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Information and education have long been essential tools for promoting health, controlling disease, and improving the quality of life in our families and communities. However, in the shadows of managed care, the ability to support traditional ways of health promotion and disease prevention is dwindling. Reimbursement issues are making it increasingly difficult to manage and/or monitor a more acutely ill population in our current community setting. Providers are required to "do more" with less money yet still document maintained or improved patient health outcomes as a result of their service interventions (Kinsella, 1998).

In contrast, patients influenced by the explosion of medical knowledge available on the Internet Me demanding access to new treatments and exerting more control over their own health care (Davis and Miller, 1999). No longer are patients willing to comply with the old adage of "take two aspirin and call me in the morning." Armed with reams of information garnered from a variety of medical Web sites, patients are asking about new techniques and treatments that in some instances their own physicians are not yet aware of. This new consumerism threatens to change not only the future of the physician/client relationship but the landscape of health care delivery as well. How physicians manage to keep pace with this newly developing environment while maintaining client confidence remains to be seen. Electronic mail may help to relieve some of the burden.

The author does not intend to discuss every facet of the use of e-mail in the physician/client interaction but merely touch upon some of the obvious benefits, risks, and alternative strategies available in maintaining, albeit improving, the quality of patient care.

The attraction of e-mail is due in part to its relative simplicity and speed. For years, even the most novice computer users have utilized e-mail to connect with distant family members, friends and business clientele. It is cheaper than the telephone and quicker than the U.S. Postal Service. As a communication medium, c-trail knows no time constraints and in many instances enhances efficiency for frantic lifestyles. The seeming magic and ease of e-mail has, in many cases, displaced the wonder of previously coveted technologies such as voice mail, answering machines and express mail services.

According to a Forrester Research Survey, by 1997, there were approximately 50 million e-mail users and that number was expected to rise to well over 100 million by the year 2000. In addition, a report from MSNBC (1999) revealed that 43% of all computer users in 1997 were actively searching the Internet for health information. Today, with access to more than 15,000 health-related Web sites, and an exponential rise of online users, there is a great potential for the Internet to serve as a conduit for consumer health education (Laino, 1999).

Is it any wonder then why patients and physicians wouldn’t want to utilize this tool to communicate with each other on a higher level? By reading health related information, or interacting with other healthcare professionals over the Internet or e-mail, consumers may improve their ability to manage their own care between office visits, improve treatment compliance, avoid health complications and assess whether they are receiving quality care. Unfortunately, many c-mailing patients do not share this enthusiasm with like-minded providers and few physicians practice in settings that have embraced this technology.

Patient access to online health information raises many new issues for the practicing physician. One common concern is that patients will not be able to fully comprehend information they acquire nor discern its accuracy. This places added responsibility on the physician to not only recognize that their patients are accessing information, but to now encourage them to openly discuss their findings, help interpret the information and guide them to credible resources - a very time consuming endeavor.

The decision to use e-mail with patients requires careful consideration. While physicians cannot control which Internet resources patients decide to use, there remain several compelling reasons for the incorporation of e-mail into the physician/client relationship. These include speed, convenience, improved communication, and enhanced patient education.

Historically, by the time a patient seeks a doctor’s help, the disease process or problem has been developing for a long time. For example, an asthmatic child who ends up being seen in the emergency room may have been edging toward a crisis for over a week. A diabetic nearing shock may have had insulin levels that have been out of control for days. In addition, as a result of the Balanced Budget Act of 1997, reduction of payments to home health agencies has forced families to take a more active role in the patent’s care at home. Families that are giving injections and monitoring conditions in the home often require assistance and support to help them cope with new responsibilities. Intervention via e-mail to answer questions, identify symptoms and monitor patient conditions would allow the physician to solve problems before they get out of control (Davis and Miller, 1999).

One of the most attractive features of e-mail is the fact that it’s asynchronous. The physician does not have to be available at the same time as the patient for the communication to take place. Patients can compose their thoughts and methodically document their condition into a detailed query at home, work, or within the confines of their bedroom in the middle of the night. There are no logistical or time constraints. E-mail correspondence may be comprised of brief updates of ongoing medical conditions, or more direct, pointed questions focusing on specific disease processes. Moreover, it can eliminate the need for "telephone tag" and third-party messages, which are frequently misplaced or inaccurately transcribed.

