Patient Communication: Email

When I first started practice almost nine years ago, the primary method of communication with my patients was vocally. They either saw me in clinic or left a message on the telephone. With the advent and explosion of the Internet, direct verbal communication has diminished a bit. Of course, it's not simply communication, but all aspects of modern medical care, that have been affected by technology. In this case, it's about the changes in patient-physician communication.

Is email a legitimate form of communication between doctors and patients? If so, what's the best way to make this happen in the modern world of HIPPA? Is it possible to use email to benefit our practice and perhaps even make money?

Concerns

First, let's look at some reasonable concerns physicians may have. One concern is the lack of certainty that we are communicating with the person we think we are communicating with. Perhaps another family member is inappropriately looking at the email without the patient's consent. This may violate your patient's privacy.

A second concern regards documentation. Using a standard email does not necessarily translate into an appropriately documented communication encounter in the patient's chart. An EMR system that tracks email conversations eliminates this potential problem. Many EMR systems now have a patient portal in which patients are able to access their health information and communicate with their physician.

Another concern physicians may express is the extra work of emailing patients, work which may occur during non-business hours. Additionally, a doctor may be reasonably concerned about an email replacing an in-person office visit, which may have monetary effects on the practice through decreased volume.

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Good Communication?

A study from Kaiser followed 35,423 patients with diabetes, hypertension, or both for two months using a matched-control analysis. Researchers found that patients who communicated with their providers by email were found to have improved healthcare measures. Blood pressure, blood sugar control, and cholesterol levels were found to be improved from 2 to 6.5% higher for patients who had email access to their physicians.¹

Unfortunately, it is difficult to make a truly evidence-based decision on this when looking at the medical literature. According to a Cochrane Database systematic review from 2012, "The evidence base was found to be limited with variable results and missing data, and therefore it was not possible to adequately assess the effect of email for clinical communication between patients/caregivers and healthcare professionals. Recommendations for clinical practice could not be made.²"

Given that the Cochrane group, perhaps the highest quality systematic reviews available, found only nine studies looking at this topic, each with the potential for significant bias, it's too early to make a definitive statement about the efficacy of email for communication. More research to come!

HIPPA Compliance

As it turns out, there is in fact a way to email patients and remain in compliance with federal regulations. According to the Department of Health and Human Services (HHS), the privacy rule does allow providers to communicate electronically with some caveats and suggestions:³

1. They must apply "reasonable" safeguards.
2. Avoid unintentional disclosures such as sending an email to the wrong address.
3. Unencrypted emails are allowed (for now) but the HHS recommends limiting the amount and type of information included in the email.

What's the message from this vague set of rules? Clearly we have to be cautious about the security of our communications and the amount of detail we relate in our communications. Luckily, we don't have to encrypt our emails (yet)!

Practice Benefits

Perhaps it's too early in the development of this technology as it relates to medicine, but currently this is not a direct revenue stream for the practicing podiatrist. Telemedicine is a potential source of revenue, but is a much different method than email communication. Unlike lawyers, physicians don't bill for our time on the telephone and surely not via email.

However, the indirect benefit to practice comes in the form of improved patient satisfaction through better communication and increased access to the doctor. This should translate to increased word-of-mouth referrals and practice volume. Until someone invents a new revenue source through online and email conversation, we'll just have to be satisfied with happier patients.

Best wishes,

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

References

1. ZhouYy, Kanter MH, Wang JJ et al. Improved Quality at Kaiser Permanente Through E-Mail Between Physicians and Patients. Health Affairs, 2010;29(7):1370-1375.
2. Sawmynaden P, Sheikha, Email for clinical communication between patients/caregivers and healthcare professionals. Cochrane Database Syst Rev. November 2012.
3. Does the HIPAA Privacy Rule permit health care providers to use e-mail to discuss health issues and treatment with their patients? Last accessed March 15, 2015.

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