Julianna Troy, MD
Staff Psychiatrist, Counseling and Psychological Services, Purdue University, Lafayette, IN
Dr. Troy has disclosed that she has no relevant relationships or commercial interests in any companies related to this educational activity.
Do you use email to communicate with your patients? Chances are good that you don’t. One recent survey of psychiatrists found that just 5% routinely and 25% sometimes used email with patients (Koh S et al, J Psychiatr Pract 2013;19(3):254–263). This means that there is a significant disconnect between what we do and what patients want, as over 70% of patients say they want to communicate with their providers electronically (Schickedanz A et al, J Gen Intern Med 2013;28(7):914–920).
In this article, I’ll start by describing my approach to emailing patients, and then discuss some of the legal and regulatory issues that you’ll need to consider as you develop your own policies.
I have been communicating with patients electronically in some format since beginning work at Purdue University in 2008, in large part in response to requests from the university students who I treat. In the last several years, this has been via a secure messaging feature that is part of our electronic health record (EHR), which automatically encrypts communications. For many of my student patients, email or texting is their primary means of communicating with friends, family, and professors. It can be unusual for students to even talk on their mobile phones; it is not uncommon for many of them to not even have their voice mail set up.
Advantages of Email
Over the past few years, I’ve found several advantages of using email in clinical practice.
Convenience and workflow efficiency. Email cuts down on “phone tag” and overall time spent on the phone, since I can often address concerns more rapidly by email. Messages can be sent at the provider’s convenience and read at the patient’s convenience, making it a win-win for both parties. For example, I had one patient with depression whose screening lab work showed significant hypothyroidism. I was able to send the results to him directly via secure message, along with a referral list for endocrinologists. He wrote back within the hour stating that he had just made an appointment with an endocrinologist on the list, and was planning to print out his lab results to bring to that appointment.
Enhanced privacy. Yes, you read that right—ironically, given the common worry about privacy breaches with email, such communication often improves a patient’s ability to communicate with us privately. Patients who are at work or in other public settings are uncomfortable having a phone call about their mental health issues, but reading and responding to emails is discrete. I’ve also found that it can be a good way for patients to broach more sensitive topics, such as concerns about gender identity. Initiating a discussion over email provides a sense of safety and distance and can increase comfort about having a more thorough discussion at the patient’s next appointment. However, see the caveat below about protecting patient privacy in accordance with HIPAA regulations.
Enhanced communication of clinical information. When I provide medication instructions via email, I use a concise, clear format that patients can refer to several times if needed, increasing their understanding and adherence. I have found that electronic communication is ideal for sending lab results, medication handouts, referral lists to specialists, handouts detailing relaxation and sleep hygiene techniques, and for receiving and responding to prescription refill requests.
More efficient appointment management. I sometime use email for appointment reminders and to check in with patients after missed appointments. When I do this with university students, it is not uncommon to receive a reply within the hour explaining the circumstances of the missed appointment and stating an intent to reschedule. This is not only a source of relief when working with higher risk patients, but also substantially decreases the amount of time that would otherwise have been spent trying to follow-up with the student. If you are lucky enough to work with an EHR that provides a secure messaging feature for communicating with patients, this information will usually be automatically added to the patient’s medical record, further improving workflow efficiency.
Regulatory and Other Considerations
As you can see, there are many advantages of emailing patients—however, before you begin, you should know about various ethical, legal, and practical issues. (See “Five Tips for Using E-Communication Successfully in Your Practice” at the end of this article for a brief summary of recommendations). Consider the following:
Know your state regulations. First of all, make sure you don’t run afoul of the law. Clinical emails may be regulated at the state level, usually by state licensing boards. For example, the Medical Licensing Board of Indiana lists some very specific requirements on its website (http://bit.ly/180JCYu). The state requires that you obtain written informed consent from patients prior to initiating email contact. This informed consent agreement must specify what types of information are permitted to be emailed (for example, refill requests and scheduling information), must state that email is not to be used for emergencies, and must detail when patients should call the office, schedule an appointment, or seek emergency care instead of using email. The regulations also specify that security measures (such as password protection and encryption) must be in place to protect patient confidentiality. Finally, it requires that all electronic communications must be included as part of a patient’s medical record.
