Guidelines for Physician-Patient Electronic Communications

Providing quality health care depends on the clinician’s ability to adequately communicate diagnosis and treatment programs, as well as furnish appropriate health education information.

Written and verbal (face-to-face and telephone) communications have traditionally been the primary mechanisms for communicating health information. However, with advances in technology, Internet applications for communications among physicians and between clinician and patient are emerging as another viable avenue for patient communication. E-mail has taken on increased significance as a mode of communication that is readily available to patients and health care professionals.

The use of e-mail by physicians allows for follow-up patient care and clarification of advice provided in a professional office setting. E-mail creates a written record that removes doubt as to what information was conveyed. E-mail is especially useful for information the patient would have to commit to writing, if it were given orally. Examples include addresses and telephone numbers of other facilities to which the patient is referred; test results with interpretations and advice; instructions on how to take medications or apply dressings; and pre-and postoperative instructions. Some frequently used educational handouts can be ported to an e-mailer template or formatted for the clinician’s home page on the World Wide Web.

E-mail messages can also embed links to educational materials and other resources on the practice’s Web site or on external sites. In some electronic mail applications, clicking on a "live" universal resource locator (URL) link inside a mail message launches a web browser and takes the user directly to the indicated resource. Practices can provide lists of URLs on a particular topic, such as pregnancy, and create e-mail reply templates with pointers to frequently used reference sites.

With the continued increased usage of computers and the Internet by individuals, e-mail can be a valid, simple, convenient, and inexpensive mechanism for communication. It can aid the health care delivery process by allowing written follow-up instructions, test results and dissemination of educational materials for patients, as well as, a means for patients to easily reach their physician on routine health matters. At the same time, issues of privacy, confidentiality and security must be addressed to ensure the efficacy and effectiveness of e-mail.

In 2000, at the request of the Young Physicians Section, the AMA Board of Trustees issued guidelines to aid physicians in communicating electronically with patients. These guidelines were updated in June 2001 and in June 2002.

AMA Guidelines

New communication technologies must never replace the crucial interpersonal contacts that are the very basis of the patient-physician relationship. Rather, electronic mail and other forms of Internet communication should be used to enhance such contacts. Patient-physician electronic mail is defined as computer-based communication between physicians and patients within a professional relationship, in which the physician has taken on an explicit measure of responsibility for the patient’s care. These guidelines do not address communication between physicians and consumers in which no ongoing professional relationship exists, as in an online discussion group or a public support forum.

(1) For those physicians who choose to utilize e-mail for selected patient and medical practice communications, the following guidelines be adopted.

1. Establish turnaround time for messages. Exercise caution when using e-mailfor urgent matters.
2. Inform patient about privacy issues.
3. Patients should know who besides addressee processes messages during addressee’s usual business hours and during addressee’s vacation or illness.
4. Whenever possible and appropriate, physicians should retain electronic and/or paper copies of e-mails communications with patients.
5. Establish types of transactions (prescription refill, appointment scheduling, etc.) and sensitivity of subject matter (HIV, mental health, etc.) permitted over e-mail.
6. Instruct patients to put the category of transaction in the subject line of the message for filtering: prescription, appointment, medical advice, billing question.
7. Request that patients put their name and patient identification number in the body of the message.
8. Configure automatic reply to acknowledge receipt of messages.
9. Send a new message to inform patient of completion of request.
10. Request that patients use autoreply feature to acknowledge reading clinicians message.
11. Develop archival and retrieval mechanisms.
12. Maintain a mailing list of patients, but do not send group mailings where recipients are visible to each other. Use blind copy feature in software.
13. Avoid anger, sarcasm, harsh criticism, and libelous references to third parties in messages.
14. Append a standard block of text to the end of e-mailmessages to patients, which contains the physician’s full name, contact information, and reminders about security and the importance of alternative forms of communication for emergencies.
15. Explain to patients that their messages should be concise.
16. When e-mailmessages become too lengthy or the correspondence is prolonged, notify patients to come in to discuss or call them.
17. Remind patients when they do not adhere to the guidelines.
18. For patients who repeatedly do not adhere to the guidelines, it is acceptable to terminate the e-mailrelationship.

