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J Am Med Inform Assoc. 1998 Jan–Feb; 5(1): 104–111. | PMCID: PMC61279 |
Copyright © 1998, American Medical Informatics Association Guidelines for the Clinical Use of Electronic Mail with Patients Beverley Kane, MD and Daniel Z. Sands, MD, MPH Affiliation of the authors: American Medical Informatics Association, Bethesda, MD. Received July 18, 1997; Accepted September 22, 1997. 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. The purpose of this document is to guide clinicians and health care
delivery organizations in the use of electronic mail (e-mail) communication
with patients so that this method of communication might enhance the value of,
rather than introduce complications into, the provider—patient
relationship. 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. 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. 1Although there is some literature in praise of electronic messaging between
providers, 2,3,4,5
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. 10Clinician—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. 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. 14,15Guidelines 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). | Table 1Summary of Communication Guidelines |
| Table 2Medicolegal and Administrative Guidelines |
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. Patient—Provider Agreement In general, the use of e-mail depends upon negotiation between patient and
provider. Negotiation should focus on the following issues: 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. 16Handling of Messages - Automatic reply to incoming messages. E-mail software should be
configured to send automatic replies in response to all incoming messages from
patients. Replies should be of the form, “Your message has been received
by Dr. Leslie Smith. I will attempt to process your request within one
business day. If you need immediate assistance, please call Pat, my nurse, at
444-555-6666.”
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. - Archiving of e-mail transactions. E-mail exchanges constitute a
form of progress note. Unless the provider is using an electronic patient
record that allows the inclusion of e-mail messages, each e-mail message
should be printed in full and a copy placed in the patient's paper record.
The following steps result in efficient archiving: (1) Include the full
text of the patient's query in the e-mail 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. - Confirmation of action on patient's request. A new reply message
should be sent out upon completion of patient's request for prescription
refills, records transfer, and other transactions.
- Acknowledgment of messages. For messages containing important
medical advice, patients should be instructed to acknowledge messages by
sending a brief reply. When such acknowledgment is expected, the printed
(chart) copy should not be filed until this confirmation is received.'
In the absence of such confirmation, it cannot be assumed that the patient
has received, much less read, important instructions. When in doubt, confirm
delivery by telephone. - Escalation of communication. E-mail from providers should include
a footer (signature file) that invites patients to escalate communication to a
phone call or office visit, should they feel that e-mail is insufficient. The
footer should give the appropriate contact information. Providers may need to
actively discourage the use of e-mail as a substitute for clinical
examination.
- Address book and group mailings. Each provider should maintain a
list of patients who communicate with him or her electronically. The address
book feature of nearly all e-mail software permits easy maintenance of such a
list. If it becomes necessary to notify the general patient population, or a
group of patients, of an impending shutdown for network maintenance, recent
mail blackouts, new clinic services, or a change of address, the clinic will
have a ready-made mailing list. However, group-addressing, where those in the
group see each other's names, should never be used to send mail to patients.
Even the fact that a person sees a particular health care provider is
confidential information. In addition, patients have become indignant about
open inclusion on lists like the age-revealing list of women who are due for
mammograms.
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. - Emotional content of e-mail. Irony, sarcasm, and harsh criticism
should not be attempted in e-mail messages. The impersonal nature and
ambiguity of e-mail often results in real or imagined exaggeration of
animosity toward the recipient. Providers must realize that sick, anxious, or
angry patients might indeed express stronger sentiments with e-mail than they
would face-to-face or over the phone. Clinicians should make an effort to
restrain their language despite their own stress and fatigue.
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: - Description of security mechanisms in place: an explanation of the
general nature of the network and its level of security. Is the clinic using
an intranet with a firewall? Is the provider or the institution directly on
the Internet, or is there an intermediary Internet service provider (ISP) who
conceivably monitors transmission? Is encryption software in use?
- Indemnity for technical features: a clause to limit liability for
network infractions beyond the control of the health care providers. Examples
include system crashes, power outages, and overloads at the ISP level.
- Waiver of encryption requirement: a mechanism for patients to opt
out of the use of encryption if they do not wish (or are unable) to comply
with the extra processing required. As of this writing there is no widely
available, inexpensive, easy-to-use, highly secure, cross-platform encryption
program suitable for global use.
