 Lesson 24, Volume 15—The E-health Perspective for the
Pulmonary Clinician: Using E-mail for Patient Care
By Gary R. Epler, MD; and Carl Zack, MPH
Effective December 31, 2004, PCCU Volume 15 is available for review purposes only. CME credit for this volume is no longer being offered. Objectives
- Define "e-health" as it is currently used.
- Characterize the electronic patient-doctor relationship.
- Reduce risk by utilizing e-mail services in a pulmonary clinical
practice.
- Show the required steps for using e-mail services for patient
care.
- Understand the characteristics of a large group of patients
utilizing e-mail services for patient care.
Key words
e-health; e-mail; risk management
Abbreviations
BOOP = bronchiolitis obliterans organizing pneumonia;
IPF = idiopathic pulmonary fibrosis
E-Health is defined
as health-care relationships, educational opportunities, or transactions
that are enabled by communication technology or the Internet.1-12 E-health
includes hospital and office exchange of claims information, hospital
management, office management, health and disease education, connecting
providers and information through e-mail, and telemedicine. This
also includes office marketing such as listing staff credentials
and announcing special lung health and disease programs. Importantly,
e-health includes developing the electronic doctor-patient relationship,
which is represented by e-mail consultations, communicating diagnostic
testing results, and coaching or assisting patients managing their
health and disease. This lesson will be a review of the current
status of e-health and describe a standardized method for using
e-mail services in pulmonary clinical practice.
Hospitals and Health Care Systems
E-health had its beginning in the hospital billing
department in the 1950s and 1960s. Both hospitals and payers found
that electronic billing was more efficient and less expensive.
This soon became standard practice in physician offices. Hospital
payroll management and materials management were added. Pharmacy
was added initially through faxing and then through hospital intranets.
At about this time, various parts of the electronic medical record
were added with the ability to obtain laboratory studies and later
chest radiograph and chest CT images. During this time, e-mail
among physicians and consultants became popular to the point of
becoming the preferred method of communication.
Electronic medical records also had a beginning in
hospitals. Early attempts failed because methods were developed
to convert the paper medical record to an exact electronic replica
of the record. Direct translation of paper to electronic was not
effective. Electronic communication is fundamentally different
from a paper-based medical record, and it was soon realized that
it was much better. The failings of paper-based medical records
are numerous (Table 1).1 Hand-written
notes are often illegible, causing numerous errors in medications
and iatrogenic mishaps. Paper records frequently have missing information
or are not available during a patient encounter. The paper records
are being used in two or more places at the same time. Paper records
are very costly to maintain. The cost of pulling a chart for a
clinic visit and returning the chart to the file room is high.
Patients who receive care in multiple locations have multiple records,
resulting in time-consuming redundant record-keeping. Finding aggregate
patient information for clinical research or practice management
from paper records is very time-consuming. Paper records are not
secure and breach of security cannot be traced. For all of these
reasons, electronic medical records are a requirement.
Table 1—The Failings of Paper-Based
Medical Records
Illegible hand-written notes
Information missing at the time of a patient encounter
Information in transit during a patient encounter
The medical record needs to be in two or more places at the same
time
Costly to maintain and require extensive space
Expensive retrieval and filing costs
Multiple paper-based records may be developed
Time-consuming for clinical research and practice management
Paper records are not secure
A breach of security cannot be traced |
Electronic systems search and retrieve information.
Systems need to be developed that offer an easy, rapid way to search
for the information combined with having all of the information
available. Some difficulties persist. A major obstacle has been
to develop a system that can be used by clinicians for an intermittent
5- to 10-min encounter with a patient among four or five examination
rooms. Another difficulty has been the inability to develop a searching
system that physicians can use to retrieve information from all
of the disparate sources such as the chemistry laboratory, bacteriology
laboratory, surgical suite, and imaging departments. Although there
have been continued improvements, and individual physicians and
hospitals have developed successful systems, there is still no
single system that will give physicians everything that they want.