Incorporating e-mail into the office setting can free support staff from telephone calls that usually interrupt scheduled activities and allows non-urgent patient requests to be addressed at more opportune times. As an added benefit, lack of interruptions during regular office hours may enhance efficiency for physicians and their staff and minimize the chance for errors. E-mail can be extremely useful in attending to the more mundane tasks of office life such as requests for managed care referrals, prescription refills, lab results, appointment reminders, insurance questions, home-health measurement reporting (i.e., blood glucose levels) and routine follow-up (Kane & Sands, 1998). According to a comment by Dr. Daniel Sands (1998), a Boston internist in a large academic practice who uses e-mail with selected clients, "patients don’t want to bug you, they just want access to convenient, concise communication with their providers,"

In addition to being convenient, e-mail can improve physician/client communication Physicians who service large geographic regions or more rural settings can keep m contact with patients easier and at a relatively low cost, saving time and travel fees. E-mail interactions can augment patient education performed in the office or ambulatory setting by providing patients with a written reminder of instructions This is especially useful with ambulatory surgical patients who, under the influence of an anesthetic, may be unable to remember key points of their post-operative care upon discharge. Patients who frequently travel can easily communicate with their physician while away from home.

Some patients may even express themselves more effectively with the use of electronic mail. Office visits can be frightening and uncertain for some individuals, depending on the patient or the reason for the visit. Under stress, patients frequently forget to ask important questions or may not feel comfortable articulating their opinions in a face-to-face situation during an appointment. A study by Eysenbach (1999) suggests that e-mail frees clients from direct confrontation and may help patients better articulate their concerns by avoiding the "fear of asking stupid questions" that a real-time office visit brings.

E-mail can enhance patient education by providing an opportunity for patients to formulate and submit questions that arise even after their office visit. In addition to answering queries, physicians can provide electronic handouts and links to information on their practice Web site or at other credible locations on the web that may be of interest.

In selected cases, it may be possible to forego routine follow-up appointments entirely based on the nature and documentation of the e-mail interaction. E-mail communications provide documentation of patient instruction, and, as such, they must be included within the patient’s medical record, either as a printout for paper records or as an attachment to an electronic medical record As an added benefit, Patients save time and money by staying home and going about their activities of daily living, and physicians are free to spend their office consultation time evaluating more acutely ill patients.

Exactly how effective is e-mail consultation? There are many limits to the medium. Losing the human touch is one if them. According to Bowser (1998), detecting nuances in tone of voice, touch, and visual clues helps physicians make informed decisions about their patient’s well being. Without face-to-face contact, the physician’s inability to express a concerned look or use body language to emphasize a point is of equal importance. Thus, in the absence of effective communication skills, poorly written messages are left open to interpretation.

Without tests, physicals and hands-on evaluations, doctors must rely on the patients written documentation to assess a problem. Even if a diagnosis is likely under such constrained circumstances, most physicians who use e-mail will not make one because of liability and licensure concerns (Huang, 1999).

Another simple factor in the reluctance to use e-mail is that not all physicians and clients are comfortable with the technology and they do not wish to learn. The physician’s caring for patients today entered medical school at least seven years ago. They are learning on the job, and playing catch-up with the latest in information technology. Younger physicians, and those in medical school, are more frequent users of the latest technological gadgets. Computers are now becoming commonplace in their educational training (Davis & Miller, 1999).

Physicians who are comfortable with the new technology have concerns that patients may abuse the privilege of access and send an overwhelming number of messages concerning unimportant matters (Goldwyn, 1997). This threatens to burden busy clinicians with yet another activity for which they are not reimbursed. Worse still, a disgruntled patient could distribute the physician’s e-mail address on the Internet, exposing the physician to many patients who could potentially send messages (Eysenbach, 1999).

Electronic mail is not useful for the discussion of time-sensitive information since there is no way to know when the message will be received or even to ensure its receipt. For this reason, e-mail should be used only for non-urgent communication.

Because the use of encryption is not common with electronic mail, confidential information passed between physician and client may jeopardize patient privacy and present a potential liability risk for the physician. In theory, messages can be intercepted during delivery, examined while on the mail server, or accessed directly on either the patient’s or physician’s computer by unauthorized users. Furthermore, if patients receive e-mail at their work address, their employers will have access to the content of their unencrypted messages, potentially exposing confidential medical information that could be used to discriminate against the employee/patient (Fox. 1995).

