Gulf Coast Pain Management
Lynne Carr Columbus, D.O. / Hee (Dennis) S. Lee, M.D.
Physicians Slowly Adopt e-mail to Communicate with Patients
Trend Likely to Gain Momentum in Coming Years
 
The next time you consult with your patient, it could be over the Internet instead of in your office.
 
That’s because physicians are slowly, but steadily, increasing using e-mail to communicate with patients.(1, 2) The percentage of doctors using this mode of communication hovers around 20%.(3, 4) Demand for this technology, however, is not coming from physicians, but rather from patients. In the first half of 2005, the number of US adults who sought
healthcare information on-line has increased to approximately 117 million-up from 111 million in 2004-representing 72% of all on-line adults.(5) More importantly, the vast majority of consumers want to be able to communicate with their doctors
via e-mail.(6)
 
Consumer demand coupled with the government’s push to promote healthcare information technology fuel the growing trend. Give it five years and some predict that this mode of communication will be commonplace.
 
“Patients want access to their doctors, and e-mail is another way to give them that access,” notes Joseph Kvedar, MD, who chairs the ADD’s Telemedicine Task Force. Patients want on-line access because they sometimes forget to ask a question during their in-office visit, want information that doesn’t require a physical examination, or are unable to reach the
doctor  by phone. Patients don’t like playing telephone tag any more than do doctors, he adds.
 
Physicians typically use e-mail for discussing symptoms/treatment: determining whether an office visit is indicated, notifying patients of test results, scheduling appointments/answering billing inquiries, and filling prescription refill request.(7)
 
The benefits are numerous. It eliminates phone tag, serves as documentation, frees up staff time to do more important tasks, enables the physician to focus on patients with more urgent care needs, and is convenient for doctors and patients, alike. It’s easier to sit down with five e-mails than it is to make five return phone calls, says Dr. Kvedar, who has been using e-mail for patient communication for approximately four years.
 
If the benefits are so numerous, why aren’t more physicians jumping in the e-mail bandwagon? The biggest barrier is security of information. Under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), electronic transactions containing patient information must be safeguarded. Standard e-mail is not secure, meaning that it
does not provide patient privacy, which breaches the HIPPA law. “Using standard e-mail is like sending a post card,” explains Lynn C Columbus, DO, a pain management specialist in Palm Harbor, Florida, who lectures about e-mail communications to physicians. “Anyone can pick it up and read the back of it.”
 
Other reasons physicians cite for not using e-mail include malpractice liability and lack of reimbursement, as well as the belief that they will receive an overwhelming number of e-mails, which will overburden their exiting workload.(7, 8)
 
Those barriers, however, are slowly being broken down. Companies like Medem and RelayHealth offer providers a secure way of communicating with patients and documenting that communication, says Hon Pak, MD, a lieutenant colonel in the US Army and chief of information technology, engineering division of the Telemedicine and Advanced Technology Research Center.
 
Both RelayHealth and Medem, the latter of which is the for-profit venture of several medical societies including the American Medical Association (AMA), provide on-line secure messaging. They require a login ID and password, and can only be accessed by registered users. Because both systems are secure, on-line patient encounters can be reimbursed. 
 
On the down side, such platforms require the user to open another application. “This technology requires an additional step and unless there’s a perceived value by the provider, there won’t be widespread adoption, says Dr. Pak. In addition, adopting secure messaging platforms requires the physician and patient to use the same platform and that requires
additional training.
 
Encryption software such as ZixMail gets around the need for the physician and patients to use the same platform because it enables the physician to encrypt, decrypt, and send private and secure, digitally signed e-mail and attachments to anyone even if the recipient is not a subscriber.
 
As long as physicians are using a secure site, HIPPA is not an issue, adds Lynne Lynne Carr Columbus, D.O. Another barrier-medical liability-can be mitigated by the use of guidelines for e-mail communication. Several medical associations, including the AMA, the American Medical Informatics Association, and the American Academy of Family Physicians, have developed such guidelines. Probably the most well known are the ERisk Guidelines developed by the ERisk Working Group of Healthcare, a consortium of professional liability carriers, medical societies and state board representatives. Among the topics addressed by guidelines include security, authentication, confidentiality, unauthorized access, informed consent, subject matter, doctor-patient relationship and medical records. For example, guidelines talk about the need to have an established physician-patient relationship in order to communicate via e-mail. “You are liable in terms of what you say on e-mail,” says Dr. Pak, “but the good news is that it will be documented unlike a telephone conversation. Assuming physicians are using a secure messaging system, their liability would go down,” he adds. “If they are using regular e-mail, their risk would go up.”
 