Despite these difficulties, electronic retrieval of patient information
is rapidly increasing and will soon be indispensable.
Another perspective of electronic medical record
information is the availability of this information to patients.
Several hospitals are now giving their patients passwords so that
they can access their own hospital record information. Patients
can obtain results of their laboratory studies or cardiac studies
as well as reports of their imaging studies.
Physician Offices
Electronic billing rapidly became the norm for office
practices to the extent that some insurers would not accept hand-written
forms or penalized the office for not using electronic billing.
However, this continues to be the extent of e-health services in
the majority of office practices. Virtually all supplies can be
ordered electronically, yet most are obtained via catalogue transactions.
Other electronic-based systems can include scheduling, patient
reminders, managed care applications, patient records, treatment
alerts, referrals, telemedicine, and prescriptions. Communication
with patients via e-mail is at the bottom of the list.
Developing a website for the practice is an excellent
way for patients and their families to find out about the practice.
Currently, a study of 809 physician group executives reported that > 55%
of practices have a website.2 The site is used for marketing
in 86% of practices and patient education in 56%. Less than 10%
use the site for scheduling and 33% use the site for patient communication.
The practice's site can be used as a portal for patients to learn
about the doctor's credentials and special interests, find out
about scheduling, and submit insurance information, and for marketing
special events. The site can also be used for educational programs
for patients.
Electronic office patient management includes obtaining
registration and insurance information, scheduling appointments,
obtaining test results, and contacting the doctor.
E-mail Doctor-Patient Communication
There are now 40 million households connected to
the Internet. There are 135 million e-mail users and 1.4 trillion
e-mail messages. Although 20% of physicians may utilize e-mail
for some types of patient-related activity, < 5% of physicians
use e-mail routinely for patient care services. This is the same
percentage as physicians who used the telephone for patient care
in the 1920s.
E-mail is the basis for the electronic doctor-patient
relationship. E-mail services include education and information,
consultation, and individualized disease management. Doctors want
more time to see patients, more free time, less paperwork, efficient
communication systems, fewer management errors, and a healthy patient
panel. Patients and consumers want convenient access, no waiting,
easy scheduling, fast feedback, and an efficient billing system.
Patients want to manage their own health and to be included in
medical decisions.
The benefits of e-mail include more efficient communication
systems, documented patient care interactions, less management
errors, improved patient satisfaction, improved physician access,
less waiting, and improved feedback of diagnostic testing results.
E-mail improves the efficiency and cost of delivering contractual
medicine because patients unable to talk to the doctor will go
the emergency department. Patients are asking for e-mail services
from their doctor, and patients will change doctors to get e-mail
services. In addition, e-mail services can help meet risk management
guidelines of the Joint Commission on Accreditation of Healthcare
Organizations, National Committee for Quality Assurance, and Health
Insurance Portability and Accountability Act.
The risks of e-mail are minimal. These generally
include mistakes such as forgetting to log off the computer. Another
issue is sending copies to the wrong individuals. Using the blind
copy feature can eliminate problems with group mailings. Time can
be lost by too many e-mail exchanges between the doctor and the
patient. Virtually all of these risks can be managed successfully.
Why don't doctors use e-mail? There are several reasons.
- The legal risk: Yes, e-mails are discoverable and can be utilized
in the courts, yet the benefits of having a documented record
of your advice, warnings, and desired follow-up action far outweigh
this risk.
- Doctors are worried about lack of security, which can be minimized
by publishing your guidelines for e-mail use.
- Doctors say it takes too much time. Initially it will take
time, but eventually time is saved.
- There are too many rambling patients. This can occur anywhere.
Guidelines can minimize this issue.
- Doctors can't type. Not really; doctors seem to manage.
- Patients won't use it. To the contrary, patients and consumers
are asking for e-mail services.
Doctors need to use e-mail for patient care. Patients
and consumers are asking for it. It will improve patient access.