While there appears to be much brouhaha over the legal ramifications in creating a written record for what traditionally has been an informal conversation, most detractors of e-mail agree that the e-mail message per se does not change a physician’s liability. The legal test stems from whether a determination can be made about the physician-client relationship (Huang, 1999). Some of the issues that arise relative to physician-client electronic interaction are: If a doctor-patient relationship has been established and the physician did not answer any e-mail, is he liable under the Good Samaritan law if patients harm themselves because the physician did not reply? If physicians answer all requests, are they liable if they draw the wrong conclusions from the limited data that they receive from their patients? If physicians refer patients to another information source by giving them a hyperlink, are they liable if this source contains wrong or harmful information? If they answer individual requests with a standard information text about a given disease, are they liable if patients are misled by not getting specific advice about their own condition?

These and other considerations have caused organizations like the American Medical lnformatics Association to develop guidelines for the use of patient-physician e-mail. Rules for use reflect privacy values including: (I) obtaining patient informed consent before wing e-mail for direct correspondence, (2) explaining and using security mechanisms, (3) prohibiting the forwarding of patient e-mail without express authorization, (4) informing patients about those having access to their messages and whether their messages will become part of their medical records, (5) responding to messages responsibly, and (6) avoiding references to third parties (Kane, 1998).

Electronic medical consults across geographical boundaries may result in licensure issues. Currently, physicians must be licensed by the states or countries in which they practice. If the patient is from one particular state or county and the physician practices in another state or country, which licensing requirements apply? In addition, advice given across country borders complicates liability issues as different legal systems and professional and ethical codes of medical practice may collide (Fox,1995).

Apart from the legal issues there are also problems inherent with patients becoming their own diagnosticians. The wealth of medical information publicly accessible on the Internet coupled with the ability to query physicians via email could tempt people to diagnose or treat themselves, even when their physical condition would in fact require seeing a physician in person. Bazell (1999) states that doctors are seeing increasing numbers of people who think they are sick because of information they find on the Net. These "cyberchondriacs" flood doctor’s offices and e-mail boxes with all kinds of presumptive diagnoses and alarming information that they never had access to in the past.

Like the telephone, fax machine, or face-to-face discussions, e-mail is another form of communication that can facilitate patient-physician interaction. As security, confidentiality and liability issues are resolved and the comfort level rises for generic e-mail use, patients and their providers have the potential to reach a new level of collaboration.

Concerns still abound as to whether patients will be using medical information on the Internet as a replacement for real-time physician consults, and there remain fears that electronic advice may be overused by chronically ill and frustrated patients looking desperately for additional information. Yet one thing appears certain, the advances in technology create opportunities to streamline and improve the delivery of quality health care.

As leery as some physicians are to adopt e-mail use as a standard of practice, most clinical settings will be using it before long. The competitiveness of many health care providers may well be determined, in part, by how well they embrace the emerging telecommunication techniques of providing patient care. Patients want to be part of the decision making process and those who are using the Web will more than likely seek out more net-savvy physicians who support their dews. Therefore, rules for physician/client communication should be clearly established and documented before any type of collaboration takes place. Physicians must impress upon their clients that information given over an electronic mail system is to be used primarily as a support mechanism and not as a replacement for an office visit.

By reaching, informing and motivating people in innovative ways, this technology can augment healthcare attempts to educate patients, improve functional status and help minimize cost at the point of contact. Electronic communications could strengthen the relationship between patients and health professionals by not only expanding access to time-constrained physicians and specialists (especially in remote areas) but in several other ways as well. For example, by providing appropriate health information to patients outside the context of an office visit, patient-provider encounters may be better focused and more efficient. By enabling and facilitating shared decision making processes, patients are more likely to achieve their desired outcomes and express satisfaction with their care.

The Internet has created new ways for doctors to help informed patients put information into perspective. Better informed patients communicating freely via e-mail with their collaborating physicians will, in the long run, result in better health decisions.

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Kane, B., and Sands, DZ., (1998). 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. Journal of the American Medical Information Association, 5(1): 104-111

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