E-mail, instant messaging (IM), video chat, and social networks—notably blogs and online communities such as Facebook and Twitter—have emerged as essential business and social communication tools.1 Electronic communication is speedy and efficient, crossing continents in seconds (e-mail) or, in some cases, nanoseconds (as with Google Wave and Skype technologies).
In this age of social media, even basic e-mail exchanges are already verging on obsolescence for people under age 30. More young people now use Twitter than e-mail. But whether messages are conveyed by e-mail or Twitter or Facebook, the advantage in patient-doctor exchanges is that they all originate at times convenient to the sender and recipient; appropriate phrasing can be thoughtfully chosen; concerns can be reflected on; and decisions can be considered before being uttered. Standard answers and qualifications to commonly asked questions can be composed in advance, which saves time and trouble for physicians.
Yet, in 2004, fewer than 10% of the US public was communicating with their doctors electronically. In the United States and Europe, only 20% to 25% of doctors were using e-mail and, then, only to communicate with select patients.2 A survey conducted by Manhattan Research found that the figure had gone up to 31% by the first quarter of 2007.3
Quicker, more efficient communication
In a study of 4203 primary care physicians conducted in 2005, only 16.6% had personally used e-mail to communicate with patients, although 63% did use e-mail for other purposes.4 An increasingly sophisticated, knowledgeable, and wired public demands individualized care from physicians and wants the convenience of being able to e-mail for appointments, send prescription requests, receive test results, and get answers to post-visit questions that they had forgotten to ask.5 Young people, especially those under 35, are overwhelmingly confused by a basic question: “Why can’t I get advice from my doctor over mobile, Web-enabled technology using text messages just as I do from other service providers?”
In 2009, despite the widely upheld ideal of a medical system that is “patient-centered” and responsive to patient needs and preferences, very few patients are communicating electronically with their health care providers via basic e-mail, and far fewer via social networking tools such as Twitter (whose more regular use could enable a quick 140-character update to advise chronically ill patients, for example, that their blood test results were normal).6
■ E-mail provides a medium through which patients can express worries and concerns and physicians can respond in a patient-centered way.
■ E-mail and social media exchanges with patients do, however, carry potential liability in a variety of areas, including confidentiality, privacy, security, timeliness of response, and clarity of meaning.
■ Basic e-mail exchanges are already verging on obsolescence for people under 30 in this age of social media.
Patients now expect electronic communication in all modern, professional service interactions. In a study that explored the extent to which e-mail messages between patients and physicians mimic traditional medical dialogue, 8 volunteers supplied copies of their past 5 e-mail exchanges with their physicians. The investigators concluded that e-mail provides a medium through which patients can express worries and concerns and physicians can respond in a patient-centered way.7
Even the decades-old term “patient-centered” seems anachronistic when discussing these concepts. A growing proportion of patients around the world are so-called e-patients, ie, Web-savvy, often chronically ill patients who turn to e-mail correspondence and online illness communities to participate actively in their own care. Modern participatory medicine demands that social media and e-mail be harnessed in the clinical setting and beyond.
For psychiatrists, there are specific challenges. Psychiatrists tend to be “late adopters” of new technology and, like other doctors, do not want to be communicating with patients outside office hours when the service is nonreimbursable.8 In addition, psychiatrists are sensitive about potential boundary crossings—electronic communication seems more informal, less business-like than making a telephone call. E-mail may also blur the distinction between professional interest and friendship.9 Realistically, however, between-session issues need to be addressed—appointments need to be made or cancelled, emergencies occur, and prescriptions need to be filled; questions need to be resolved, quick advice may be required, and misunderstandings need to be cleared up.
Ten years ago, in the still relatively early days of e-mail, 2 of us wrote about the promise and perils of e-mail communication with patients. We ended by warning that “psychiatrists of the future may be just as legally liable for not using technology as they may be now for applying it in novel and nontraditional ways.”10 Has that time come? Since malpractice is defined by comparisons with local professional standards, is it now malpractice to ignore e-mail or social media communication from patients?
By common law standards, the ability to communicate with patients using electronic media is now expected by most patients under the age of 40. If failure to communicate electronically does not constitute malpractice, at the very least, it will lower your ratings on physician evaluation Web sites, such as RateMDs.com and mydochub.com. These ratings, more than anything else these days, make your reputation and can provide early “signal detection” to hospital boards concerned about future re-credentialing.
Avoiding liability and security risks
E-mail and social media exchanges with patients do, however, carry potential liability in a variety of areas, including confidentiality, privacy, security, timeliness of response, and clarity of meaning. These concerns are not different in kind from those that exist in all modes of patient-doctor communication.
