Physician-Patient E-Mail Guidelines Needed

NEW YORK, Oct 20 (Reuters) -- E-mail provides an effective way for physicians to communicate with patients, according to reports published this week in The Journal of the American Medical Association.

But physician groups should develop guidelines about e-mail communication between physicians and patients, to clarify ethical and legal issues, researchers conclude.

Dr. Tom Ferguson, of the University of Texas in Houston spoke about physician-patient online communication on Tuesday at the American Medical Association's (AMA) Science Reporters Conference in Durham, North Carolina.

"E-mail has become a ubiquitous tool for communicating with business associates, friends, and family," said Ferguson in an AMA statement. "So there should be little surprise that Net-savvy patients would like greater digital access to their physicians. Yet, it appears that only about 1% to 2% of physicians offer patients this option."

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

Dr. Stephen M. Borowitz, of the University of Virginia, in Charlottesville, and Dr. Jeremy C. Wyatt, of University College London, UK, report on the issues raised by a pilot program at the University of Virginia Children's Medical Center, where faculty pediatricians put an e-mail form on their website and invited questions in an attempt to increase referrals.

Over 33 months, the center received 1,239 requests for information or a second opinion, Borowitz and Wyatt report. Most requests, 81%, came from parents. Ten percent came from physicians, and 9% came from other health professionals.

The researchers report that it took an average of 4 minutes for them to read and respond to an e-mail message, and most were answered within 48 hours of the initial request.

But physician-patient e-mail communication does raise potential legal issues, they write, including "physicians practicing 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." And they note that no guidelines exist "regarding the use of e-mail between clinicians and patients without any prior relationship."

The authors of a 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 a potentially life-threatening skin disease. From 58 dermatology websites, including 45 university-affiliated sites, the researchers sent e-mail describing the symptoms and asking for advice.

Even though the problem described was a medical emergency, only 29 individuals responded, Eysenbach and Diepgen report. Most replies arrived within 1 to 2 days, but response time ranged up to 10 days.

Of the 29 individuals who did respond, 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 response contained incorrect information.

In a subsequent survey of the same websites, 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 websites should develop their own policies, Eysenbach and Diepgen recommend. At a minimum, they say, websites 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 a 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 any patient, including precautions relevant to confidentiality, informed consent, medical recordkeeping, practice standards and medical licensing.

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

SOURCE: The Journal of the American Medical Association 1998;280:1321-1324, 1333-1335, 1353-1359, 1361-1362.