Additional Recommendations - Workstation screen. Avoid leaving open e-mail on the computer
screen. If the computer is in the same room as other patients, use a
password-activated screen saver so that patient files are not visible to other
patients, especially if the provider is called out of the room.
- Forwarding. Never forward a patient's message or
patient-identifiable information to a third party without the express
permission of the patient. Text forwarded to a colleague for the purpose of
consultation should not contain the patient's name or e-mail address.
- Mailing lists. Never use a patient's e-mail address in clinic
marketing schemes or supply such addresses to third parties for advertising or
any other use.
- Headers. Consider the use of a banner at the top of each e-mail
message such as:
--------------------------------------------- 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. - Offsite processing of patient mail. As with other parts of the
medical record, patient-identifiable e-mail must not be taken out of the
office. If providers answer e-mail from home, they must take special
precautions to prevent other household members from intercepting messages from
patients. Providers must not share e-mail accounts or passwords with friends,
family, or nonmedical coworkers. Providers who communicate with patients
should have their own accounts for professional use. Providers must see to it
that e-mail processed off site on home systems or portable computing devices
is subsequently printed in the office and included in the medical record.
- Encryption. As soon as practicable, clinics should establish a
means of secure communication using the data encryption methods described
below. Commercial encryption programs, encryption capabilities in commercially
available e-mail software, and security features provided by the vendors of
major clinical systems are becoming more common. The United States Post Office
is testing a postmarking and encoding system specifically aimed at medical,
legal, and financial
transactions.18 At
least one semiconductor corporation is marketing a decoder ring device that
provides security and encryption in a combination of wearable hardware and
computer
software.19
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. - Avoidance of computer—human interaction error. Mistakes due
to poor interface design and lack of fail-safe mechanisms are particularly
troublesome in medical communications. By late 1996, there was litigation
pending in the United States courts alleging that a physician inadvertently
posted his patient's diagnosis of breast cancer to the public area of a major
commercial online service. As the doctor and patient had had prior e-mail
exchanges, the mistake was almost certainly due to an interface design
characteristic in the client software. Such an error can occur when an e-mail
application defaults to a “reply to all” feature rather than the
“reply to sender (only)” option. Until foolproof software is
available, and until e-mail is routinely encrypted, correspondents must
habitually double-check the “To:” box in every message prior to
sending.
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: - Triage. Who will triage e-mail, and what is to be the response
time?
- Clerical overhead. Who will print messages and place them in
patients' charts?
- Categorization and redirection of mail. Will each provider have
her own account, or will there be catagoric accounts for all billing
questions, medical questions, and scheduling questions?
- Selective access for patients. Should all patients be given the
provider's e-mail address or can the provider give it out on a selective
basis?
- Archiving and backup. How is e-mail cleared from the server? Does
it stay on the provider's local machine or on the clinic or ISP mail server,
or both? How are both repositories archived and cleared? How long should
e-mail be stored on backup systems? How will messages be indexed for
retrieval?
- Forbidden topics. Will the clinic disallow discussion of certain
highly sensitive topics such as an AIDS diagnosis or psychiatric
conditions?
- Selective confidentiality. Will patients be given a choice as to
what content from their e-mail messages appears in the chart? If patients can
opt to exclude material from the chart, will the clinic establish a secure
repository, either electronic or paper-based, to recall the text of the
original message? Or will the transaction be more like a phone call where the
conversation is relegated to second-hand progress notes? How will providers
handle a patient's request to omit material from his or her record when it is
the clinic's policy to print all mail? Be aware that altering or expurgating a
message, or sequestering an archive of private material, may be against state
law and leave the clinic on shaky legal ground.
- Encryption. Will encryption systems be required? If so, how soon
and what kind? Will patients be given the encryption software by the
clinic?
- Clinic-provided e-mail accounts. Should clinics provide patients
with e-mail accounts on the institutional server? Will such accounts be inside
or outside the clinic's firewall?
- Outcomes evaluation. How will the efficacy and usefulness of
e-mail with patients be evaluated? Will it be possible to determine utilities
based on a monetary cost-benefit analysis, patient satisfaction, provider
perception, or clinical outcomes?
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 stake-holders 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
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<http://www.nap.edu/readingroom/books/ftr/>.
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specific Policy Formulation