Email consultations in health care: 2—acceptability and safe application
http://www.100md.com
《英国医生杂志》
1 Department of Primary Care and Social Medicine, Imperial College London, London W6 8RP, 2 Division of Community Health Sciences: GP Section, University of Edinburgh, Edinburgh EH8 9DX
Correspondence to: A Sheikh aziz.sheikh@ed.ac.uk
Electronic communication promises to revolutionise the delivery of health care. In the second of two articles considering the potential for email consultations, Car and Sheikh summarise the evidence about public and professional attitudes to them and discuss how to ensure their safe use
Introduction
Wider adoption of email consultations seems to be hindered by concerns, voiced mainly by doctors, about the quality, security, and safety of email consultations. These concerns are receiving considerable attention as managed care organisations and insurance companies (mainly in the United States) strive to realise the potential that email consulting has to offer.
Ensuring safety
Email is generally viewed as a good means of communicating simple information and non-urgent requests between patients and doctors. In one study, however, up to 90% of patients who used email to communicate with their doctors relayed important and sensitive medical information electronically.3
In order to ensure safe and high quality email consultations, each specialty should develop policies and standards that will earn the trust of the public and healthcare professionals.10-13 w22 w23 These should include guidance on organising the service, training, and strategies for mitigating risk during all stages of processing emails (receipt, triage, and response).11 Selection of optimal software for email consultation is extremely important (see box 1).w24
A key concern is whether email management is appropriate? Whenever in doubt doctors should revert to safer modes of consulting. A second concern is that the key points of a consultation have been correctly understood. Doctors can facilitate understanding by following the principles used in face to face or telephone encounters—such as the use of simple language, encouraging patients to ask questions, and summarising the main points covered.2 14 Additionally, a feedback loop may be used, whereby patients report what action they will take. If the subject being addressed is likely to require several emails back and forth, it is best to advise the patient to have a face to face or telephone consultation (see fig 1).
It may (initially) be appropriate to use a standard protocol clearly delineating the types of email communications that will be considered (for example, appointment scheduling, reporting of home records such as peak expiratory flow or blood pressure, ordering repeat prescriptions, obtaining test results, and consultations for a predefined set of conditions). Unsuitable topics, because of their complexity or sensitivity (because of the associated security concerns), may also be predefined. Patients should be advised not to use email for urgent communications. Similarly, when a doctor wants to ask a patient about symptoms that may require prompt action (such as chest pain or shortness of breath) a synchronous mode of consulting should be used. It may also be appropriate that each email includes a reminder about the importance of alternative forms of communication for emergencies.
Patients and doctors should communicate only through designated email addresses and services. Triage nurses may screen emails, as they do telephone calls, before they are routed to the appropriate person for a response.15 An automatic reply from the clinic can acknowledge receipt of a patient's email, and patients should be requested to acknowledge reading a doctor's email. Emails should be flagged as "unresolved" until an acknowledgment is received. Standardising specific communications (use of customised templates or protocols) to meet the needs of various specialties and tasks (such as repeat prescriptions) may make communication easier and increase quality and safety (see fig 2).
Fig 2 Example of a step in a structured, web based, email consultation for allergic symptoms. (Modified with permission from RelayHealth webVisit)
Box 1: Key features of optimal software for email consultations
Ease of adoption (combining with existing technologies)
Adaptability to an organisation's unique requirements for managing personal health information
Seamless operating with existing infrastructures
Enabling communication over various operating systems (such as Windows or Linux) and software programs
User friendliness—easy to set up, manage, and use by doctors and patients
Effective, invisible security over wired and wireless environments (without users needing to be aware of safeguards)
Easy authentication methods
Integration with existing medical records systems
Possibility of the use of customised templates for email consultations
Automation functions (such as automatic replies)
System for preventing generation of messages to an addressee if previous messages remained unanswered for longer than set permissible time
Integrated customisable message content filtering (if desired)
Virus scanning
Track and audit messaging system
Archiving and logging
Further considerations include which system is less error prone, needs less intensive support, and is more productive
The written record of email consultations enables close monitoring and evaluation of appropriateness and safety. Whereas face to face and telephone consultations are rarely recorded verbatim (typically being documented with only a few key words), email provides direct evidence of patient-doctor conversation. Thus, email consultations have the potential to facilitate accurate record keeping. However, if the system is not seamlessly integrated with medical records, as is the case with many healthcare organisations, quality of recording may be poor. At present, many doctors need to "copy and paste" email messages into records or print out and file a paper copy of them. Collaboration between developers of secure email software and providers of electronic health records is needed to achieve their seamless integration.