Because e-mail may contain personally identifiable health information, it is protected under the Health Insurance Portability and Accountability Act (HIPAA). Some states have adopted additional privacy safeguards. All psychiatrists who use e-mail with patients should be familiar with HIPAA and state law and should adopt adequate procedures to safeguard the personal health information of their patients. For concerned psychiatrists, the ethical and legal as-pects of e-mail use—including American precedents—are well covered in a recent article on e-mail and the psychiatrist-patient relationship by Recupero.11
Practice tip No. 1. Ninety percent of patients who send e-mail or social media correspondence to their doctors are communicating sensitive medical information.2 Patients should know who has access to your e-mail. There are many security risks end-to-end on all unencrypted e-mail sent over the Internet, and patients must be so advised. They should sign prior informed consent.
E-mail correspondence outside of a secure system is indelible, it can be misaddressed, it can be forwarded, intercepted, circulated, and changed without the knowledge or permission of the sender, and the true identity of the sender of a normal e-mail is impossible to verify. Patients must also be advised that e-mail can be used as evidence in court and that it is subject to applicable rules on patient-doctor confidentiality. On open-source microblogging networks, such as Twitter, correspondence can be “cached” or copied forever on the World Wide Web. As such, it is accessible to anyone, despite the fact that the submitter retracts the original copies of “tweets.” Also, programmers with access to the Remote Application Programming Interface may retain access.
Practice tip No. 2. Take great care when addressing correspondence to anyone, patient or other care provider. Often e-mail software has an “auto-complete e-mail-address” feature so if you have 2 patients with the same first name, it is easy to send to the wrong patient. Be careful!
When writing a draft e-mail, it is easy to send it prematurely. (You mean to save the draft, but you hit Send instead.) To avoid this, first write the e-mail and then address it. Send e-mail the way that you send postal mail: only add an address “on the envelope” when you have fully completed and signed the letter (ie, leave the “To” address blank until you have fully completed the e-mail). To reply to an e-mail, hit the Forward button instead of the Reply button. Write the e-mail and only then insert the e-mail address.
When you send a group mailing to patients, use the “bcc” (blind carbon copy) feature so that names and addresses of recipients are kept private. Avoid Reply All. The patient may have copied others, but your reply should go back only to your patient.
Practice tip No. 3. Consider the source of your e-mail chain. Institutional e-mail is a problem because the institution has access to it. Free e-mail and Internet services are best avoided because they may be accessible to unauthorized persons. The same is true for mobile devices where “eavesdropping” is possible. Open-source or searchable social networks such as Twitter or Facebook open themselves up to exponentially larger unauthorized access.
Practice tip No. 4. To use encryption software, the patient is required to also install the same software. The hassle factor of installing such software on computers on both ends of an e-mail is why such encryption software has not become standard. There are excellent Web-based services, such as e-Courier.ca, that offer the highest security possible without the installation of any encryption software. e-Courier.ca also permits massive e-mail attachments, such as CT scan results for instance, that normally would get bounced. Moreover, you receive notification when the patient has opened your e-Courier.ca e-mail.
Practice tip No. 5. Electronic exchanges should all be kept within the patient’s file and the patient should be so informed.
Practice tip No. 6. Because it is impossible to guarantee that e-mail will be read and responded to within a set period, emergency messages and time-sensitive material should not be sent by e-mail. While generally received by the recipient’s e-mail server within seconds, e-mail can sometimes take a circuitous route and ar-rive hours later. Moreover, a patient may not review his e-mail for hours or even days, so ask patients to acknowledge receipt of e-mails by reply e-mail or telephone. Subject lines can contain words denoting urgency or deadlines, such as “Time-sensitive, please acknowledge receipt.”
Practice tip No. 7. Because speed of typing results in typos and the perception of curtness, take great care with clear wording and be as brief as possible.
Practice tip No. 8. Prepare standard, courteous messages for unsolicited mail that you do not wish to respond to (eg, “Thank you for your e-mail. Due to the high volume of e-mails, I will not be able to respond. To reach my assistant, please phone during office hours. For after-hour emergencies, please contact so-and-so. For immediate needs, please contact the physician on call or visit your nearest emergency room”).
Be sure to provide accurate Web links and current telephone numbers for all referral information. Such standard responses may be set up in a variety of ways, depending on the sophistication of your e-mail software. One simple method is to prepare a variety of e-mail “signatures,” each with a different response.
Practice tip No. 9. Steer unknown e-mailers seeking medical advice to a local physician or medical center. Increasingly sophisticated e-mail filter technology can advise you of who is and who is not a current patient. In all instances, it is your ethical obligation to provide referral information to all those who contact you.
