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The Online Patient


The New Physician September 2000
Imagine a technology that would allow you and your patients to communicate instantly, from a distance, at the touch of a button. You could remotely diagnose patient problems, answer questions about therapies, give timely encouragement during difficult lifestyle changes. But there’s a danger to this type of communication. Not speaking face-to-face, you might miss something between the lines—risking your patients’ health and inviting a lawsuit. Add to this the possibility that these novel patient encounters might not be reimbursable, there may be privacy problems and you could become overwhelmed with constant patient requests.

Been There. Done That. When Alexander Graham Bell invented the telephone in 1876, physicians were among its early users, quickly seeing the potential of this new marvel. By the mid 1920s, the telephone was well-integrated into medical practice.

E-mail is the new communications kid on the block, promising similar benefits and risks as those of its telephonic ancestor 100 years earlier. Yet, there are differences between the old and the new—worth knowing if you wish to join the roughly 3 percent of physicians in the United States who touch base with their patients in cyberspace.

The End of Phone Tag. Unlike the telephone, e-mail communication is “asynchronous”—as computer network gurus say—since sender and receiver need not be available at the same time. E-mail-using physicians often find they can answer patient questions more efficiently by sending electronic messages than by using the phone, and they can do it in their own time. They can also more carefully craft their message using
e-mail. Plus, if they have favorite sources of Web-based patient information, they can imbed the URLs in the message. There’s also the added advantage of e-mail’s self-documentation—physicians can just print the entire exchange for insertion into the patient chart.

And think of e-mail’s efficiency. Electronic patient records, linked to e-mail, could be used to identify and contact groups of patients for sending reminders for preventive health measures. Lab results, drug warnings, office newsletters and call schedules could be easily and cheaply distributed with e-mail.

The benefits of improved patient communications should not be underestimated in the time-pressured managed-care era. But are there too many risks?

Common Misperceptions. The risks of e-mail are subtler than the benefits, largely because e-mail is commonly misperceived as immediate, informal, local, temporary, personal and private. In fact, e-mail can be all or none of these.

The immediacy misperception could be extremely dangerous to patients who assume you’re in your office and checking your e-mail regularly. This false assumption may lead them to sending time-sensitive and health-critical questions. But what if you’re actually on vacation?

And because e-mail seems informal, you might be tempted to say things in the message that you would never write in the chart. Harvard University educator and attorney Alissa Spielberg says e-mail communications are a type of medical record and should automatically become part of the chart, so you need to be careful of what you type in your message and recognize that e-mail is not a simple, casual chat. Plus, the federal government could view the e-mail exchange as telemedicine, and as such, it can incur medical liability.

And what about the misperceived geographic closeness of the physician and patient? E-mail appears to be local, or more precisely, the distance between the two typists just doesn’t seem real. What are the implications of giving medical advice to a person who is not your patient and resides in another state? You could find yourself practicing medicine without a license without even realizing it, and your malpractice insurance carrier could try to deny coverage.

Plus, watch out—e-mail isn’t temporary. Yes, you can hit delete, and that may work well at home, but your employer’s e-mail is probably backed up every night, and a long-deleted message may be technically recoverable and legally discoverable. And if your patient has a copy of the message, you’d better have one, too.

As for e-mail’s apparent personal nature, don’t be fooled. Remember, neither of you can actually see the other person. The “patient” may really be an interloper looking for damaging personal information. Even if it is your patient, the visual cues such as facial expressions can lead to misunderstandings—making irony, humor and sarcasm hazardous. Plus, giving bad news through e-mail is insensitive and potentially dangerous. So, you shouldn’t use electronic communication for that type of personal and intimate exchange.

Perhaps most deceptive is e-mail’s semblance of privacy. It appears to be a confidential exchange, but there are complications in both directions. Employers currently have the right to read their employees’ e-mail because they own the system—a risk for both patient and physician. Even if the message is encrypted during transmission, it may become vulnerable when decrypted by the e-mail software. Internet service providers have access to their clients’ e-mail, and they can be legally required to release it. Furthermore, once an e-mail exchange becomes part of the medical record, it assumes the privacy risks of that medium (see The New Physician’s May–June 2000 “InfoMed”). The exchange becomes accessible to third-party payers, employers, law enforcement officials and others the patient may not have expected when the supposedly private, personal e-mail was sent. Therefore, nothing said in e-mail should be considered “off the record,” although legal arguments can be made that e-mail should be considered more private than your progress notes and even stored separately.

Other Risks. Imbedding URLs pointing to online information sources can be perilous if the information you are leading them to changes without your knowledge.

E-mail interface problems can also be troublesome. For example, if you participate in Internet discussion groups, you already know that a message frequently gets sent to the entire group when it should have gone to a specific individual. Errors like these are usually annoying or mildly embarrassing, but in the case of sensitive medical data, such mistakes can be damaging.

Constructing a Safety Net. Given these risks, how can we proceed in a way that is positive for both patient and physician? Ace Allen, editor of Telemedicine Today, describes the proper course: “Do what makes sense clinically, make sure your legal counsel knows what you’re doing, and establish a formal policy.”

The American Medical Informatics Association, as well as Spielberg and other experts, have offered guidelines for e-mail usage which you can use to craft this policy.

First, make patients aware of e-mail’s limitations, and have them enter into a written agreement about how e-mail is to be used in the physician–patient relationship. The agreement would explain why e-mail should not be used for emergency communications, why it isn’t necessarily private, and it should detail what security procedures are in place. It should also say that sensitive information, like mental health and HIV status, should never be discussed in cyberspace. The patient should decide whether encryption must be required or waived, they should be aware of how you will handle your e-mail, whether anyone else in your office will see it, whether e-mail will be printed for the chart, and who else has access to your charts.

Second, follow certain procedures to reduce risks and speed processing. For example, since an interloper might send e-mail posing as one of your patients, don’t just hit “reply.” Instead, create a new message, using the e-mail address the patient initially gave you. Consider asking patients to put standard subject headers (like “Pharmacy,” “Appointment” or “Nurse”) that would allow you to easily route mail that doesn’t need your attention. Agree to answer e-mail within a certain number of days. Include an automatic header in your clinical e-mail, like “This is a confidential medical communication,” and a footer that explains what patients should do in an emergency or when they don’t receive a timely reply.

Third, know that it’s dangerous to give advice to strangers online. As Spielberg explains, “The key issue is whether the e-mail exchange has the hallmarks of a doctor–patient relationship.” If you charge for your advice, for example, you probably established a relationship, and the issues of licensure and malpractice come into play. But if it’s just general advice, like you’d get from a radio call-in show, you’re probably safe.

Finally, recognize that low-income patients may not have access to e-mail. Ensure traditional communication methods survive so the benefits of this new technology for some do not create barriers to access for others.

With careful attention to the risks and an awareness that the online legal waters are largely uncharted, you and your patients can help shape how e-mail is integrated into medical practice and culture.
New Physician contributing editor Rick Stahlhut is a medical informatics writer and consultant. This “InfoMed” marks his final column. If you have questions for Rick, contact him at, or check out his Web site, at