Currently, email consultations with unknown patients are considered unsafe, and there are no agreed standards for such consultations (see box 2). A pragmatic approach to an unsolicited email from an unknown person or someone unregistered for use of email consultations is to reply with a standard disclaimer.
Box 2: Email consultations with an unknown person
Some healthcare professionals consult by email with patients they have never met in person.16 17 w25 w26 For some patients, such anonymous email communications may be less intimidating than face to face consultations. These communications may help them understand the nature of their problem and decide to seek help.w27-w30 However, the quality of such advice may vary greatly, and patients cannot be sure that replies are actually written by a doctor.
Currently, determining the identity and credibility of "cyberdocs" is difficult. In future, this could be overcome—for example, by using digital signatures (electronic proof of identity, which could also confirm that a doctor is officially licensed to provide such a service). Until standards are established, email consultations outside pre-existing patient-doctor relationships should not be considered as a method of rendering medical care.10 11 16 17 w30-w32
Suggestion for an automatic reply to an unsolicited email "Your email has not been read by any of the staff from Wood Thorpe Medical Centre. This is an automatic reply from a computer to an unsolicited email. No medical advice can be given without prior informed consent for email consultations. If you need any clarification about this automatic computer reply, please telephone 0171 540 4987."
Additional educational resources
Kane B, Sands DZ. Guidelines for the clinical use of electronic mail with patients. The AMIA Internet Working Group, Task Force on Guidelines for the Use of Clinic-Patient Electronic Mail. J Am Med Inform Assoc 1998;5:104-11.
Medem. eRisk Working Group for Healthcare: guidelines for online communication. www.medem.com/phy/phy_eriskguidelines.cfm (accessed 7 May 2004)
Safeguarding patient information
The ethical considerations, professional etiquette, and legal rules that guide traditional communication between healthcare professionals and patients are equally applicable to email consultations.10 18 19 w33Patients should be informed of the potential risks and benefits of email use, the ramifications, safeguards for privacy and confidentiality, and the practice or hospital policies on when and how to use email.
Ideally, informed consent should be obtained from patients before email communication is started.w34 Patients should know who will process and have access to emails, including the times when the addressee is unavailable. They should be informed about the time in which email will be read and replied to—such as by the end of the next working day. An email should be forwarded (for example, to a specialist) or edited only with the sender's consent.
Email use in health care has developed without encryption. The security of unencrypted email is low, and email content can be inadvertently disclosed on the internet or local computer. Many countries now oblige healthcare organisations to follow the same strict data protection rules as do commercial institutions such as banks. As well as firewalls and conventional network security to protect content stored on an organisation's network, software that helps to achieve secure email communication (either web based or with standard email software) is available from several companies (such as Secure Data in Motion, Sigaba,w35 Medemw20). A critical factor in any solution for ensuring security is its user friendliness, and this may differ for patients and doctors and with different clinical settings and purposes.w36 Safeguarding patient information also depends equally on paying due attention to organisational and technical considerations. Doctors risk breaching patient confidentiality if they use non-secure email with patients.
Conclusions
Car J, Sheikh A. Email consultations in health care: 1—scope and effectiveness. BMJ 2004;329: 435-8.
Car J, Sheikh A. Telephone consultations. BMJ 2003;326: 966-9.
Neill RA, Mainous AG III, Clark JR, Hagen MD. The utility of electronic mail as a medium for patient-physician communication. Arch Fam Med 1994;3: 268-71.
Mandl KD, Kohane IS, Brandt AM. Electronic patient-physician communication: problems and promise. Ann Intern Med 1998;129: 495-500.
Couchman GR, Forjuoh SN, Rascoe TG. E-mail communications in family practice: what do patients expect? J Fam Pract 2001;50: 414-8.
Kleiner KD, Akers R, Burke BL, Werner EJ. Parent and physician attitudes regarding electronic communication in pediatric practices. Pediatrics 2002;109: 740-4.
