Article from the Boston Globe’s On Call Magazine, September 2003

By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting

Used wisely, e-mail and the World Wide Web can benefit both patients and providers. Many people use e-mail and the Web to get the news, buy airline tickets, and make dates with business associates or friends. But despite the increasing level of comfort most people have with these electronic tools, few people use them to communicate personal health information. Daniel Sands, MD, MPH, is the clinical director of electronic patient records and communication at Beth Israel Deaconess Medical Center (BIDMC), and he is working to change that.

There are natural benefits, Sands says, to using e-mail and the Web. E-mail, for instance, combines the informality of speaking with the permanence of the written word. It is also self-documenting, allowing patients to print out messages they want to read and share with others and letting providers make copies of messages for medical records. Another benefit to using the tools available on the Internet is that both e-mail and Web sites can include links to other related online resources. And communicating over the Internet allows users, both patients and providers, to send or reply to messages at their own convenience.

But electronic communication also poses challenges, most notably concerns about privacy and security. For instance, e-mail from computers with “shared accounts” (computer accounts used by more than one person) can be read by others than the intended recipient. Also, if patients send or receive e-mail at work, their employer has a legal right to read their messages. There are, though, ways to address those concerns, Sands says. For instance, BIDMC uses a Web-based messaging system with its “PatientSite.” Patients with a password can log on to a secure site and exchange messages with their health providers that do not go through their employer’s e-mail system. They can also see a list of links to other sites with information that is specifically relevant to them. For a demonstration, go to https://patientsite.bidmc.harvard.edu/whatis.asp

Communication Guidelines

Sands says electronic communication between patients and providers can enhance patient-provider relations, support patient education, and save both time and money. Before you begin communicating this way, though, you should talk with your patients about guidelines. Sands recommends that providers draft and discuss written agreements which they can then have patients sign. Examples of these types of agreements can be found on the Electronic Patient Centered Communication (ePCC) Website at http://www.e-pcc.org.

Here are some suggestions for how to use e-mail or Web-based communication in your own clinical practice.

E-mail only when necessary. Just because e-mail is convenient doesn’t mean that you and patients need to communicate more frequently than usual. Talk with patients about when they should (or should not) e-mail you and what types of information to communicate this way.

[Bold]Clearly label e-mail messages[end bold]. When you send messages to patients, indicate on the subject line whether those messages are about “prescriptions,” “appointments,” “medical advice,” or “billing questions.” And ask patients to do the same when communicating with you. Also, ask patients to put their full name and medical record number at the beginning of each message.

Agree on “turnaround” times. Let patients know when they can typically expect a reply from you  — such as within 24 hours or  one to  two days. You can use an “auto responder” to automatically notify patients that you received their message and will reply within (x) hours or days. In the auto-response, you should include a phone number that patients can call if they need immediate assistance.

Make it clear that e-mail is not to be used for emergencies. Patients need to fully understand that using e-mail in an emergency can be dangerous since there is no assurance that you will read their message right away. Likewise, responding to an urgent message by e-mail creates a serious risk that a patient will not get the information he or she needs.

Alert patients to privacy concerns. Let patients know how e-mail is handled in your office. Let them know, for example, if your office staff is authorized to read and triage all messages. Tell patients, as well, that you will put their e-mail messages in the medical record and may also forward it to other professionals on their treatment team.

Ways to Improve Understanding

Because e-mail uses the written word, patients need adequate literacy skills to read and understand messages. Also, since it is a one-way form of communication, you can’t tell from visual cues whether or not patients are understanding what you are saying. Here are some issues to be aware of when considering how well your patients can understand your messages.

• Words. Use the principles of clear writing. This includes using short, familiar words rather than medical jargon or acronyms. Sands gauges what level vocabulary to use by looking at the messages patients write to him. If he sees a lot of spelling, punctuation, and vocabulary errors, he makes sure to write at a most basic level.
• Emotions. Be aware of e-mail’s limitations. Sands points out that e-mail lacks the richness of spoken messages, with few options to convey nuances, emotions, or humor. He feels that “emoticons” (combinations of symbols and letters used to convey emotions) are unprofessional and have no place in patient-provider communication. Fancy fonts, bold, and pictures are also not options, he says, because you cannot assume these embellishments will appear in the other person’s message. Don’t try to make the message do more than it can.
• Appropriateness. Given the limitations of e-mail, Sands feels strongly that it should not be used to convey bad news or complex information. Just because patients send an e-mail doesn’t mean you need to reply this way, he says. Know when it is preferable to talk by phone or to meet in person.

Electronic communication is good business. It saves time, money, and improves both patient and provider satisfaction. Although many providers express concern that they will be swamped by e-mail from their patients, Sands says this is not likely to occur. He cites a recent study that looked at how often patients send clinical messages (not queries for appointments or prescriptions) to their providers. The study found that, out of every 100 patients who could e-mail their providers, just one person did so each day.

In addition, e-mail messages between patients and providers tend to be succinct and to the point. This means that little time is spent on niceties like, “I’m sorry to bother you.” And, since electronic communication is asynchronous, little time is lost playing telephone tag or waiting for appointments.

Sands says that few insurance companies reimburse providers for time spent exchanging e-mail with patients. But he sees this changing soon, especially now that associations like the American Medical Association and the American College of Physicians are advocating for change.

How to Learn More

Daniel Sands, MD, MPH is the clinical director of electronic patient records and communication at Beth Israel Deaconess Medical Center. You can reach him by e-mail at dsands@bidmc.harvard.edu

In Print

Kane, B and Sands, D. “Guidelines for the Clinical Use of Electronic Mail with Patients,” Journal of the American Medical Informatics Association, Vol. 5, Number 1, Jan/Feb 1998: 104- 111.

On the Web

• Electronic Patient Centered Communication Resource Center, www.e-pcc.org
• Healthy E-mail, www.healthyemail.org
• Healthology, www.healthology.com,
• PatientSite at Beth Israel Deaconess Medical Center, https://patientsite.bidmc.harvard.edu