Be aware of federal regulations. You should also be aware of federal HIPAA regulations governing the privacy and security of your patients’ protected health information or (PHI). If you are sending an electronic communication that contains PHI, you need to ensure its security. While HIPAA regulations do not require that you encrypt email, many HIPAA consultants recommend healthcare providers encrypt such communication to prevent a security breach. You may be fortunate enough to work for a healthcare organization that encrypts electronic communications for you, but if you have your own practice it may be worth the expense to invest in an encryption solution. Encryption may be less expensive than a HIPAA breach in the long run.
Follow professional standards. You should also check guidelines of professional associations, since such guidelines are considered standard of practice by courts—and thus very important if you ever get sued. The American Medical Association offers guidelines that emphasize obtaining informed consent from patients before initiating or responding to electronic communication and safeguarding patient confidentiality. They recommend using email to supplement face-to-face office visits but never using it to initiate a patient-physician relationship (Bovi AM, Am J Bioeth 2003;3(3):W-IF2).
It is notable that the Idaho Board of Medicine recently disciplined a physician for calling in a prescription following a telephone consultation, stating that it was a breach of standard of care to prescribe medication without an in-person examination of a new patient (Idaho Press-Tribune, April 28, 2014, http://bit.ly/1fMMaGV).
Although this case is related to telephone consultation, it is easy to see how a similar scenario could potentially involve electronic communication instead. This makes intuitive sense for the practice of psychiatry, where a great deal of important diagnostic information is provided through visual and auditory cues, such as psychomotor behavior, speech patterns, and affect. These factors make face-to-face assessment of new patients, and even of new concerns in established patients, essential.
Protect confidentiality and maintain therapeutic boundaries. Some additional considerations when using email in your practice relate to confidentiality and therapeutic boundaries. It is always possible for email to be misaddressed or read by someone other than the intended recipient. Several years ago I worked with a student who slightly misspelled my email address when sending a correspondence that contained a great deal of clinical information. Instead of going to me, the email was received by a professor in the student’s department. To make matters worse, the student had cc’ed an off campus member of the treatment team, who replied using the “reply all” feature, compounding the problem. This type of risk to confidentiality should be included in written informed consent agreements with your patients before using email.
A final concern relates to therapeutic boundaries. As with phone calls, some patients may email excessively, and some may use email to state urgent concerns in spite of a prior informed consent agreement not to. It is best to address this just as you would any other boundary issue, and I have even found that on some occasions patterns of email use by patients can provide important clues to characterologic diagnoses, which can inform treatment planning.
But don’t let all this scare you away from judiciously using a modern technology that has the potential to improve your communication, and therefore, the quality of care for your patients. While there are both advantages and risks in using email in clinical practice, my experience has been that in most cases the pros far outweigh the cons.
TCPR’s Verdict: Email enhances communication—and communication is how we help our patients.
Five Tips for Using E-Communication Successfully in Your Practice
Never establish new patient relationships, make a new diagnostic assessment, or substantially change a treatment plan based on an e-communication.
Use a written informed consent agreement in advance of establishing e-communication that details:
Potential confidentiality risks and what steps the provider will take to try to protect confidentiality
That all e-communications will be a part of the patient’s medical record
Who will check e-communication (ie, just the provider, nursing staff, and/or practice partners)
The expected turnaround time for replies
What topics are and are not appropriate for e-communication, and what to do for urgent or emergent concerns that should never be addressed through e-communication
Use an autoreply feature not only to signify message delivery, but also to summarize your e-communication policy and provide explicit instructions for what patients should do to address urgent or emergent concerns. Include this information in a footer at the end of all e-communications as well.
Arrange for a practice partner to check your e-communications for you while you are away on vacation. If this is not possible, update your auto reply to include information about when you will be out of the office and how patients should have concerns addressed in your absence (ie, by calling the office or a covering physician).
Monitor for inappropriate and/or overuse of e-communication by patients, since this can provide important diagnostic information and inform treatment planning. Address inappropriate and/or overuse of e-communication as you would any other therapeutic or boundary issue.