Sittig DF, King S, Hazlehurst BL. A survey of patient-provider e-mail communication: what do patients think? Int J Med Inf 2001;61: 71-80.
Baker L, Wagner TH, Singer S, Bundorf MK. Use of the internet and e-mail for health care information: results from a national survey. JAMA 2003;289: 2400-6.
Patt MR, Houston TK, Jenckes MW, Sands DZ, Ford DE. Doctors who are using e-mail with their patients: a qualitative exploration. J Med Internet Res 2003;5(2): e9.
Medem. eRisk Working Group for Healthcare: guidelines for online communication. www.medem.com/phy/phy_eriskguidelines.cfm (accessed 7 May 2004).
Kane B, Sands DZ. Guidelines for the clinical use of electronic mail with patients. The AMIA Internet Working Group, Task Force on Guidelines for the Use of Clinic-Patient Electronic Mail. J Am Med Inform Assoc 1998;5: 104-11.
US Department of Health & Human Services. Medical privacy—national standards to protect the privacy of personal health information. www.hhs.gov/ocr/hipaa/ (accessed 6. May 2004).
NHS Information Authority. NHSnet: safe computing guidance. www.nhsia.nhs.uk/nhsnet/pages/emailmessaging/policies/safe_comp_guide.asp (accessed 6. May 2004).
Car J, Freeman GK, Partridge MR, Sheikh A. Improving quality and safety of telephone based delivery of care: teaching telephone consultation skills. Qual Saf Health Care 2004;13: 2-3.
Katz SJ, Moyer CA, Cox DT, Stern DT. Effect of a triage-based e-mail system on clinic resource use and patient and physician satisfaction in primary care. a randomized controlled trial. J Gen Intern Med 2003;18: 736-44.
Eysenbach G, Diepgen TL. Evaluation of cyberdocs. Lancet 1998;352: 1526.
Eysenbach G, Diepgen TL. Responses to unsolicited patient e-mail requests for medical advice on the world wide web. JAMA 1998;280: 1333-5.
Department of Health. Confidentiality: NHS Code of practice. London: DoH, 2003. (www.dh.gov.uk/assetRoot/04/06/92/54/04069254.pdf, accessed 6 May 2004.)
Anderson R. Security in clinical information systems. London: BMA, 1996.
Committee on Quality Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001.(Josip Car, doctoral stude)
Correspondence to: A Sheikh aziz.sheikh@ed.ac.uk
Electronic communication promises to revolutionise the delivery of health care. In the second of two articles considering the potential for email consultations, Car and Sheikh summarise the evidence about public and professional attitudes to them and discuss how to ensure their safe use
Introduction
Wider adoption of email consultations seems to be hindered by concerns, voiced mainly by doctors, about the quality, security, and safety of email consultations. These concerns are receiving considerable attention as managed care organisations and insurance companies (mainly in the United States) strive to realise the potential that email consulting has to offer.
Ensuring safety
Email is generally viewed as a good means of communicating simple information and non-urgent requests between patients and doctors. In one study, however, up to 90% of patients who used email to communicate with their doctors relayed important and sensitive medical information electronically.3
In order to ensure safe and high quality email consultations, each specialty should develop policies and standards that will earn the trust of the public and healthcare professionals.10-13 w22 w23 These should include guidance on organising the service, training, and strategies for mitigating risk during all stages of processing emails (receipt, triage, and response).11 Selection of optimal software for email consultation is extremely important (see box 1).w24
A key concern is whether email management is appropriate? Whenever in doubt doctors should revert to safer modes of consulting. A second concern is that the key points of a consultation have been correctly understood. Doctors can facilitate understanding by following the principles used in face to face or telephone encounters—such as the use of simple language, encouraging patients to ask questions, and summarising the main points covered.2 14 Additionally, a feedback loop may be used, whereby patients report what action they will take. If the subject being addressed is likely to require several emails back and forth, it is best to advise the patient to have a face to face or telephone consultation (see fig 1).
It may (initially) be appropriate to use a standard protocol clearly delineating the types of email communications that will be considered (for example, appointment scheduling, reporting of home records such as peak expiratory flow or blood pressure, ordering repeat prescriptions, obtaining test results, and consultations for a predefined set of conditions). Unsuitable topics, because of their complexity or sensitivity (because of the associated security concerns), may also be predefined. Patients should be advised not to use email for urgent communications. Similarly, when a doctor wants to ask a patient about symptoms that may require prompt action (such as chest pain or shortness of breath) a synchronous mode of consulting should be used. It may also be appropriate that each email includes a reminder about the importance of alternative forms of communication for emergencies.
