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Pearls


Sensible use of e-mail in clinical practice

Consider e-mailing appointment reminders or drug instructions to facilitate patient understanding and adherence

Vol. 8, No. 7 / July 2009

As Internet use grows, so has patient demand for e-mail access to their physicians. Using e-mail in psychiatric practice has many advantages but also some unique drawbacks.

Advantages

For you, e-mail’s advantages include:

  • decreased “phone tag” with patients
  • ability to respond to requests at your convenience
  • an automatically generated medical record1
  • easy distribution of handouts and references to patients, eliminating the need to store paper copies.

Using e-mail also could facilitate patient understanding and adherence. For example, consider e-mailing appointment reminders or medication instructions or asking cognitive-behavioral therapy patients to send in daily homework.

E-mail’s advantages for patients include:

  • increased satisfaction and participation in care
  • convenience
  • better understanding of instructions that can be reread vs verbal information that might not be recalled.

Some patients may be more comfortable discussing sensitive topics via e-mail than in person.1 In my practice, I’ve found this to be the case with university students, particularly those with anxiety disorders.

For example, a patient of mine with a history of trauma dropped out of treatment after revealing aspects of the trauma early in therapy. He did not respond to my phone calls, but after several weeks he unexpectedly e-mailed me. After an e-mail exchange about what happened, he returned to therapy and came weekly for several years. I feel this positive outcome occurred because he could contact me in a way that provided him a sense of distance, control, and safety.

E-mail guidelines

Potential risk of malpractice is a drawback of using e-mail in clinical practice. Malpractice by definition requires 2 elements:

  • a patient-physician relationship—which unsolicited e-mail likely can establish if a physician gives advice that the patient takes2
  • a breach of duty that results in harm to the patient.

The American Medical Association’s extensive guidelines suggest how physicians who use e-mail can reduce their malpractice risk (Table).3 In addition, individual states may have rules governing the use of e-mail in clinical practice.

Don’t diagnose or treat by e-mail

Diagnosis and treatment via e-mail could be considered substandard care. Patients might not be forthcoming about symptoms in an e-mail, either because of concerns about how symptoms might be perceived or poor insight. The lack of auditory and visual cues makes proper assessment difficult and can increase the risk of misdiagnosis and inappropriate treatment.2 This is especially true in psychiatry, where diagnosis can rely heavily on analyzing a patient’s physical presentation, including psychomotor behavior, affect, and speech patterns.

For example, if a patient you are treating with a selective serotonin reuptake inhibitor for a depressive episode e-mails you about feeling anxiety in the presence of others, it may be tempting to diagnose a comorbid anxiety disorder. However, anxious feelings also can be caused by paranoia related to an evolving first lifetime episode of mania with psychotic features. Clues to this diagnosis—such as expansive affect, pressured speech, and psychomotor agitation—might be detected during an in-person assessment but missed in an e-mail.

For this reason, avoid making new diagnostic assessments or changing a treatment plan based on an e-mail exchange. If you are tempted to do so, call the patient to discuss the issue or ask him or her to come in for an office visit.

Set e-mail boundaries

Using e-mail in clinical practice could be time-consuming, adding extra work to already packed days. A subset of patients—such as those with personality disorders—might e-mail excessively, bring up subjects that are inappropriate for e-mail, or try to build permeable boundaries into the patient-physician relationship. Minimize these concerns by clearly outlining which topics are and are not appropriate for e-mail.3

Table

6 strategies to minimize liability when using e-mail

Protect patient confidentiality, especially when e-mail contains sensitive mental health information. E-mail easily can be misaddressed or read by other people

Avoid establishing new patient-physician relationships via e-mail

Use an informed consent procedure. Detail confidentiality risks, how often e-mail is checked and by whom, and how long before patients generally can expect a reply. State clearly that e-mail never should be used for urgent concerns or in an emergency

Add a footer to outgoing e-mails that summarizes your e-mail policy. Also include office and emergency contact information

Use an ‘Auto Reply’ message that includes this footer that will be sent in response to every message you receive

Include e-mail in the medical record

Source: Reference 3

For example, you could use e-mail only for appointment scheduling, medication refill requests, and providing instructions, handouts, and references, all of which could increase practice efficiency. Some psychiatrists may be comfortable discussing some therapeutic issues via e-mail or allowing patients to communicate thoughts and concerns during the week—without expecting a reply—to be addressed during their next session. You could decline to provide your e-mail address to patients who might abuse the privilege and instruct them to call the office instead.

Inappropriate use of e-mail can be addressed during a session as you would any other transference-countertransference or boundary issue, potentially yielding important therapeutic gains.

References

1. Spielberg AR. On call and online: sociohistorical, legal, and ethical implications of e-mail for the patient-physician relationship. JAMA. 1998;280:1353-1359.

2. Recupero PR. E-mail and the psychiatrist-patient relationship. J Am Acad Psychiatry Law. 2005;33:465-475.

3. American Medical Association. Guidelines for physician-patient electronic communications. Available at: http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/young-physicians-section/advocacy-resources/guidelines-physician-patient-electronic-communications.shtml. Accessed June 11, 2009.

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