1. Develop a patient-clinician agreement for the informed consent for the use of e-mail. This should be discussed with and signed by the patient and documented in the medical record. Provide patients with a copy of the agreement. Agreement should contain the following:
2. Terms in communication guidelines (stated above).
3. Provide instructions for when and how to convert to phone calls and office visits.
4. Describe security mechanisms in place.
5. Hold harmless the health care institution for information loss due to technical failures.
6. Waive encryption requirement, if any, at patient’s insistence.
7. Describe security mechanisms in place including:
8. Using a password-protected screen saver for all desktop workstations in the office, hospital, and at home.
9. Never forwarding patient-identifiable information to a third party without the patient’s express permission.
10. Never using patient’s e-mailaddress in a marketing scheme.
11. Not sharing professional e-mail accounts with family members.
12. Not using unencrypted wireless communications with patient-identifiable information.
13. Double-checking all "To" fields prior to sending messages.
14. Perform at least weekly backups of e-mail onto long-term storage. Define long-term as the term applicable to paper records.
15. Commit policy decisions to writing and electronic form.

(2) The policies and procedures for e-mail be communicated to all patients who desire to communicate electronically.

(3) The policies and procedures for e-mail be applied to facsimile communications, where appropriate. (BOT Rep. 2, A-00; Modified: CMS Rep. 4, A-01 and BOT Rep. 24, A-02)

AMA Ethics Policy

The following recommendations of the AMA Council on Ethical and Judicial Affairswere adopted as AMA Ethics Policy at the December 2002 Interim Meeting of the AMA House of Delegates. The full report is available upon request by calling 312-464-4823, or e-mailing jennifer_favorite@ama-assn.org. CEJA anticipates that the AMA House of Delegates will issue an Opinion on this issue in June 2003.

Electronic mail (e-mail) can be a useful tool in the practice of medicine and can facilitate communication within a patient-physician relationship. When communicating with patients via e-mail, physicians should take the same precautions used when sending faxes to patients. These precautions are presented in the following considerations:

• E-mail correspondence should not be used to establish a patient-physician relationship. Rather, e-mail should supplement other, more personal, encounters.
• When using e-mail communication, physicians hold the same ethical responsibilities to their patients as they do during other encounters. Whenever communicating medical information, physicians must present the information in a manner that meets professional standards. To this end, specialty societies should provide specific guidance as the appropriateness of offering specialty care or advice through e-mail communication.
• Physicians should engage in e-mail communication with proper notification of e-mail’s inherent limitations. Such notice should include information regarding potential breaches of privacy and confidentiality, difficulties in validating the identity of the parties, and delays in responses. Patients should have the opportunity to accept these limitations prior to the communication of privileged information. Disclaimers alone cannot absolve physicians of the ethical responsibility to protect patients’ interests.
• Proper notification of e-mail’s inherent limitations can be communicated during a prior patient encounter or in the initial e-mail communication with a patient. This is similar to checking with a patient about the privacy or security of a particular fax machine prior to faxing sensitive medical information. If a patient initiates e-mail communication, the physician’s initial response should include information regarding the limitations of e-mail and ask for the patient’s consent to continue the e-mail conversation. Medical advice or information specific to the patient’s condition should not be transmitted prior to obtaining the patient’s authorization.

Bibliography

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5. Lindberg DAB, Humphreys BL. Medicine and health on the Internet: the good, the bad, and the ugly. JAMA. 1998;280:1303-1304.
6. Kane B, Sands DZ. Guidelines for the clinical use of electronic mail with patients. JAMIA. 1998;5:104-111. Available at http://www.jamia.org/cgi/reprint/5/1/104
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Additional Guidelines

Medem, in collaboration with over a dozen of the nation's medical societies and 30 malpractice carriers representing over 70% of the nation's insured physicians, created an eRisk Working Group for Healthcare to address the issues and concerns associated with physician-patient interaction and communication via the Web. The outcome of a work effort since June 2000 is a series of documents that address potential online liability issues, online payment, and help guide patient-physician communications on the Internet.