Communicating With Your Teen Patients by EMail: Its Easy

1
Communicating With Your Teen Patients by E-Mail
Its Easy!

• Hot Topics, Friday, March 24, 2006,
• Session II, 200- 215PM
• David Paperny MD FAAP FSAM
• I have no financial interest in any proprietary
  websites mentioned

2
E-mail Guidelines

• AMIA Guidelines, 1998 8yrs ago!
• www.amia.org
• American Medical Informatics Association
• releases, disclaimers, criteria, security
• 2 addresses, 1 list (bcc)

3
Physician-Patient Email Sands, D J Am Med
Inform Assoc. 2004260-67

• Qualitative analysis of doctor-patient email
• 3007 messages over 11 months (83 one-issue)
• Sensitive info in only 5
• Urgent messages 0

• Referrals 9
• Other 9
• Appointments 5
• Non-health related 5

• Info updates 41
• Rx renewals 24
• Health questions 13
• Test results inquiry 11

4
Anatomy of an E-mail Message

• Address user_at_host Case-independent, no spaces
• Subject line (Jimmy MR445566 re acne)
• Messages
• Body (Text you type or copy, MR )
• Signature
• Attachments (Describe all attachments)

5
E-mail Signatures for Practitioners

• 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.

6
Body Signature

• Hi Lisa
• Your lab tests were ok.
• - - - - - - - - - - - - - - - ) - -- - - - - -
  - - - - -
• David Paperny MD,FSAM,FAAP  Kaiser Adolescent
  Clinic, Honolulu
• HI.Dr.DavidPaperny_at_kp.org Urgent
  matters, call [phone]
• 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.

7
Consequences of No Signature

• E-mail misinterpreted or ignored
• Huh? Who is this guy?
• Comments misinterpreted in undefined context
• This pe459x19_at_prodigy.com needs to ask a
  doctor!
• Recipients cannot respond to urgent info
• Does anyone know teendoc_at_ca.govs 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? Id better delete it to
  be safe.

8
Writing 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?

9
E-mail Pros Cons

• 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

10
AMIA Guidelines Communication

• Establish turnaround time often 2-4 days if not
  on vacation
• Disclose privacy issues who sees messages when
  docs 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 (dont
  message cellphones)
• Maintain a mailing list of patients-- use blind
  copying feature bcc

11
AMIA Guidelines Administrative and Legal

• 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 Drs
  e-mail address
• ALSO
• Password-protect workstations
• Use care with patient-identifiable data
• Double-check the To field
• Back-up policy procedure - Short-term,
  Long-term

12
A 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,
  dont 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 physicians 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.

13
Spam 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

14
Spam Avoid Becoming It

• Always use a Subject line
• Make the subject very personal eg John Doe
  -MR556677 -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

15
E-mail Reimbursement ?

• Spielberg AR. Online Without a Net
  Physician-Patient Communications by Electronic
  Mail. Am J Law and Med. 199925290-1
• 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.

16
A Simple Approach to 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

17
SummaryE-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

18
E-mail - like Telephone Calls

• 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

19
Mailing Lists - use bcc !!

• Two Addresses, One List
• LISTSERVs bang for the buck cheap conferencing
• Subscribe LISTSERV by e-mail
• Send request to ADMINISTRATIVE address
  (e.g.,LISTSERV_at_teendoc.com)
• Participate LISTSERV by e-mail
• Send message to MAILING LIST address (e.g.,
  LISTNAME_at_teendoc.com)
• Unsubscribe LISTSERV by e-mail
• Send request to ADMINISTRATIVE address (e.g.,
  LISTSERV_at_teendoc.com)
• Keep LISTSERV instructions ( like
  SAM-L )

20
Web-based Mailing ListsNot 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/list
  s/

21
E-mail Messaging vs. Phone

• NEJM 3501705-1707, 2004. Delbanco T, Sands D,
  Electrons in Flight - E-Mail between Doctors and
  Patients.
• PEDIATRICS Vol. 114 No. 1, July 2004, pp. 317-321
• E-mail Communication Between Pediatricians and
  Their Patients Gerstle R, and AAP Task Force
  on Medical Informatics http//pediatrics.aappublic
  ations.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