It will enhance patient education. It will improve patient satisfaction.
It is useful for hearing-impaired patients and for patients who
are frequent travelers. It will eliminate "telephone tag" and
eventually may decrease telephone time and costs.
Guidelines for Clinical Use of E-Mail With Patients
A task force of the American Medical Informatics
Association developed guidelines for the use of e-mail with patients
in 1998.3 The basic principles continue to be applicable
to today's situation. E-mail is not like a telephone conversation
or writing a letter. It is more spontaneous than letter writing
and offers more options than a telephone conversation. E-mail prevents
telephone tag and avoids interruptions from telephone calls or
pagers.
E-mail follow-up allows retention and clarification
of advice from the office visit and a documented source for follow-up
home care. For example, the e-mail can include addresses and telephone
numbers for follow-up care, test results such as cholesterol readings
or pulmonary function test results that can be retained for monitoring
purposes, instructions for using medications or inhalers, and websites
with useful disease information.
The comparison of e-mail to the telephone indicates
that telephone messages are often overlooked or lost among charts.
The pink or yellow telephone message slips are often lost in the
process of a busy office practice. The hand-written scribbles are
sometimes impossible to read. Voice-mail systems often have long
and frustrating menus of choices. In contrast, e-mails are printed
documents that can be saved in the patient's record in the office
and saved at home. E-mails are robust. The physician can send not
only a message, but also patient management guidelines, follow-up
care, instructions for monitoring, and disease education; a disclaimer
can be added so the patient is aware of the benefits and limitations
of e-mail.
In a survey of 117 patients that utilized e-mail
with their doctor, they cited speed, convenience, ability to manage
simple problems, efficiency, improved documentation, and no telephone
tag as positive characteristics.4 It has also been reported
that patients had concerns about confidentiality, not so much about
the e-mail itself, but they used the e-mail at their workplaces
to correspond with their doctors. They were concerned that their
employers would read their e-mail.5
Guidelines for Physician Use of E-mail With Patients
There are continual changes and upgrades regarding
e-mail; however, most of these guidelines continue to be applicable
(Table 2). The use of e-mail depends upon
a negotiation between the patient and the doctor. There are several
useful considerations.
Table 2—E-mail Communication
Guidelines
from the Journal of the American Informatics Association*
- Establish a turnaround time for messages.
- Do not use e-mail for urgent matters.
- Inform patients about who processes messages during usual
business hours and during vacation or illness.
- Establish types of transactions and sensitivity of subject
matter permitted over e-mail.
- Instruct patients to put category of transaction in subject
line of message such as prescription, appointment, medical
advice, or billing question.
- Request that patients put their name and patient identification
number in the message.
- Configure automatic reply to acknowledge receipt of messages.
- Print all messages with replies and confirmation of receipt
for the patient's medical record.
- Send a message to inform a patient of completion of request.
- Request that patients use auto-reply feature to acknowledge
reading provider's message.
- Maintain an e-mailing list of patients, but do not send
group mailings where recipients are visible to each other.
Use the blind copy feature.
- Avoid anger, sarcasm, harsh criticism, and libelous
references to third parties in messages.
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*Modified from Kane B, Sands DZ.3 |
Turnaround time. Determine a maximal
turnaround time. Traditionally, a turnaround time of 1 to 2 business
days has been used for e-mail messages; however, as e-mail becomes
the preferred medium, messages may need to be checked and triaged
several times daily. The question may determine the urgency. Two
or 3 days may be tolerated for results of a cholesterol screen,
yet a same-day or next-morning response may be expected for a question
about side effects of a medication.
Privacy. Privacy is addressed in terms of
who will see the e-mail, including office staff, triage person,
or other consultants. There should also be mention of the possibility
of others reading the e-mail if it is sent from a public or employer's
computer. Sometimes e-mail addresses are from offices or nicknames
or electronic names, so the patient should add his or her full
name on the message as well as the medical record number if known.
