Communicating With Communicating With Your Teen Patients by Your Teen Patients by

E-Mail: E-Mail: It’s Easy!It’s Easy!

Hot Topics, Friday, March 24, 2006, Session II, 2:00- 2:15PM

David Paperny MD FAAP FSAMI have no financial interest in any proprietary websites mentioned

E-mail GuidelinesE-mail Guidelines

AMIA Guidelines, 1998 8yrs ago!

www.amia.org American Medical Informatics Association releases, disclaimers, criteria, security

2 addresses, 1 list (bcc)

Physician-Patient EmailPhysician-Patient Email Sands, D; Sands, D; J Am Med Inform Assoc.J Am Med Inform Assoc. 2004:260-67 2004:260-67

Info updates: 41%Rx renewals: 24%Health questions: 13%Test results inquiry:

11%

Referrals: 9% Other: 9%

Appointments: 5% Non-health related:

5%

Qualitative analysis of doctor-patient email3007 messages over 11 months (83% one-issue)

Sensitive info in only 5%Urgent messages 0%

Anatomy of an E-mail Anatomy of an E-mail MessageMessage

• Address: user@host Case-independent, no spaces

• Subject line (Jimmy MR#445566 re: acne)

• Messages:– Body (Text you type or copy, & MR# )

– Signature– Attachments (Describe all attachments)

E-mail Signatures for E-mail Signatures for PractitionersPractitioners

• The Most Important Part of Your E-mail!• Automatically append it to every outgoing

message• Keep it short (5-7 lines)• Elements to consider:

– Name, relevant degrees– Address, Phone & fax numbers– Best e-mail address used for PATIENTS ONLY– Disclaimers & standard info:

• “In case of emergency…”• “This is not medical advice.”• “This is not my signature.”

Body &Body & SignatureSignatureHi Lisa:

Your lab tests were ok.

- - - - - - - - - - - - - - - :) - -- - - - - - - - - - -

David Paperny MD,FSAM,FAAP  Kaiser Adolescent Clinic, Honolulu

HI.Dr.DavidPaperny@kp.org Urgent matters, call (808)432-2400

This is not medical advice.   In emergency: 911 or 432-0000

No marketing activities or bulk mail.   This is not my signature.

Never forward without permission. Intended for addressee only.

Email placed in medial record: Include Medical Record number.

Content not encrypted, protected, or guaranteed confidential.

Consequences of No Consequences of No SignatureSignature

• E-mail misinterpreted or ignored– “Huh? Who is this guy?”

• Comments misinterpreted in undefined context– “This pe459x19@prodigy.com needs to ask a

doctor!”• Recipients cannot respond to urgent info

– “Does anyone know teendoc@ca.gov’s phone number?”

• E-mail becomes dead end– “I tried to e-mail him back but it bounced. Oh well!”

• Attachments avoided– “Whoa… is this a virus? I’d better delete it to be

safe.”•

Writing E-mail with PatientsWriting E-mail with Patients• Like a phone message (informal, asynchronous)• Like a letter (hard copy, signature)• Netiquette often unfamiliar : R U goin 2 C

me?

• Acceptable uses:– Prescription refills– Documentation requests, Forms– General, non-urgent questions– Lab results (especially if confidential)– Routine follow-up / chronic disease management, ie.

DM– Confidential / sensitive questions (ie. spotting on

depo)– Appointment reminders (vs. calls, especially

confidential)how feeq check?

E-mailE-mail ProsPros & & ConsCons

• Office visit not needed

• Less intrusive

• Detailed• Hard copy or into EMR

• Teens all have email

• Efficiency vs. tele calls

• Streamlines follow-up

• No reimbursement

• Overuse by some

• Nuances missing

• Admin support

• Netiquette

• Security issues• Legal issues

AMIA Guidelines: AMIA Guidelines: CommunicationCommunication

• Establish turnaround time: often 2-4 days if not on vacation• Disclose privacy issues: who sees messages & when doc’s away• Establish acceptable uses and guidelines for sensitive

matters• Content of “Subject” line to indicate type of message• Require patient ID : MR# in Subject or Body of message• Auto-reply & out of office responses: autoresponse via server: .

