Get in with the e-crowd

Bryan P. Bergeron, MD

VOL 107 / NO 7 / JUNE 2000 / POSTGRADUATE MEDICINE

I hate to admit it, but I'm responsible for killing more trees than anyone else I know. The reason? E-mail. I can't tolerate reading on my computer screen the dozens of e-mail messages I receive every day. My eyes simply can't take it. So I print out virtually all of my e-mail messages, preferably on low-contrast oyster-white paper, and read them when I've finished my high-priority tasks. What's worse, the deluge of spam--junk e-mail consisting of unsolicited advertisements and promotions--seems to be accelerating. More trees will certainly die unless someone puts a stop to this insanity.

Today, e-mail is second only to the telephone as an internal communications method in most service organizations, including many hospitals. Within a couple years, e-mail will eclipse telephone calls, faxes, and surface mail combined in internal and external communications volume and will most likely become the major external communications vehicle for your practice as well. As more of your patients become wired to the Internet, you will be under more pressure to join in the expanding e-mail community.

However, universal adoption of e-mail in medicine won't occur overnight. There are many unresolved issues regarding payment, potential liabilities, and the overall effect on patient-physician relationships. On the other hand, despite these and other unknowns, there are many potential benefits associated with properly integrating e-mail into your practice.

The possibilities of e-mail

To a large degree, the potential utility of e-mail to your practice depends on your patient population. If you have a lot of health zealots who sit at their computer for hours every day looking for advice on how to cure their ills, you'll be inundated with e-mail. Making your e-mail address known to these patients may make you too accessible, and you'll probably want to maintain a healthy distance.

If you're paid a flat fee per patient, e-mail can help cut expenses. For example, if a 1-minute e-mail can obviate a 20-minute office visit, e-mail is a win-win option for you and the patient. But if you're reimbursed for office visits and not for phone or e-mail consultations, you'll be hurting your bottom line if you spend much time on e-mail with your patients.

E-mail is an excellent communications conduit between staff in a large healthcare organization. Our department, in fact, our entire hospital, lives by our e-mail system. And why not? It's fast, accurate, and self-documenting. With a telephone conversation, you often have to play phone tag to reach someone and then need to keep notes of the conversation, especially if it contains critical information and promises.

The catch, of course, is what to do about the outside world. The problem is twofold: how to handle patients and how to avoid a barrage of spam and still be available to friends, relatives, and other physicians on the Internet.

Handling patients' e-mail

Interacting with patients via e-mail can be a real challenge. Issues include minimum acceptable response time, provisions for security, reimbursement for your efforts and time, and legal implications. For example, if you give all of your patients unlimited e-mail access, how will you get any work done? If a patient sends you crucial information about his or her condition, should it become part of the official medical record? What about the patient who e-mails you about chest pain one evening and is found dead the next morning--with the message to you still displayed on the computer monitor? Are you liable?

Most of these challenges are easily surmountable. In handling the time problem, you might establish a quota of e-mail messages per patient or charge for the service. It may help to think of e-mail not as a potential burden but rather as a profit center. Encourage your patients to write often, and charge them a set price for each e-mail response from you. Of course, the real change will occur if insurers decide to cover e-mail consultations.

Another way to control the time you spend on e-mail is to give different groups of patients different e-mail addresses, such as one account for those you expect to be heavy users and another account for typical patients. You'll know what to expect from each group and can manage them separately--on your own time line. Yet another approach is to designate a gatekeeper, such as your nurse, to screen your e-mail and pass important or urgent messages to you as needed. Or you can teach your staff to read and answer at least some of the questions, and you can hit the "send" button once you've reviewed the question and answer.

However you handle e-mail, be sure to set your patients' expectations of response time. It's better to say you'll reply within the week and then delight patients with a 3-day delay than to promise to answer in 3 days and take a week. But do develop a system to answer in a timely fashion. While messages are sitting on your computer waiting for your attention, your patients may be patiently sitting by their computer waiting for your reply.

It's important to think security when you're dealing with patient e-mail. Your e-mail messages can potentially be read by others, so be careful about what you write and how you write it. Anything you e-mail could end up in a court of law. Services such as AOL archive e-mail messages for years. If you store patient e-mail messages on your computer, consider using a simple encryption program to make text unreadable to someone snooping around your computer.

There's a privacy issue from patients' perspective as well. If your patients use a computer at work to send and receive e-mail from you, the company has the right to archive and review the information. Sensitive information, such as a positive AIDS test, might ruin a patient's career if it is discovered by the employer.