Patients and doctors should communicate only through designated email addresses and services. Triage nurses may screen emails, as they do telephone calls, before they are routed to the appropriate person for a response.15 An automatic reply from the clinic can acknowledge receipt of a patient's email, and patients should be requested to acknowledge reading a doctor's email. Emails should be flagged as "unresolved" until an acknowledgment is received. Standardising specific communications (use of customised templates or protocols) to meet the needs of various specialties and tasks (such as repeat prescriptions) may make communication easier and increase quality and safety (see fig 2).
Fig 2 Example of a step in a structured, web based, email consultation for allergic symptoms. (Modified with permission from RelayHealth webVisit)
Box 1: Key features of optimal software for email consultations
Ease of adoption (combining with existing technologies)
Adaptability to an organisation's unique requirements for managing personal health information
Seamless operating with existing infrastructures
Enabling communication over various operating systems (such as Windows or Linux) and software programs
User friendliness—easy to set up, manage, and use by doctors and patients
Effective, invisible security over wired and wireless environments (without users needing to be aware of safeguards)
Easy authentication methods
Integration with existing medical records systems
Possibility of the use of customised templates for email consultations
Automation functions (such as automatic replies)
System for preventing generation of messages to an addressee if previous messages remained unanswered for longer than set permissible time
Integrated customisable message content filtering (if desired)
Virus scanning
Track and audit messaging system
Archiving and logging
Further considerations include which system is less error prone, needs less intensive support, and is more productive
The written record of email consultations enables close monitoring and evaluation of appropriateness and safety. Whereas face to face and telephone consultations are rarely recorded verbatim (typically being documented with only a few key words), email provides direct evidence of patient-doctor conversation. Thus, email consultations have the potential to facilitate accurate record keeping. However, if the system is not seamlessly integrated with medical records, as is the case with many healthcare organisations, quality of recording may be poor. At present, many doctors need to "copy and paste" email messages into records or print out and file a paper copy of them. Collaboration between developers of secure email software and providers of electronic health records is needed to achieve their seamless integration.
Currently, email consultations with unknown patients are considered unsafe, and there are no agreed standards for such consultations (see box 2). A pragmatic approach to an unsolicited email from an unknown person or someone unregistered for use of email consultations is to reply with a standard disclaimer.
Box 2: Email consultations with an unknown person
Some healthcare professionals consult by email with patients they have never met in person.16 17 w25 w26 For some patients, such anonymous email communications may be less intimidating than face to face consultations. These communications may help them understand the nature of their problem and decide to seek help.w27-w30 However, the quality of such advice may vary greatly, and patients cannot be sure that replies are actually written by a doctor.
Currently, determining the identity and credibility of "cyberdocs" is difficult. In future, this could be overcome—for example, by using digital signatures (electronic proof of identity, which could also confirm that a doctor is officially licensed to provide such a service). Until standards are established, email consultations outside pre-existing patient-doctor relationships should not be considered as a method of rendering medical care.10 11 16 17 w30-w32
Suggestion for an automatic reply to an unsolicited email "Your email has not been read by any of the staff from Wood Thorpe Medical Centre. This is an automatic reply from a computer to an unsolicited email. No medical advice can be given without prior informed consent for email consultations. If you need any clarification about this automatic computer reply, please telephone 0171 540 4987."
Additional educational resources
Kane B, Sands DZ. Guidelines for the clinical use of electronic mail with patients. The AMIA Internet Working Group, Task Force on Guidelines for the Use of Clinic-Patient Electronic Mail. J Am Med Inform Assoc 1998;5:104-11.
Medem. eRisk Working Group for Healthcare: guidelines for online communication. www.medem.com/phy/phy_eriskguidelines.cfm (accessed 7 May 2004)
Safeguarding patient information
The ethical considerations, professional etiquette, and legal rules that guide traditional communication between healthcare professionals and patients are equally applicable to email consultations.10 18 19 w33Patients should be informed of the potential risks and benefits of email use, the ramifications, safeguards for privacy and confidentiality, and the practice or hospital policies on when and how to use email.
