Editor
Dr Ahmad Risk 

HIE Library Archive 1998/9  

Source: Reuters Health Information, Inc

The use of e-mail to communicate with patients has practical, legal and ethical ramifications that need to be addressed by institutional policies and clinical guidelines, according to several papers published in the October 21st issue of the Journal of the American Medical Association. Dr. Tom Ferguson, of the University of Texas in Houston, introduced the topic in an editorial in the journal and spoke about the promise and pitfalls of online communication on Tuesday at the AMA Science Reporters Conference in Durham, North Carolina.

The American Medical Informatics Association has produced guidelines for physician-patient e-mail, Dr. Ferguson notes in his editorial. "However, these guidelines apply to electronic exchanges within an established patient-physician relationship."

Drs. Stephen M. Borowitz, of the University of Virginia, in Charlottesville, and Jeremy C. Wyatt, of University College London, report on the issues raised by a pilot program at the University of Virginia Children's Medical Center, where faculty paediatricians put an e-mail form on their Web site and invited questions in an attempt to increase referrals. Over 33 months, the centre received 1,239 requests for information or a second opinion, Drs. Borowitz and Wyatt report.

Ten percent came from physicians, 9% from other health professionals and 81% from parents. Dr. Borowitz logged his time and found that he spent an average of 7.3 minutes per day responding to 166 consecutive messages, "...comparable to the amount of time physicians spend answering a patient-initiated phone call."

The pilot program resulted in three referrals. Ninety-two percent of the requests originated outside Virginia and West Virginia. Fifteen percent of all requests came from outside the US, the authors determined. Eighteen percent of correspondents sent follow-up questions, and in 12 cases faculty members engaged in ongoing e-mail consultations lasting months or years. "Potential legal issues include physicians practising without licensure in the state or country in which the patient resides, alleged medical negligence, and abandonment of patients should the consultant not continue the relationship,"

Drs. Borowitz and Wyatt write. They note that no guidelines exist "...regarding the use of e-mail between clinicians and patients without any prior relationship."

The authors of the second study draw a similar conclusion, suggesting that physicians need guidelines about how to respond to unsolicited e-mail queries.

Drs. Gunther Eysenbach and Thomas L. Diepgen, of University Hospital Erlangen in Germany, posed as a 55-year-old man who developed herpes zoster infection while taking cyclosporine. The researchers sent e-mail describing the symptoms and asking for advice to 57 dermatology Web sites, including 45 university-affiliated sites.

Even though the problem described is a medical emergency, only 29 individuals responded, Drs. Eysenbach and Diepgen report. Most replies arrived within 1 to 2 days, but response time ranged up to 10 days. Of the 29 respondents, 89% said they were physicians. Two respondents declined to give any advice at all, 7 advised the patient to see a physician but declined to elaborate, and 20 gave additional information, including 5 who gave detailed advice. No one gave incorrect information. In a subsequent survey of the same Web sites, 27% of the respondents said they never or rarely answer patient e-mail, 24% said they always or usually reply with a standard message, and 24% said they answer individually. Until physicians agree on a uniform approach, medical Web sites should develop their own policies, Drs. Eysenbach and Diepgen recommend.

At a minimum, they say, Web sites should post a disclaimer "...indicating that unsolicited patient e-mail may not be answered and is not a substitute for obtaining medical advice in person from a health professional."

In the third paper, attorney Alissa R. Spielberg, of Harvard Medical School, Boston, Massachusetts, reviews the legal precautions that physicians should take in exchanging e-mail with patients, including those relevant to confidentiality, informed consent, medical record keeping, practice standards and medical licensing.

"E-mail communications are not merely virtual approximations of medical practice," Ms. Spielberg cautions. "[They are very real exchanges of information, advice, and emotions."

JAMA 1998;1321-1324,1333-1335,1353-1359,1361-1362.