Guidelines also help physicians establish value around this mode of communication, says Dr. Kvedar. That credibility is paying off as some insurers are beginning to reimburse for e-mail consultations. Among them are Blue Cross and Blue Shield of California., Florida and Tennessee. Dr. Kvedar and the entire Dermatology Department at Brigham
and Women’s General Hospital are enrolling patients in a trail in conjunction with Blue Cross and Blue Shield of Massachusetts, which is evaluating follow-up e-visits to determine if they can provide enough information for the physician to make judgments regarding treatment. After the pilot is complete, the insurance carrier will determine appropriate levels of reimbursement. In addition, the Center for Medicare and Medicaid Services (CMS) has adopted a temporary code to monitor how the technology is being used, says Dr. Pak. The assumption is that if e-mail communication proves
cost-effective, CMS will reimburse for the technology.
 
In the meantime, even if insurance carriers aren’t willing to pay for e-visits, nearly 40% of patients pilled in 2002 Harris Interactive Survey would be willing to pay to communicate with their own physicians on-line.(6)
 
Finally, numerous studies have shown that patients don’t abuse e-mail. In fact, most patients adhere to recommend guidelines designed to focus e-mail content by limiting the number of request to one per message, avoiding urgent request or highly sensitive information, and using an appropriate and courteous tone.(8, 9) Studies have also found that e-mails is a more convenient and satisfactory form of communication for both patients and physicians, the latter of whom do not receive an excessive volume of messages no spend an excessive amount of time answering them.(10) “Doctors should know it will most likely make interactions between them and their patients more efficient,” says Dr. Kvedar.
 
Physicians who want to use e-mail for patient communication should inform patients that the practice is implementing this new service and explain how it works, suggest Lynne Lynne Carr Columbus, D.O. They should develop and disseminate written guidelines on how the practice ill use this mode of communication. For example, the guidelines would indicate when not to use e-mail, such as for emergent health problems, and delineate expected message response times. Guidelines developed by the various medical associations can be helpful when developing office guidelines. Then patients should sign a letter of informed consent before e-mail connection is established.
 
“You have to establish rules of the road with your patients around this mode of communication,’ says Dr. kvedar, who told his patients that he will read e-mails in the evenings. “So if they send it at 8 a.m., they should’ve expect a response for 24 hours,” he says, adding. “They are people who once they send a message will wait for your reply.” He also makes it clear that the e-mails should be based within the context of their current relationship and an existing condition. In other words, If he’s treating the patient for psoriasis, don’t e-mail regarding a new pigmented lesion.
 
The standard of care will always require face-to-face consultation, Dr. Kvedar says, adding, “but I look forward to rigorous discussion and trials so that we can learn which aspects of our care process are most amenable to this technology.
 
SIDEBAR: Two Web sited provided physicians with a wealth of information regarding the use of e-mail for communication with patients. The Web site www.healthyemail.org offers guidelines, policies, and educational materials for using e-mail appropriately in addition to encryption software. The Web site www.e-pcc.org us designed to educate
physicians about the benefits, risks, and appropriate use of electronic patients centered communication, also known as ePCC.
 
REFERENCES:

1. Online Patient-Physician Communications: Assessing Market Readiness for Payers. Concept Report. Jupiter Research. Sept, 2, 2004. www.ihealthbeat.org/index.cfm?Action-dspItem&itemID=106423.
   Accessed Aug, 2, 2005.

2. Harris Interactive: eHealth’s influences continues to grow as usage of the Internet by physicians and patients increased. Health Care News.3(6). April 17, 2003. HIMSS survey: handhelds hot, email not for US physicians. Nov, 4, 2002

3. 2001 AMA Study on Physicians’ Use of the World Wide Web. May 9, 2001. Accessed Aug, 2, 2005.

4. Harris Interactive: Number of “cyberchondriacs” –U.S adults who go online for health information – increased to estimated 117 million. Health Care News. 5(8) July 28, 2005.

5. Harris Interactive: Patient/physician online communication: Many patients want it, would pay for it, and it would influence their choice of doctors and health plans. Health Care News. 2(8). April 10, 2002.

6. Miller RH, Hillman JM, Given RS: Physicians use of it: Results from the Deloitte research survey. Journal of Healthcare Information Management. 18(1):72-80, 2004.

7. Sands DZ: Help for physicians contemplating use of e-mail with patients. J Am Med Inform Assoc. 11(4):268-269, 2004.

8. Casey B, et al: A content analysis of e-mail communication between patients and providers: patients get the message. J Am Med Inform Assoc.
   11(4):260-267, 2004.

9. Leong SL, et al: Enhancing doctor-patient communication using email: a pilot study.  J Am Board Fam Pract. 18(3):180-188, 2005

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