Email has come a long way since the birth of the Internet 40 years ago. (1) Many use email as their communication tool at home and work, and email has replaced much face-to-face, written, and phone communication. These days, we are quite surprised if friends or colleagues say they do not use email.
Despite this, email communication is not yet commonplace in the health care setting. According to the Center for Health System Change, just 24 percent of U.S. physicians use email to communicate with patients. (2) While many physicians use email outside the office, several barriers exist that prevent them from using email to communicate with their patients.
But that may change. According to an article in Archives of Surgery, while "the fundamental basis of the physician-patient relationship has always been face-to-face communication, advances in communications technology have, from time to time, challenged that assumption." (3) Communication via email may make more sense when time for face-to-face patient-physician communication is limited to "15-minute appointments." (2)
This article will discuss the challenges physicians face when integrating patient email into their practices and will offer recommendations on how physicians can meet these challenges.
PATIENTS PREFER EMAIL
According to the Pittsburgh Tribune Review, surveys show that 90% of Americans want to email their physicians. (2) "Patients are willing to use email and use physicians' websites to communicate with their doctors in an effort to save time, as long as they do not have to pay for the ability, according to results of a survey." (4)
One of the main reasons patients want to email their physicians &mdash they believe it will save time. Patients report that they would use email for "receiving routine test results (59 percent), requesting repeat prescriptions (53 percent), confirming appointments (53 percent), and updating their doctors on existing conditions (51 percent)" according to surveys conducted by Lightspeed Research. (4)
Patients also like email because it offers them the ability to communicate in an unobtrusive manner. A patient can send an email and receive a response without staying on hold or waiting by the phone. The physician can review and respond to patient email at his or her convenience. Email can reduce the number of interruptions caused by patient phone calls, and many advocates believe email will cut down on repeat and non-essential office visits. (2, 5) Physicians can also attach supporting documentation to patient emails. (6)
In 2008, Aetna began implementing a plan to pay physicians and cover members for "e-visits" — including secure messaging and e-consults. "Members have used the service for prescription refills or appointment scheduling, and the plan has found a 'high rate of satisfaction' among members and doctors. Plans emphasize that they are introducing e-visits as a way to extend the physician-patient relationship. It's an extension of the relationship; it's not a replacement of the physician-patient relationship." (7)
PHYSICIANS STILL RELUCTANT
Despite the benefits of communicating with patients via email, many physicians hesitate because of "potential legal problems, adapting to something that changes a practice's workflow, the expense of installing a secure, encrypted system &mdash even the possible loss of practice revenue." (2)
Lack of reimbursement has been one of the main stumbling blocks. (7) Only a few private health insurance plans reimburse for email consultation because of their concerns with security and potential problems with quality of care. (8) Still, while some insurers will reimburse for email consultation, Medicare has been reluctant. (6) According to an article published by the American Health Information Management Association (AHIMA), growth in online consultation has been slow partly because of the lack of reimbursement from Medicare. If that were to change, it is possible that,"electronic communications between provider and patient are likely to increase." (6)
Privacy laws may also cause confusion for the physician's office. State and federal laws vary when it comes to patient privacy, particularly for patient conditions such as sexually transmitted diseases, HIV, substance abuse, and treatment for mental health conditions. Laws about emailing patients who seek care for these conditions are very stringent. (9)
Another disadvantage to physicians is the speed at which email communication occurs. Many patients may come to expect a quick response to email, which is a fast and immediate medium. "As consumers, when we send email out we come to expect an answer in a few hours. This can cause problems for physicians since they are already squeezed for time and cannot answer emails quickly," says Jane Holeman, vice president of risk management at TMLT.
"Patients may send an email about an emergent situation. Many medical situations must be assessed over the phone or in person and email communication could be much too slow in a life-threatening situation."
Litigation is also a concern for physicians. According to Holeman, physician-patient emails are discoverable, and should be considered part of the medical record. "Physicians should not forget that even though it is an email, it is still physician-patient communication. Physicians should be cautious, avoiding sloppy word usage and broad generalizations intended to be lighthearted, that may be misinterpreted." A plaintiffs' attorney who is considering filing a claim could use a poorly written email to depict the physician as unprofessional or uncaring. (9)
HOW EMAIL CAN WORK
For physicians who decide to implement patient email, examples of effective use include online scheduling, prescription refills, communicating the results of lab work, and patient education. (6)
Before instituting an email system, consider the following recommendations.
- Survey patients to see if email is something they are comfortable with. Determine whether they think email will improve communication.
- Establish policies, rules, and turnaround time. Set expectations and limitations with patients about what they can email and how long it will take to respond.
- If you decide to implement an email system, research security and encryption. Also consider the appropriate levels of access for your staff.
- Look for a system that is secure but easy to use.
- Make sure that the emails are stored as part of your medical records system. Make the process similar to documentation of phone calls, which is required under Texas Medical Board (TMB) rules. 7, 9, 10 TMB rules are available at http://www.tmb.state.tx.us/rules/rules/bdrules.php.
- Before introducing an email system, obtain written approval from your patients by having them sign a consent form. (Please see sample consent form.)