“e-mail received, expect answer in a few days” “away from office until April 9. Call 432-0000 for assistance”

• Print and put in chart, or copy into EMR• Request acknowledgment from patients –(don’t message

cellphones)

• Maintain a mailing list of patients-- use blind copying feature: bcc

AMIA Guidelines: Administrative and AMIA Guidelines: Administrative and LegalLegal

• Put your e-mail policies in writing (Informed consent?)– Agree to terms of your communication guidelines– Terms for “escalation” to telephone– Describe security protocols - & lack thereof, waive

Encryption

– Disclaimer for equipment failures

• RULES: NO forwarding, marketing, sharing Dr’s e-mail address

• ALSO:

Password-protect workstationsUse care with patient-identifiable dataDouble-check the “To:” fieldBack-up policy & procedure - Short-term, Long-term

A Signed Written Agreement with PatientsA Signed Written Agreement with Patients Kaiser-Permanente e-mail Agreement specifies:• Email non-urgent health questions or concerns which can

wait a few business days for a response. • If your concerns are urgent, or you are ill, don’t use e-mail. • Issues best handled by e-mail include general questions

about non-urgent or long standing problems, or test results.Kaiser-Permanente e-mail Consent form includes:• I understand that sensitive Protected Health Information may

be contained in e-mail and I willingly choose to use this NON-SECURE method of communication.

• I understand that my physician’s e-mail is not monitored in his/ her absence, and urgent /time-sensitive communications should be addressed by phone or office visit with a covering physician.

Spam: Avoid Receiving ItSpam: Avoid Receiving It• Use filtering in your e-mail program

– Whitelist patients in your address book

• Have your e-mail server take care of it– Less control; more likely to miss real messages

– Less fiddling with settings

– Associated with pricey services, e.g., AOL• Route mail through spam-filtering service, e.g., SpamCop

…OR use only Secure Messaging... not always feasible…

Spam: Avoid Becoming ItSpam: Avoid Becoming It• Always use a “Subject” line• Make the subject very personal –

eg: “John Doe -MR#556677 -lab results normal”

• Use one e-mail account name for patient mail

• Make sure you are whitelisted before sending important messages

E-mail personality disorder (DSM-IV 301.73): – Rudeness: 90%, Flaming: 73%

E-mail Reimbursement ?E-mail Reimbursement ?Spielberg AR. Online Without a Net: Physician-Patient Communications by Electronic

Mail. Am J Law and Med. 1999;25:290-1• “Public and private insurers do not see

telemedicine as a therapeutic modality that deserves reimbursement, …so

• E-mail consultations will likely not be reimbursed.

• This is consistent with traditional medical practice where telephone calls and letters are not reimbursed.”

A Simple ApproachA Simple Approach to E-mail with Patientsto E-mail with Patients

• You email patient the terms of email service:

including Policies and Rules,

• Patient Replies with a copy of your terms

and includes MR#, Birthdate, & “I Agree”

SummarySummaryE-mail with PatientsE-mail with Patients

• E-mail skills– Signature– Use e-mail lists: Two addresses*, one

list *1 to communicate, 1 to send

• Spam: filters, server-side• E-mail Process

– Look to AMIA e-mail guidelines for policies– Consider “Secure Messaging”

E-mail E-mail - like Telephone - like Telephone CallsCalls

• not encrypted or authenticated• may breach privacy by using employer e-

mail

• no charge capture function• no template or medical records

features• not “safety-proofed” for healthcare• not always consistent with HIPAA or eRisk

standards

Mailing ListsMailing Lists - use - use bccbcc !! !! “Two Addresses, One List”

LISTSERVs =bang for the buck: cheap conferencing

• Subscribe LISTSERV by e-mail– Send request to ADMINISTRATIVE address (e.g.,LISTSERV@teendoc.com)

• Participate LISTSERV by e-mail– Send message to MAILING LIST address (e.g., LISTNAME@teendoc.com)

• Unsubscribe LISTSERV by e-mail– Send request to ADMINISTRATIVE address (e.g., LISTSERV@teendoc.com)

• Keep LISTSERV instructions ( like SAM-L )

Web-based Mailing ListsWeb-based Mailing ListsNot via E-mailNot via E-mail

• Offers a listserv that all your patients can JOIN – they interact and share “discussion” you authorize

• PEDTALK Mailing List = http://www.pcc.com/lists/

E-mail E-mail && Messaging Messaging vsvs.. PhonePhone

• NEJM 350:1705-1707, 2004. Delbanco T, Sands D, Electrons in Flight - E-Mail between Doctors and Patients.

• PEDIATRICS Vol. 114 No. 1, July 2004, pp. 317-321E-mail Communication Between Pediatricians and Their Patients;

Gerstle R, and AAP Task Force on Medical Informatics http://pediatrics.aappublications.org/cgi/content/full/114/1/317

Reports e-mail patient communication issues for physicians & appropriate use of e-mail in the office setting:

• e-mail in the office environment• available e-mail technologic solutions• e-mail privacy and security concerns• legal status of e-mail