Content. It is useful to discuss permissible
transactions and content. For example, some clinics forbid the
discussion of HIV status, mental illness, or worker's compensation
claims in electronic mail.
Subject headers. Instruct patients to use
appropriate subject headers such as "appointment" or "medical
question." The use of "About Your HIV Test" is not
acceptable.
There are several important issues when handling
messages.
Automatic reply. This can be useful on a day-to-day
basis, but is especially useful during vacation days or holidays.
The software can be configured to send an automatic reply to all
incoming e-mails stating that the message has been received and
will be processed within 24 h; if necessary, the patient may be
instructed to contact the nurse at the telephone number provided.
For vacations or holidays, the message should include the provider's
date of return and instructions regarding whom to contact for assistance.
Keeping records. E-mail exchanges should be
printed and placed in the paper medical record. They can also be
cut and copied for the record. They can also be placed in the electronic
files of an electronic medical record and should be kept as long
as legally required.
Acknowledgement of messages. Patients should
be instructed to acknowledge the message by a brief reply if the
message contains important medical follow-up medical advice. It
is important to know that the patient has read the message and
understood the instruction. The reply is placed in the medical
record along with the other e-mail correspondence.
Footer. The footer is used to remind patients
that e-mail should not be used for emergencies or sensitive information,
to acknowledge the possibility of a delayed response, and to instruct
patients to call for an office visit. E-mail should not be used
as a substitute for a clinical examination.
Address book. The address book feature should
be used to maintain the e-mail addresses of patients. It is important
to use the blind cc feature for group mailings.
Emotional content. Irony, sarcasm, and harsh
criticism should not be used in e-mail messages. Patients who are
very ill or anxious may express stronger sentiments via e-mail
than face to face. Clinicians need to restrain their language.
E-mail messages are typically stored for months to years on backup
systems; pressing the delete button will erase messages from the
screen but they can still be read by retrieval software programs.
Guidelines for Medicolegal Issues
These concerns can be managed and controlled (Table
3). The task force noted that "medicolegal anxiety" should
not be allowed to disable open communication as the basis for
a healthy doctor-patient relationship. One approach is to have
patients sign a printed form outlining the guidelines that will
be used in the office. Security is one issue that needs to be
covered in the document, with a description of the security mechanisms
in place and an explanation of the limits of security of e-mail.
Specify whether the clinic is using an internal system, an intermediary
Internet service provider, or a public e-mail service. Also,
include an indemnity clause to limit liability for network failures
beyond the control of the health-care providers such as system
crashes, power outages, or overloads.
Table 3—E-mail Communication
Medicolegal Guidelines
from the Journal of the American Informatics Association*
- Consider obtaining informed consent for use of e-mail.
The written form should include itemized terms, provide
instructions for when to use phone calls or office visits,
describe security mechanisms in place, indemnify the health-care
facility or office for information loss due to technical
failures, and waive encryption requirement, if any, at
patient's request.
- Use password-protected screen savers for desktop workstations
in the office, in the hospital, or at home.
- Never forward patient-identifiable information to a
third party without the patient's express permission.
- Never use a patient's e-mail address in a marketing
scheme.
- Do not share professional e-mail accounts with family
members.
- Do not use unencrypted wireless communications with
patient-identifiable information.
- Double-check all "To:" fields prior to sending
messages.
- Perform at least weekly backups of mail onto long-term
storage media. Define "long-term" as the term
applicable to paper records.
- Commit policy decisions to writing and in electronic
form.
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*Modified from Kane B, Sands DZ.3 |
Additional Task Force Recommendations
There are several additional recommendations suggested
by the task force regarding the use of e-mail for patient care.
Some of these may change as use of e-mail becomes more common;
however, at this time, it seems prudent to consider these recommendations.
Workstation screens. Avoid leaving an open
e-mail message on the computer screen. Use a password-activated
screen saver so that the patient files are not visible to other
patients, especially if the provider is called out of the room.