HIPAA regulations can also cause confusion for physicians implementing patient email. HIPAA does not prohibit physicians from communicating with patients by email, but it does require physicians to protect their patients' privacy.
When communicating with patients, HIPAA requires physicians to send the minimum information to get the message across; therefore, emails should only include basic information.
For example, appointment emails should only include the physician's name and time of the appointment, but not the reason for the appointment. (9)
Additional federal mandates that relate to email consultation were passed in 2003. Physicians are required to choose a system that confirms to which patients information was sent and confirms that the information was received. HIPAA does not require a particular level of encryption or technology, but encryption is required when email is sent over an open network, i.e. the Internet. Encryption is not required when physicians send email over a closed network, which would be handled, for example, by a third party email system. (11)
According to the American Medical Association web site, the American Recovery and Reinvestment Act of 2009 sets the punishment for HIPAA violations. Even if a physician unknowingly violates HIPAA while exercising reasonable diligence, "the minimum penalty is $100 per violation, with an annual maximum of $25,000 for repeat violations and a maximum of $50,000 per violation, with an annual maximum of $1.5 million." (12)
Texas Physicians must also follow rules set by the TMB. Section 174.4 of the TMB rules state that, "written policies and procedures must be maintained when using electronic mail for physician-patient communications. Such policies and procedures must address: privacy to assure confidentiality and integrity of patient-identifiable information; health care personnel, in addition to the physician, who will process messages; hours of operation and availability; types of transactions that will be permitted electronically; required patient information to be included in the communication; and quality oversight mechanisms. (13) (Please see sample email policy)
Furthermore, the TMB rules state that "all patient-physician e-mail must be stored and filed in the patient's medical record." (13)
Exactly how and in what manner email is stored can be a concern. "Email is considered part of the legal electronic health record and will have the same retention as the medical record itself. Archival of email that is part of the record may need to be accomplished electronically, as a feed into the electronic chart.
In a hybrid environment, it may need to be printed and filed into the medical record where it may eventually be scanned. Record management professionals are now starting to realize that the document management systems used to scan remaining paper medical records into their electronic health records may be the tip of the iceberg. It may take many document management systems including an email archiving system, to manage the volumes of email typical in most organizations." (10)
Physician-patient emails are considered health care organization business records and are therefore subject to the same storage, retention, retrieval, privacy, security, and confidentiality provisions as any other patient-identifiable health information. Organizations need to develop policies to manage email records just as they manage any other medical records. (10)
A final benefit to patient email &mdash it provides an opportunity to market your practice. "Email is so well-liked by patients that it could be used as a marketing tool by physicians." Email may be the service that you offer that others do not. (2)
However, email between patients and physicians may soon be the rule. Some advocates of email believe that change is inevitable. "There are barriers to email usage, but they will be overcome. It's inevitable it will be used &mdash every other industry does it." (2)
- Norris M, Block M. Listeners Recall First Time On The Internet. National Public Radio. November 30, 2009. Available at http://www.npr.org/templates/story/story.php?storyId=120963356. Accessed December 16, 2009.
- Stouffer R. Doctor use of patient email still low despite benefits. Pittsburgh Tribune Review. August 3, 2008.
- Email access may improve patient-surgeon communication. Physician Business Week. March 4, 2008.154.
- Rajecki R. Patients see benefits of email and web communications &mdash if free. Med Econ. Available at http://medicaleconomics.modernmedicine.com/memag/Modern+Medicine+News/Patients-see-benefits-of-e-mail-and-web-communicat/ArticleStandard/Article/detail/636485?contextCategoryId=7155. Accessed December 16, 2009.
- Queenan J. Can Your Patients Reach You? Obstet Gynecol. October 2008. 112(4): 744-45.
- Adkins M, Cardamone NR, Chien R. Email as a Provider-Patient Electronic Communication Medium and its Impact on the Electronic Health Record. AHIMA. Available at http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_022164.hcsp?dDocName=bok1_022164. Accessed November 20, 2009.
- Gearon C. Take Two and Email me at your convenience. AHIP Coverage. 2008. 49(4):22-26.
- Silverman J. Reimbursement urged for certain E-Mail consults. Clinical Psychiatry News. June 1, 2003. Available at http://www.thefreelibrary.com/Reimbursement+urged+for+certain+E-Mail+consults.+%28CMS+Against...-a0105368277. Accessed December 17, 2009.
- Weiss G. Find your e-advantage. Med Econ. August 7, 2009. 25-28.
- Nunn S. Managing email as record. Journal of AHIMA. September 2008. 54-55.
- Weiss N. E-mail consultation: Clinical, financial, legal, and ethical implications. Surg Neurol. 2004.61:455-9.
- American Medical Association. HIPAA Violations and Enforcement. Available at http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/hipaahealth-insurance-portability-accountability-act/hipaa-violations-enforcement.shtml. Accessed December 23, 2009.
- Texas Medical Board. TMB Rules. Available at http://www.tmb.state.tx.us/rules/rules/bdrules.php. Accessed December 23, 2009.