Routing questions through a Web site

Another way to communicate with patients is by creating a Web site, complete with links to sites that you recommend and an e-mail link to you. (For a free site, try http://www.salu.net or http://www.pol.net, or use the Web creation tools at http://webmd.com if you're a member of Healtheon/WebMD.) Add lists of frequently asked questions (FAQs) to your site, and take the time to update them whenever patients ask a new question. Then in your e-mail response, you can direct patients to the FAQ list if you know their questions have been answered there. Again, control patients' expectations of the e-mail link on your Web page with a disclaimer, such as, "Questions will be answered only as time allows."

You can keep your typing to a minimum by having responses ready in a number of common areas. When the question fits your prepared answer, you can simply copy the text from your word processing program and paste it into your e-mail message. For example, you can develop a generic answer for many questions regarding diabetes (eg, drugs, side effects, nutrition, exercise) that will probably be sufficient for most of your patients.

Some large organizations have methods of handling patient questions so individual physicians aren't targeted for the answers. For example, in lieu of direct e-mail, Kaiser Permanente supports online discussions that are moderated by clinicians and other healthcare professionals.

Avoiding spam

As you know, your time is your most valuable asset. It takes time just to scroll through lists of e-mail and delete messages that are obviously junk. It's even more annoying to actually open e-mail messages only to find you've been tricked by their misleading titles (eg, "Your account," "Re: your question") into thinking they're something you're interested in.

The most time-efficient way to combat spam is to use a software filter that allows only certain messages into your e-mail account. Filters vary in their degree of complexity. Some can block any message with specific words (eg, sex), and others have only relatively crude cut-off standards (eg, block all e-mail that originates from outside a given network). AOL, Eudora, Outlook, and other commercial e-mail systems provide some built-in spam filtering. If you use AOL, for example, you can set the integrated spam filter to various levels of protection. If you use Microsoft Outlook for e-mail, periodically check the Microsoft Web site (http://www.microsoft.com) for spam filter updates.

You can also control spam by using different aliases in addition to your main screen name. You might want to use one screen name to receive e-mails from patients and another name for friends and relatives. Give friends a code word to put in the subject field so you don't inadvertently delete an important message. I usually follow my subject words with my full name, just in case.

If your e-mail account is provided by your hospital, your information services department undoubtedly has the capability of blocking spam. Contact your e-mail support desk and determine what spam filter options are available. And don't give your internal e-mail address to anyone not in your hospital or clinic.

The downside to maximum spam protection, regardless of the vendor, is that legitimate e-mail has a greater chance of being blocked. You might lose an important e-mail message if the level of protection is set too high. At lower levels of protection, some spam will get through the filters.

Products to improve and protect e-mail

Literally hundreds of products are available to make e-mail more secure, more efficient, and immune from spam attacks. Many of these products are either freeware or shareware, and my favorite of these is http://www.TuCows.com. Of the commercial offerings available, Message Inspector (http://www.elronsoftware.com) is an excellent tool for a larger group practice or department. It's flexible, easy to use, and blocks prurient materials as well as attachments infected with viruses. The downside, other than cost (about $1,000 for 25 users), is that the software requires an NT server.

If you stay connected to the Internet all day, coming to check your e-mail between patients, you're more open to a security breach than is someone who logs in sporadically. This is especially problematic if you have a high-speed cable modem connection, because this technology uses a consistent Internet address for your computer. To safeguard your patient e-mails, try NetWatcher, a $25 software package from http://www.moonlight-software.com. When someone tries to break into your cable modem connection, it shuts him or her out and records the network address.

You can cut down on computer time by using utilities that speed log-in, connect, and log-out processes. A macro program accomplishes this and also cuts down on the amount of typing needed to answer e-mails. With such a program, you can develop a short keyboard sequence that opens an e-mail message, adds specific text, and sends the message. I like QuicKeys ($40), which works with most e-mail programs and can be downloaded from the Web (http://www.quicKeys.com).

Final considerations

Various groups, such as the American Medical Association, the American Medical Informatics Association, and large healthcare enterprises, are developing guidelines for patient-physician e-mail. If you're in private practice, the real issue is how well you know your patients. Will they abuse your offer of e-mail communication or simply consider it an adjunct to the telephone? The other question to ask, of course, is how comfortable are you with e-mail? If you're not yet part of the e-crowd, it wouldn't hurt to begin experimenting with the medium so you'll be ready to meet your patients' inevitable expectations.

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