Forwarding. Do not forward a patient's message
or patient-identifiable information to a third party without the
express permission of the patient. Text forwarding to a colleague
for the purpose of consultation should not contain the patient's
name or e-mail address.
Mailing lists. Do not use a patient's e-mail
address for clinic marketing schemes or supply these addresses
to third parties for advertising or any other use.
Headers. Consider using a banner at the top
of each e-mail with a message such as "This is a confidential
medical communication."
Out-of-office e-mail management. Patient-identifiable
e-mail must not be taken out of the office. If providers answer
e-mail from home or elsewhere, it is important that household members
and others do not intercept messages from patients. Providers should
have their own accounts for professional use. E-mail accounts or
passwords should not be shared with friends, family, or nonmedical
coworkers. It is also important that off-site e-mail messages be
printed and placed in the patient's medical record.
Encryption. This is an evolving issue. Most
e-mail systems are currently not secure. This openness allows for
ease of use, the "anywhere and any time" concept. The
patient should be made aware of this limitation and be willing
to use e-mail within these limitations. High-level encryption is
possible, but it is expensive and both parties must have appropriate
hardware and software. Utilizing a practice website that is secured
in the office and giving each patient a secure password can improve
security and limit e-mail exposure to office staff. There are several
commercial ventures to develop reliable and easy-to-use encoding
systems; however, none has yet evolved to meet the needs of the
busy clinician. Currently, informing the patient of the nature
of e-mail and the limitations of security is the most common practice.
Avoidance of computer-human error. Sometimes
errors are made by clicking the wrong key and accidentally sending
an e-mail to everyone on the list. It is important to double-check
the "To:" box in every message prior to sending.
Office Organization and Policy Development
The use of e-mail may eventually result in cost savings
to offices and clinics. This is because of time saved from telephone
tag and decrease in repetitious instructions as well as replacing
some types of office visits. It is important that written policies
are developed to address the triage, technical, and medicolegal
issues of the communication system.
Triage. Who will triage and direct the e-mail
for billing questions, scheduling questions, or medical questions?
What is the response time? Will each provider have an account?
Clerical. Who will print the messages and
place them in the patient's medical records?
Archiving and backup. How is e-mail cleared
from the server? Does the e-mail stay on the provider's local machine,
the clinic's, or the public provider's? How are repositories archived
and cleared? How long should e-mail be stored on backup systems?
How will messages be indexed for retrieval?
Forbidden topics. Are there any topics that
will be disallowed, such as an AIDS diagnosis or psychiatric condition?
Confidentiality. How will the office handle
a patient's request to omit material from the medical record when
it is the policy to print all e-mail messages? Will a secure repository
be developed to recall the text of the original message? There
may be state laws regarding the issue of altering or expurgating
a message, or sequestering an archive of private material.
Encryption. Will encryption systems be required?
What type will they be?
Clinic accounts. Will the office provide patients
with e-mail accounts? If so, will the accounts be on a secured
office site or a public site?
Quality and outcome monitoring. How will the
process-monitoring program be developed? How will the response
time, retrieval percentage and percentage of successfully completed
responses be monitored? How will patient satisfaction and provider
perception be evaluated?
Examples of how to instruct patients to write an
e-mail message (Table 4), how physicians
can answer e-mail (Table 5) and an example
of an e-mail agreement (Table 6) are included
in this discussion.