Ideally, informed consent should be obtained from patients before email communication is started.w34 Patients should know who will process and have access to emails, including the times when the addressee is unavailable. They should be informed about the time in which email will be read and replied to—such as by the end of the next working day. An email should be forwarded (for example, to a specialist) or edited only with the sender's consent.
Email use in health care has developed without encryption. The security of unencrypted email is low, and email content can be inadvertently disclosed on the internet or local computer. Many countries now oblige healthcare organisations to follow the same strict data protection rules as do commercial institutions such as banks. As well as firewalls and conventional network security to protect content stored on an organisation's network, software that helps to achieve secure email communication (either web based or with standard email software) is available from several companies (such as Secure Data in Motion, Sigaba,w35 Medemw20). A critical factor in any solution for ensuring security is its user friendliness, and this may differ for patients and doctors and with different clinical settings and purposes.w36 Safeguarding patient information also depends equally on paying due attention to organisational and technical considerations. Doctors risk breaching patient confidentiality if they use non-secure email with patients.
Conclusions
Car J, Sheikh A. Email consultations in health care: 1—scope and effectiveness. BMJ 2004;329: 435-8.
Car J, Sheikh A. Telephone consultations. BMJ 2003;326: 966-9.
Neill RA, Mainous AG III, Clark JR, Hagen MD. The utility of electronic mail as a medium for patient-physician communication. Arch Fam Med 1994;3: 268-71.
Mandl KD, Kohane IS, Brandt AM. Electronic patient-physician communication: problems and promise. Ann Intern Med 1998;129: 495-500.
Couchman GR, Forjuoh SN, Rascoe TG. E-mail communications in family practice: what do patients expect? J Fam Pract 2001;50: 414-8.
Kleiner KD, Akers R, Burke BL, Werner EJ. Parent and physician attitudes regarding electronic communication in pediatric practices. Pediatrics 2002;109: 740-4.
Sittig DF, King S, Hazlehurst BL. A survey of patient-provider e-mail communication: what do patients think? Int J Med Inf 2001;61: 71-80.
Baker L, Wagner TH, Singer S, Bundorf MK. Use of the internet and e-mail for health care information: results from a national survey. JAMA 2003;289: 2400-6.
Patt MR, Houston TK, Jenckes MW, Sands DZ, Ford DE. Doctors who are using e-mail with their patients: a qualitative exploration. J Med Internet Res 2003;5(2): e9.
Medem. eRisk Working Group for Healthcare: guidelines for online communication. www.medem.com/phy/phy_eriskguidelines.cfm (accessed 7 May 2004).
Kane B, Sands DZ. Guidelines for the clinical use of electronic mail with patients. The AMIA Internet Working Group, Task Force on Guidelines for the Use of Clinic-Patient Electronic Mail. J Am Med Inform Assoc 1998;5: 104-11.
US Department of Health & Human Services. Medical privacy—national standards to protect the privacy of personal health information. www.hhs.gov/ocr/hipaa/ (accessed 6. May 2004).
NHS Information Authority. NHSnet: safe computing guidance. www.nhsia.nhs.uk/nhsnet/pages/emailmessaging/policies/safe_comp_guide.asp (accessed 6. May 2004).
Car J, Freeman GK, Partridge MR, Sheikh A. Improving quality and safety of telephone based delivery of care: teaching telephone consultation skills. Qual Saf Health Care 2004;13: 2-3.
Katz SJ, Moyer CA, Cox DT, Stern DT. Effect of a triage-based e-mail system on clinic resource use and patient and physician satisfaction in primary care. a randomized controlled trial. J Gen Intern Med 2003;18: 736-44.
Eysenbach G, Diepgen TL. Evaluation of cyberdocs. Lancet 1998;352: 1526.
Eysenbach G, Diepgen TL. Responses to unsolicited patient e-mail requests for medical advice on the world wide web. JAMA 1998;280: 1333-5.
Department of Health. Confidentiality: NHS Code of practice. London: DoH, 2003. (www.dh.gov.uk/assetRoot/04/06/92/54/04069254.pdf, accessed 6 May 2004.)
Anderson R. Security in clinical information systems. London: BMA, 1996.
Committee on Quality Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001.(Josip Car, doctoral stude)