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BY: THOMAS C. LAWRY

In using the Internet, physicians can choose among many options. One of the most practical applications is using e-mail to communicate with patients. It gives doctors an opportunity to both educate patients and increase their satisfaction.

Consumers see e-mail as a convenient way to interact with a person who is important to them. In one survey, nearly half of those respondents who were Internet users said they would like to interact with their physicians via e-mail. A third said they would be willing to change physicians in order to do so.¹

Unfortunately, the number of online consumers interested in sending e-mail to doctors is growing much faster than the number of practitioners willing to receive it. That's because physicians tend to view e-mail as just another addition to an already overcrowded schedule.

Fewer than 5 percent of physicians now use e-mail to communicate with patients. In a recent survey of healthcare professionals, 72 percent predicted that physicians would refuse to respond to e-mail from patients. Nineteen percent predicted that doctors would respond—but only if they were compensated for it.²

"The greatest impediment to physicians using e-mail in their practices is the fact that computers are not integrated into their existing work flow," says Daniel Sands, MD, an internist who teaches at the Harvard Medical School and is an expert on e-mail and patient-centered communication. "The work habits of the physician and his office staff need to be altered."

Four Complaints and Responses to Them

Physicians typically see four reasons not to use e-mail in their practices.

E-Mail Is Time-Consuming and Brings No Reimbursement But time spent answering e-mail is time saved from telephone conversations. "E-mail messages are more concise, can be answered anytime of the day or night, and preserve a record of the conversation, thus helping patients remember what they are told," says Sands. "The most efficient systems use a kind of e-mail triage. Messages go first to a staff member, who then involves the physician as needed."

As for the lack of reimbursement, Sands notes that physicians are not compensated for time spent on the phone either. But using e-mail can have a financial return. Any medical practice serving a large number of capitated patients will benefit if it uses e-mail to reduce unnecessary utilization of healthcare services.

Legal Liability Is Increased "A physician is likely to be named in a malpractice suit whether he or she uses e-mail or not," says Sands. "In a legal situation, e-mail can actually come to a physician's defense. It provides a much better depiction of events than a telephone call, where little if anything is properly documented for the record."

Patients Will Flood the Office with E-Mail This has not been the experience of physicians who currently use e-mail to communicate with patients. Sands, who routinely uses it in his practice, says patients are generally respectful of a physician's time. And e-mail has cut down on the number of rambling conversations he used to find himself involved in. "Unlike talking, whether in person or over the phone, typing offers a certain barrier to rambling," he notes.

Confidential Messages Could Be Read by Others Most confidentiality breaches are the result of human error, not of the technology used. As for e-mail, the huge volume of Internet traffic makes it highly unlikely that messages between physicians would be intercepted. A breach of e-mail confidentiality typically occurs because the message was incorrectly addressed or routed, or the sender forgot to log off, thereby allowing others to read it. Such breaches are the result of common carelessness, just like indiscreet talk or erroneously addressed letters or faxes.

But, when used carefully and effectively, e-mail can give a physician a competitive advantage. It can, for example, increase satisfaction among patients who become comfortable using it by cutting out time wasted in annoying "telephone tag" and reducing the number of phone messages overlooked, forgotten, or lost. E-mail is, as noted, a self-documenting medium; it creates a record that both physician and patient can keep. And e-mail messages can piggyback other messages; for example, the physician could embed in his or her messages standard patient care instructions or links to educational Web sites.

Tips on Getting Started
Physicians interested in using e-mail in their practices might follow these tips, offered by Sands and the American Medical Informatics Association:

• Decide whether you will offer e-mail to all of your patients or only some of them.
• Decide whether to adopt the triage method of receiving e-mail and, if you do adopt it, assign a staff member to do the screening.
• Establish turnaround times for messages. Do not use e-mail for urgent matters.
• Establish guidelines for the appropriate use of e-mail and discuss this with patients. The major points can be summarized on a sticker attached to the back of a business card (see Box, p. 12).
• Print all messages to and from patients and place them in patients' charts.

Sands says that physicians who are uncomfortable using e-mail with patients may choose to experiment first by sending e-mail messages to various staff members.

Physicians and Hospitals
The quality of the relationship between a physician and patient eventually has an impact on the mission of the hospital where the physician is on staff. The same is true of online physician-patient relationships. Because this is so, hospitals should examine the role they might play in facilitating the understanding and use of Internet-based tools among staff members. In my next column, I'll talk about what physicians can do to help make a hospital Web site successful.

Dr. Sands's Web page can be found at http://clinical.caregroup.org/ePCC/. The American Medical Informatics Association and its "Guidelines for Patient-Provider E-mail" is at http://www.amia.org/pubs/pospaper/positio2.htm. The Annals of Internal Medicine's "Electronic Patient-Physician Communication: Problems and Promise" is at http://www.acponline.org/journals/annals/15sep98/eleccomm.htm.

Mr. Lawry is president, Verus, Bellevue, WA.

Contact Tom Lawry at 4628 175 Ave., SE, Bellevue, WA 98006; phone: 425-643-7117; fax: 206-643-0302.

NOTES
1. Advisory Board Daily Briefing, November 11, 1999.
2. Forrester Research, April 2000.