refills and normal test results by nursing staff after your review and authorization, etc.);

(6) Educate patients about the limitations of your ability to make medical evaluations and diagnoses, dispense medical advice, or prescribe new medications in response to an email inquiry; 

(7) Print and initial a hard copy of patients' email messages and your responses; file the copy in patients' charts;

(8) As recommended by the American Medical Association's Guidelines for Physician-Patient Electronic Communications (available at the AMA's web site:), configure an automatic reply to patients to acknowledge receipt of their messages (e.g., "Your message has been received at the office of Dr. XX. If you have not heard from the doctor(s) within XX hours, please call, fax, or mail the office with your inquiry. Practice name, address, phone no.;"

(9) Establish a turnaround time for email messages so patients will know when to expect your response to their inquiries. How often will the incoming mailbox be checked? If your computer's email in-box is always open (that is, your computer is always logged on to the Internet or the source of your electronic mail system), program the computer to sound a distinctive alert when new messages are received. If the computer is not continuously logged on to the email system or Internet, some-one must start the program frequently to check for new messages. Important: Activate the autoreply feature in your computer (or email system) to inform patients that you are unavailable when you are off-call or on vacation. Advise them how long you will be unavailable, and whom to contact (and how) in your absence; and

(10) Ask patients to confirm that they received a message from you and/or your office.

Draft written guidelines

Once you decide how you will use email in your practice, draft written guidelines to give patients who wish to correspond with your office using email. The guidelines should inform patients: (a) about the limitations of using email; (b) that messages/inquiries should be brief; (c) about the possibility that email will not be received in a timely manner; (d) what to do if their email inquiries are not answered in a timely manner; (e) about the possibility that improperly-addressed messages or replies could be received by unauthorized persons; and (f) that reporting medical problems to the doctor by email may not be a safe alternative to seeing the doctor. Inform patients that they must decide if their request can appropriately be satisfied by email. They must obtain an appointment or a telephone consultation with the doctor it they believe their medical need is significant.

Ensure security of your electronic communication to protect patient confidentiality. 

Lawyers, medical ethicists, patient advocates, and physicians alike are concerned about the potential breach of confidentiality of information transmitted electronically. Email messages that are misaddressed - as the result of an omission or mistyping of one letter or digit in the recipient's email address - could reach the wrong party. Most ISPs return misaddressed messages as "undeliverable," unless a mistyped address is the correct address for someone else. The promptness with which misdirected messages are returned varies among ISPs.

To safeguard against the possibility that a mis-sent message is read by the wrong persons (or that a properly addressed message is read by someone who has access to the recipient's mailbox), you may encrypt your email responses - which means your office and the recipient must have the same encryption software. Inquire about encryption software to preserve the confidentiality of your email; if your email software program does not have encryption capabilities, you may have to purchase "add-on" software. Consider enrolling with a secured online service. (See online services above.)

Another safeguard against potentially misdirected email is to add a disclaimer to any online responses transmitted to patients. For example, include the notice, "This message is intended only for the use of the individual(s) or entity to which it is addressed, and may contain information that is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you received this communication in error, please notify the sender immediately by email. Thank you for your assistance."

Develop and implement a written patient-clinician privacy agreement for the use of email. 

Require patients to agree to abide by the written guidelines for the use of email communication and to sign an authorization that gives you permission to communicate with them at a designated email address. [For a sample Guideline/Agreement/Authorization see Figures 1& 2.]

Additional reading:

Tyler Chin, "Online consultation: What's it worth?" AMNews, June 10, 2002.

Tyler Chin, "Patients e-mail - but they still keep calling," AMNews, June 10, 2002.

Ann Carrns, "Online Doctor Consultations Show Promise in Pilot Study," The Wall Street Journal Online, October 24, 2002.

Tyler Chin, "Some California physicians will be paid for online advice," AMNews, November 25, 2002.

Christine Wiebe, "Doctor-Patient Email: A Revolution Waiting to Happen," Medscape Money & Medicine, 4(1), 2003.

Francesca Lunzer Kritz, "uncertainty@dr-mail.com," Washington Post, April 1, 2003.

Mike Norbut, "Doctor redefines visits with phone, e-mail," AMNews, October 20, 2003.

How to reach MIEC