Online care: Guidelines tame the wild Web

Practice issues addressed include how to handle patient e-mail and online consultations.

Editorial. Feb. 3, 2003.

For many physicians, venturing into online consultation has been the equivalent of moving to the Wild West in the 1800s. You know people are going there, and you know they'll be looking for care, but how do you operate your practice in a place that seems to have no rules?

Well, thanks to the efforts of the eRisk Working Group for Healthcare, the Internet frontier is a little less wild. The group has set guidelines covering physician use of the Internet for patient care and communication.

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Its members have the collective clout to make a difference. The consortium consists of more than 30 professional liability carriers and medical societies, including the AMA, and worked in conjunction with the Federation of State Medical Boards. Also intimately involved was Medem, the physician Internet service owned by the AMA and a number of other medical associations.

The guidelines set standards for how to handle patient e-mail and how to handle fee-based online consultations, two increasing realities for physicians.

A 2002 Harris Poll showed that more than 70% of patients want e-mail access to their physicians' offices. The poll also showed that many patients are willing to change physicians to get the service, and nearly 40% are willing to pay for online contact with their physician.

The crux of the eRisk guidelines is this: Physicians should use the Internet to diagnose or treat only patients with whom they already have a patient-physician relationship. This isn't a new idea, but it brings the AMA, other medical societies, the FSMB and liability carriers into written agreement, ensuring that there will be no confusion over who is following professional standards.

State boards have taken action against physicians who sign off on prescriptions through Rx-only Web sites after a sketchy "consultation"; the new standards suggest that diagnosing a patient you've never examined face-to-face could receive the same scrutiny and pose the same professional risk.

But the standards are also there to advise physicians who simply want to know how best to use the Internet to help their patients. For example, the guidelines state that physicians should "attempt to distinguish" between Internet consultations for preexisting conditions or ongoing treatment and new diagnosis and treatment addressed online. "New diagnosis and treatment of conditions, solely online, may increase liability exposure," caution the guidelines.

The guidelines also spell out patient protections physicians are responsible for, such as ensuring patient privacy online, authenticating that the patient identified in the e-mail is indeed that person and disclosing their fees upfront.

These guidelines are voluntary and are not offered as legal advice. But given the participation of medical boards and liability carriers, representing 70% of insured physicians, in forming them, the guidelines can give physicians some notion of what conduct might not be defensible in a liability case or could put a medical license at risk.

With these eRisk guidelines in place, putting a medical practice online is less like moving out West in the 1800s than it is moving there today. You may or may not want to do it, but at least you know there's some law and order in place.