Practice tip No. 10. Before sending an e-mail, always scroll down to the very bottom of your almost-ready-to-send e-mail. This step is good general practice because not only can you learn important information in a potential e-mail thread but there may be confidential information that you do not want to pass on.
Cost and reimbursement
Reimbursement policies for psychiatric treatment remain largely based on the volume and duration of face-to-face visits. Despite years of debate, neither phone assessments nor online encounters are reimbursed in industrialized countries—with the exception of a few demonstration projects and very few insurers. In some Canadian jurisdictions, notably Ontario and British Columbia, there exist “chronic disease management” fee codes, but it is difficult to “box” a psychiatric encounter into one of these codes. And yet, psychiatrists can spend valuable time responding to e-mail messages, just as they do responding to phone calls. E-mail adds to the daily workload, even though office staff can intercept messages, much as they answer the telephone.
There does appear to be a demographic divide: younger physicians embrace and appreciate the need to be in almost constant dialogue with clients. Medicine is changing and will become more participatory. The reality is that few patients abuse e-mail, for example, by attempting to contact the office after hours. Clear expectations about after-hour “e-access” need to be communicated to all patients.
Keep the relationship first
The telephone was once accused of dehumanizing the physician-patient relationship, just as electronic communication is today. But readers may remember that on March 10, 1876, Alexander Graham Bell’s first words over the telephone were, “Mr Watson, come here, I want you.” Bell was calling for medical assistance because he had just spilled sulfuric acid on his clothes and needed help.12 Since those early days, the telephone has saved countless lives.
E-mail is perhaps an even more powerful medical tool. It empowers patients by increasing their means of gaining access to health care. It enhances the management of chronic diseases, improves patient education and joint decision making, and facilitates continuity of care. It increases the frequency of interaction with the system from acute encounters to more regular ongoing interactions that enable patient self-management.
As Katz and Moyer13 have noted,
Navigating schedule systems, parking lots, waiting rooms, nursing stations, and checkout counters to spend an average of 10 minutes with a physician is no small price to pay for issues that, in many instances, could be better addressed through other, less burdensome modes of communication. Despite advances in phone system technology, automated message systems frustrate many patients. Largely due to the frustration with communicating with physicians, patients remain dissatisfied with access to their health care providers. For many patients, using online communication appears a better option than more traditional modes.
Instant messaging and other Web-based communications
Many patients prefer IM because it allows them to “talk” with their physicians in real time. For the doctor who can put aside a half hour a day to simultaneously answer all his or her patients’ questions, IM can be a time saver—preferable to multiple phone calls at the end of the day.
Patients are also concerned that their words not be misunderstood and that they do not misinterpret the words of the doctor. E-mail and IM “conversations” are recorded so that they can be compared and meanings discussed; recommendations can be better remembered, and doctors can be held accountable for their advice.
Many health care organizations are increasingly turning to Web-based communication tools and solutions that make it possible to exchange or store information in an easily retrievable manner and to track and document communication.14 Such systems are more secure than regular e-mail because they can be authenticated and messages cannot be easily forwarded. See the Table for safety and audit trail comparisons among various media.
We are in the midst of an explosion of information on the Web, and the most dominant forms of expression on online blogs and communities relate to health care. Discussions about mental health, in particular, are the most frequently active of all patient conversations in chronic illness groups on social media platforms, such as MySpace. Many of the most discussed topics in these communities relate to high-stigma illnesses, such as depression, bipolar disorder, and HIV/AIDS.14
As modern patients, or e-patients, express their needs, wants, and expectations of the health care system, it is incumbent on psychiatrists to take these issues seriously. E-communication is just communication by another name—even if fraught with distinct liability and security risks. The more psychiatrists can do to advance the ease of reciprocal communication and reduce barriers, the better. Psychiatrists are an ideal group to lead the e-revolution.
Dr Seeman is professor emeritus in the department of psychiatry at the University of Toronto; Mr M. Seeman is a solutions executive at Integrated Communications Services of IBM Global Technology Services; Mr B. Seeman is chief executive officer of Clera Inc, an early-stage pharmaceutical company; and Mr N. Seeman is a writer and director and primary investigator of the Health Strategy Innovation Cell at Massey College at the University of Toronto. Dr Seeman, Mr B. Seeman, and Mr N. Seeman report no conflicts of interest concerning the subject matter of this article. Mr M. Seeman reports that he is an employee of a company that sells real-time collaboration and telephony products and services to hospitals and health care organizations around the world.
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