DRG Coding Advisor-Confidential exchanges in the electronic age

Docs, patients must know how, when to e-mail

Bob Jones needs a referral from his family doctor. Because he doesn't want to wait for the doctor to return his telephone call, he e-mails the request. The next day, he has a reply with the referral.

John Smith sends a message to his doctor complaining of chest pains. The physician is not able to check his e-mail for several days and is alarmed when he gets the message.

The above scenarios show the importance of establishing a policy about how and when to use e-mail communication between physicians and patients.

Whether to allow e-mail communication at all is no longer the question. More and more computer-savvy patients prefer e-mail for nonemergent requests because they can ask their doctors questions directly without having to wait by the telephone for a reply.

This trend will only increase, says David Sanders, MD, CEO and founder of Salu.net, a provider of Internet-based private networks for physician practices and health professionals in Portland, OR.

"Communication will migrate aggressively within the next five years to e-mail-based communication," he predicts. "[E-mail] will change the way doctors, staff, and patients communicate."

A medical practice is 90% communication, he explains. About half of that communication is face to face. The other half is communication by other means such as phone or fax.

"The problem with the phone is that it requires the doctor and the patient to be available at the same time," Sanders says. "It's hard to do that when doctors are under such high time pressure. E-mail separates out the requirements for two folks being in the same place at the same time."

"There is an increasing encroachment of electronic [communication] in the physician-patient relationship," adds Faith McLellan, PhD, faculty associate in the department of anesthesiology at the University of Texas Medical Branch at Galveston.

McLellan learned about e-mail communication while researching her dissertation about patients' illness experiences. Even though she found that physician/patient e-mail communication is becoming more common, many physicians are still uncomfortable using it.

"In a larger conceptual universe, it upsets the balance of power," she says. "Suddenly, there is information and information management tools in the hands of people who have usually been the recipients of physicians' power and knowledge."

Many physicians are computer-naive, too, she adds. "They haven't thought about some of the issues such as privacy and confidentiality, and how easy it is to disseminate information to other people through e-mail and how instantaneous it can be."

Many patients use e-mail so much that they see it as a natural way to communicate with their physicians, McLellan says. A recent article in the Annals of Internal Medicine found that patients think of e-mail as creating continuous access to the health care system, something they feel is lacking as physicians spend more time on administrative tasks and less time on personal interaction.1

E-mail works well when the patient requests general information or sends routine information about a chronic illness. A diabetic patient, for example, might send her physician information about her blood glucose levels. The physician doesn't need to respond right away unless the results are abnormal. "E-mail is the perfect medium for that," McLellan says.

E-mail also provides a way for physicians to filter medical information. Some managed care plans, for example, have a site where they recommend electronic resources on medical information.

In addition, e-mail can allow patients with similar conditions to meet in electronic discussion groups. These groups can be a great relief to both the patient and the physician, McLellan says. "The patients are hooking into a source of support that they don't necessarily get from their personal physicians. It not only provides access — a route of communication between the patient and the physician — but it hooks other people up whose time is better served in discussion, answering questions, and support."

E-mail can be a barrier to patient care, however. Some questions to be considered include: What happens with e-mail communication between patients and their doctors when the doctor is on vacation, not in the office, or not on call? What happens if the physician's or patient's e-mail server goes down? When will the message be received? What kind of messages are appropriate for patients to send?

"Establishing a policy on using e-mail is a good idea," says Victor S. Sierpina, MD, an assistant professor of family medicine at the University of Texas Medical Branch in Galveston. For example, patients should be discouraged from sending emergency or urgent inquiries. They should be aware that their messages might not be answered right away.

Be aware of discrimination issues

Physicians should have an office e-mail account that is separate from their personal one. They should not use e-mail to communicate abnormal test results or to give bad news.

"You don't want to be discussing psychiatric history or HIV status — something that could be used to discriminate against the patient," McLellan says.

Physician e-mail users also should ensure that electronic communications do not widen the disparity between the haves and the have-nots. Patients without access to computers should receive the same health information, she explains. "You don't want to create a society where the patients who have e-mail are getting better care than the patients without."

Sierpina has one rule of thumb on the use of e-mail: "Don't put anything in e-mail that you wouldn't want to see on the front page of a daily newspaper."

In his experience communicating with patients, he has found that they usually write short messages and generally don't abuse the system, he says. They don't always think about the lag time between the sending and receiving of messages, however. One of his patients, the man with the chest pains mentioned earlier, luckily had a condition that did not require emergent care.


1. Mandl KD, Kohane IS, Brandt AM. Electronic patient-physician communication: Problems and promise. Ann Intern Med 1998; 129:495-500.