Friday, 28 Feb 2020

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Answering Patient Emails

A recent article by Dr. Joseph Eastern of the Pediatric News Network addressed an issue that confronts all practitioners - how do you handle email from patients?

Email has become a prevalent daily tool in commerce, personal communications and even in medicine. Many practices use email to deliver reminders, test results and some, for physician/practice to patient communications. Moreover, an integral part of "meaningful use" with today's electronic health records will require a "patient portal" for the archiving of patient information and results, but also for patient-to-provider communications.  CMS has stated that use of portals may result in more efficient and effective communication, better and more timely self-care among patients, ability to focus better on high-priority patients and improved patient satisfaction.

The belief is that secure electronic messaging between patients and the health care team will facilitate communication between office visits and improve health care. For example, patients can ask questions they may have forgotten or didn’t have time to ask during the visit. They can also share important updates with their health care team. 

The problem is that some patients will fail to communicate when they should and others will engage in a never-ending stream of queries. Such time is not reimbursed and the utility to overall care is unproven. 

Dr. Eastern canvased his colleagues to find wide variations on how other physicians handle requests for emails. In one study, a fictious, unsolicited email was sent to physicians and 50% responded to the patient’s e-mail. Of those, 31% refused to give advice without seeing the patient, but 59% offered a diagnosis, and a third of that group went on to provide specific advice about therapy. In response to the questionnaire, 28% said they tended not to answer any patient e-mails, 24% said they usually replied with a standard message, and 24% said they answer each request individually.

Having a high profile on Twitter, I often get tweets and direct messages and even emails from unknown patients who have specific clinical, diagnostic or therapeutic questions.  I try to respond to all with the default policy that it would be imprudent, improper and medically irresponsible for me to respond to their request and that I would advise they ask the same question, face-to-face, of an appropriate practitioner.

Dr. Eastern is a dermatologist and he suggests that each of us needs to have guidelines on how to handle such issues and that these guidelines address the of authentication of patient correspondents, informed consent of those patients, licensing jurisdiction (if you receive e-mails from states in which you are not licensed), and above all, confidentiality. Interestingly, HIPAA does not prohibit email communication, nor require that it be encrypted. The HIPAA website says, “Patients may initiate communications with a provider using e-mail. If this situation occurs, the health care provider can assume (unless the patient has explicitly stated otherwise) that e-mail communications are acceptable to the individual.”

There are no consensus guidelines on this issue, but many societies have addressed this. Below are several modified recommendations from the Texas Medical Board on "Emails with Patients":

1. Email communications will only be used with established patients.
2. Patients who elect to use email must be advised of this office’s email policy and sign an informed consent (see attached).
3. A copy of the consent will be given to the patient and a copy filed in the patient medical record.
4. Patient information in the email should include: patient name, identification number, and type of transaction.
5. Email communications are restricted to conditions and situations that do not require immediate attention (detailed in the consent).
6. Automatic reply to all incoming messages will state: “Your message has been received by [your practice name]. We will attempt to process your request within one business day. If you need immediate assistance, please call the office at [your phone number].”
7. Email communications are a permanent part of the patient medical record. They should be retained in the paper record and/or electronically.
9. When a patient request has been completed, the staff member responsible for completing that task will be responsible for sending a confirmation message to the patient.
10. As with any form of medical record documentation, unprofessional remarks or comments in email communications are prohibited.
11. Confidentiality of patient information will be maintained at all times to protect the integrity of patient-identifiable information.
12. When sending patient information via email, the sender is expected to double-check all “To” fields before transmitting.
13. Maintaining a master list of patients email addresses is discouraged.
14. Outgoing messages will contain discreet subject headers and a banner at the top of each message stating, “This is confidential medical communication.”
15. Each desktop workstation should be password protected.

How do you handle emails from patients?  What happens when and if this becomes required or part of your EHR?

The author has no conflicts of interest to disclose related to this subject

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