Electronic mail (e-mail), like letters, faxes,
and telephone calls, is becoming a commonly used surrogate for in-person
contact between physicians and patients. E-mail is not
new, but only in recent years has the technology been easily accessible
to the general public. The growth of the Internet and the availability
of low-cost or free Web-based electronic mailboxes have
taken e-mail out of the realm of university and governmental
researchers and placed it in a majority of American households.
It is projected that there will be a total of one billion accounts
worldwide by the year 20021. Because
of the ubiquitous nature of this medium, e-mail is becoming
a common means of communication between doctors and patients.
Perhaps because of the sudden growth of e-mail use,
there are few articles in the literature discussing e-mail as a
form of communication in the practice of medicine. While some guidelines
have been suggested for physicians in clinical practice2, practical issues such as ensuring
patient confidentiality have not been fully defined. Doctors and
patients need to understand the medical and legal implications of
e-mail use in order to anticipate and avoid problems.
We have identified five features of electronic communication
that can have a positive or negative impact on the practice of medicine. The
goals of this essay are to heighten awareness of the potential benefits
and problems associated with the use of e-mail as a means of
communication between physicians and patients and to promote a discussion
of these issues in the orthopaedic community.
E-mail is an asynchronous mode of communication. In
simple terms, this means that, in an e-mail dialogue, the
recipient does not have to sit idly while the other party is transmitting. Rather,
transmission is active, but receipt is passive; messages are retrieved
(and responded to) when convenient. In this way, e-mail
more resembles an exchange of letters than it does a conversation.
Of course, with information moving at the speed of light, rapid
responses through e-mail can resemble spoken communication.
In general, the potential for asynchrony offered by e-mail
is beneficial for doctors and their patients. A simple medical query
that does not need an immediate reply can be answered hours later,
with no need to have both parties online at the same time. Thus,
the doctor can block out some time to reply to the patient, without
concern that the patient may not be available at a given moment.
While the asynchronous nature of communication through e-mail
can be beneficial, this feature has potential problems. Patients
may not realize that the communication is asynchronous, especially
if, by chance, an earlier message had been replied to immediately.
A naive patient may use e-mail to communicate a problem
requiring immediate attention; as a result, that message could potentially
remain unattended to for an indefinite period of time. Hence, e-mail
is not the preferred means for a patient to notify a physician that his
or her cast is tight or his or her fingers are turning blue. Similarly,
if the physician were to reply to this urgent message by e-mail,
there would be the same potential for delay. That type of information
should not be allowed to sit unread on an e-mail server;
it should be communicated by telephone or in person with the appropriate sense
of urgency.
The only way for a physician to ensure that important e-mail
is not ignored for too long is to check his or her e-mail
continually. However, this is obviously unrealistic, and it would
negate the benefits of asynchrony. We therefore recommend, as noted below,
that all physicians’ e-mail accounts offer an
automatic reply instructing patients to call with urgent issues
and to give appropriate telephone numbers.
Although e-mail is sent without a charge per word, many
e-mail messages resemble telegrams in that they are short
and to the point. This can be a benefit to doctors, who can respond
to direct questions with brief replies. In a face-to-face conversation,
such directness might be considered rude; but this is not so with
e-mail. This is a benefit to patients too, as the doctor
can send answers without necessarily having cleared a block of time for
the conversation. Also, it has been suggested that certain patients
may be able to express themselves more effectively through e-mail3.
The succinct nature of e-mail has its pitfalls. E-mail
is impersonal and can inhibit complete communication. Voice tone
and inflection, which can add substantially to our interpretation
of the spoken language, are lost. Poorly written e-mail could be subject
to misinterpretation, with potentially adverse consequences3. Also, there is little chance for "therapeutic
communication" in e-mail. As we all know, patients sometimes
ask questions not only to obtain information but also to convey
concerns.
There is, in our view, no way around this issue. E-mail
implies terseness, for better or worse. The doctor, therefore, must
not allow patients to use e-mail as a complete substitute
for face-to-face conversation. Often, the right response to an open-ended question
is "come into the office and we’ll talk about
this." In addition, patients and physicians should always
remember that there is no replacement for a physical examination
in the diagnosis of a medical condition. Thus, even if the "conversation" part
of the exchange is complete, the doctor may still be missing an
important part of the picture without doing a physical examination.
This is true even if photographs are attached to the e-mail.
With the old-fashioned method—the method that many doctors
still use—the patient calls and the telephone message is
written down. The doctor returns the call, answers the question,
and, if he or she is diligent, dictates or writes a note for the
chart indicating the content of the conversation. With e-mail, all
of these steps are condensed. E-mail automatically generates
a record of the call and the content of the reply. This certainly
is a time-saver, and it may lead to better care. For these reasons, many
practitioners welcome e-mail as a method for improving
documentation of the patient’s record4.
There are several drawbacks to the permanent nature of e-mail. Many
users of e-mail (physicians and patients alike) may not
realize that an everlasting record is being created. While this
mode of interaction feels informal, it is also permanent4. The contents of computer servers,
which house electronic mailboxes, are often physically preserved
on backup tapes. Thus, even though the user of an e-mail account
may believe that a specific message is being deleted, a permanent
copy of the mailing may (and probably does) exist. The servers and
backup tapes are almost always out of the control of the e-mail
user. As a result, ensuring the permanent deletion of a message
is nearly impossible. Electronically deleted messages are
recoverable and legally discoverable4.