Table 4—Example of How To Instruct
Patients To Use E-mail*
Use other forms of communication
for:
Medical emergencies
Sensitive information—do not assume that e-mail is confidential
Situation where a response might be delayed because your doctor
is away
Indicate the reason for the e-mail in the "Re" section
Include your doctor's name at the top
Be concise
Put your name at the bottom and medical record number if available
Keep copies of e-mail you send and receive for your records
Your messages may be shared with the office staff or with medical
consultants if necessary
Medically relevant e-mail communications are filed in your medical
record |
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*Modified from Sands DZ.10 |
Table 5—Example of How Doctors
Should Use E-mail*
Include patient's name at the top
Answer the question briefly
Note the treatment or management
Add stored links for disease and management educational information
Add stored templates for treatment and follow-up
Include your name at the bottom
Use spell-check
Automatically add this footer: "Use the telephone or go to the
emergency unit for emergencies. Never rely on e-mail if communication
is urgent or sensitive. For additional information, call the office
or click here for the practice's website." |
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*Modified from Sands DZ.10 |
Table 6—Example of a Patient
Agreement for the Use of E-mail*
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E-mail offers an easy and convenient way for
patient and doctor to communicate. In many circumstances
it has advantages over office visits or telephones. But remember
that there are important differences. E-mail is not the same
as calling the office; there is no person at the other end,
just a computer. You can't tell for certain when your message
will be read, or even if your doctor is in the office or
on vacation. Nonetheless, we believe that the ease of communication
e-mail affords is a benefit to patient care. Below are our
rules for contacting us using e-mail:
- E-mail is never, ever, appropriate for urgent or emergency
problems!
- E-mail is not confidential. Your employer has a legal
right to read your e-mail if they choose. System operators
for most e-mail systems have access to all of the e-mail
that goes through that machine.
- E-mail becomes a part of the medical record when we use
it—a copy will be printed and put in your chart.
- E-mail is great for asking little questions that take
too long to ask when you have to go through a telephone.
- E-mail is also great to report the status of a problem.
- If you think that you need to be seen by the doctor,
call and book an appointment.
Either one of us can revoke permission to use
the e-mail system at any time.
A copy is filed in the patient record, and a copy is given to the
patient
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*Modified from Ives D.11 |
Usefulness of Answering E-mail Patient Inquiries
An e-patient is different from a traditional patient.
Traditionally, the doctor begins by asking a question about why
the patient came to the office. This is followed up by a series
of questions about symptoms, family health, past health, and environmental
questions. A physical examination is performed and tests are performed.
The doctor is in charge of this process from the beginning to the
end. The patient is then invited to ask questions regarding the
diagnosis, treatment, and next steps. The e-patient is different.
The doctor is not in charge. The doctor is like the Oracle of Delphi
sitting on top of the mountain. The doctor is asked a question.
However, the answer can be effective in guiding the patient to
the next step and can have a positive influence in the course and
outcome of the illness. Other health-care providers in the office
can also answer questions.
The type of question and the source of question varies
depending on the type of underlying disease. For example, among
1,000 e-mail questions about diseases such as bronchiolitis obliterans
organizing pneumonia (BOOP) and idiopathic pulmonary fibrosis (IPF),12 the
frequency of questions about treatment and end-of-life issues varied.
For BOOP, an inflammatory process that is largely treatable, 39%
of patients asked about the cause, 34% about the treatment, and
7% about end-of-life issues. Yet for IPF, a progressively fibrotic
process, 25% asked about cause, 42% asked about treatment, and
12% asked about end-of-life issues. Treatment and end-of-life issues
were more important for IPF than BOOP. Who asked the questions?
About one third of the questions were asked by the patient. About
one fifth of the questions were asked by the children of the patient,
with the question about the mother's illness twice as common as
the father's illness. About 10% of the questions were asked by
the spouse, with a wife asking a question about her husband three
times more often than a husband asking a question about his wife's
illness.
Summary and Conclusion
E-health is about health-care relationships, educational
opportunities, or transactions enabled by communication technology
and the Internet. An important part of e-health is the electronic
doctor-patient relationship and the use of e-mail for patient services.
E-mail is a complementary office program for patient care that
will enhance the office practice, improve patient satisfaction,
and improve overall care of the patient. It is important to provide
guidelines for the patient to use the e-mail services. It is important
that the doctor and office staff learn how to use e-mail successfully.
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Copyright ©2002 American College of Chest Physicians
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