Therefore, any electronic exchange between physician and patient
must be precisely and carefully worded. E-mail is not a place
for off-the-record discussions, as the recorder is running—always.
Once the fixed costs (access to a computer and an e-mail
account) are paid, the marginal cost of sending an e-mail
is close to zero. This can enrich patient-physician communication:
physician accessibility is increased. On the other hand, the elimination
of cost associated with contacting one’s doctor has a potential
downside: there is one less constraint on patients’ contacting
their doctors about anything and everything. In fact, a major concern
mentioned by physicians leery of adopting this new technology is
the potentially large volume of messages that they may receive if
they allow patients to communicate with them through e-mail
on a routine basis4. These physicians
fear being flooded with unimportant messages from patients who inadvertently
abuse this privilege because of the ease and convenience of e-mail
communication3. The answering
of e-mails could overwhelm an already busy clinician, and it would
represent yet another activity for which physicians are not reimbursed3,4. In response to the latter claim, some
authors have suggested that physicians should eventually be reimbursed
for time spent working on e-mail consultations4.
One can debate whether the Internet has really turned the world
into a global village, but one fact is undeniable: by using the
Internet, people can easily keep in touch, regardless of where they
are. By using the World Wide Web, one can read and respond to e-mail
from all over the globe. For the physician trying to keep in touch
with his or her patients, this is a great step forward. The potential
for worldwide access presents no downside to the physician: access
is voluntary but available if needed. However, the ease of access
creates vulnerability in one key area: patient confidentiality.
Confidentiality with use of e-mail is far less ensured
than it is with face-to-face conversation. Although other forms
of communication, such as letters, are also subject to breaches,
with e-mail there is no lost envelope or opened seal; the recipient
may not even realize that the message has been read by others. This unique
attribute may create an even greater demand than usual for protecting
and ensuring confidentiality.
There are several facets to the issue of confidentiality and e-mail
security. An e-mail can be sent inadvertently to the wrong account,
or it can be maliciously opened by snoopers or "hackers." While
the transfer of e-mail can be protected through encryption software,
which scrambles the message until it is received by the intended
recipient, few users of e-mail take this measure. For this
reason, some law firms prohibit communication between attorneys
and clients through Internet-based e-mail, as it is believed
that e-mail communication may not satisfy "reasonable precaution" standards
in protecting the attorney-client privilege4. It is not clear what standards are
expected of doctors in this realm, but it is possible that a doctor
could be held liable for not protecting an e-mail record from
hackers.
E-mail can also be read by parties other than the intended recipient.
The physician cannot assume that only the patient has access to
the electronic mailbox; the receipt of an e-mail message by the
patient alone is not guaranteed. For example, given that many patients
use e-mail accounts provided at their workplace, an employer
may have access to sensitive medical information3,4.
Spouses, family, and friends may also have access to a shared account.
Again, it is unclear to what extent the physician must take steps
to ensure confidentiality, but discretion should be the rule. It
is clear that e-mail creates a permanent record and that
the electronic document must be guarded with the same diligence accorded
true medical records.
We share the belief that patients must be informed of the potential for
breaches in confidentiality prior to using e-mail to communicate
with their physicians2,4. Spielberg
contends that "simply because patients use e-mail informally
in other contexts does not mean they understand the implications
about sensitive medical topics or that those communications may
become a part of their medical records (which others might see)."5 For these reasons, Spielberg (who
is an attorney) recommends that patients sign a written consent
form prior to using e-mail to communicate with their physicians.
Although that may be too much to ask, warnings to patients should
be routine.
A review of these five factors alone shows that e-mail
may represent a boon to patients and doctors but that it is not
without pitfalls. We are unsure as to what the future holds, but
we suggest that we try to shape that future, not just predict it.
We therefore offer the following suggestions to physicians, which
may help to maximize the benefits and minimize the pitfalls.
1. Give your e-mail address to patients only if you
also give them written instructions about the ground rules beforehand. Inform
them specifically about the limits of confidentiality, and provide
them with a telephone number for emergencies.
2. Create a separate e-mail account to be used solely
for communication with patients. This, if nothing else, will remind you
that e-mail to patients is a special form of communication that
is not to be taken lightly.
3. Have somebody—an office assistant, a resident, a
colleague—check that e-mail account often if you
cannot.
4. Place an automatic-reply feature in the e-mail
account used for communication with patients that advises patients
not to use e-mail for emergencies and to give telephone-contact
information. This automatic message should perhaps also include
general caveats about the use of e-mail for doctor-patient
communication (the same information given in number 1 above).
5. Print a copy of each e-mail and place it in the patient’s
chart.
6. Consider all e-mail to be official, written communication.
Do not be afraid to write back "I think I need to see you
in the office for that."
7. Do not offer new diagnoses or treatment suggestions to patients by
e-mail, especially when you do not know the patient.
8. Do not transmit emotionally charged information by e-mail. For
example, biopsy results may not be conducive to such impersonal
communication.
9. Make sure that patients acknowledge receipt of your response.
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