October 2001 Bulletin

Orthopaedists tiptoe into patient e-mail use

Survey shows some BONES practices use it selectively; most don’t, but many may in the future

By Carolyn Rogers

An informal e-mail poll of orthopaedic practices found that most don’t use e-mail as a means of communicating with their patients, but many are considering it for the future.

Of the 118 practices that responded to the survey of members the BONES Society, Inc., the national organization of orthopaedic practice administrators, 91 don’t use e-mail to communicate with their patients, while 27 practices do use utilize e-mail for this purpose. Of the 91 practices that don’t use e-mail for patient contact, more than one-third said they are considering the possibility for the future.

Here’s what some business administrators said about their use of e-mail to communicate with their patients:

"We use e-mail with patients, but very selectively, and only one of our four doctors uses it," said Jack Cruikshank, practice administrator, Rochester Knee and Sports Medicine, Rochester Hills, Mich. "Usually, [we use it] for postop instructions, i.e.: showers, bandage care…nothing too ‘heavy’ that if read by the wrong people could get us in trouble."

Robert S. West, administrator, division of arthritis surgery, Good Samaritan Hospital, Baltimore, Md., said, "we use it for appointments, clinical questions to the doctor, reference information, Q&A via the web site. E-mails are handled by both the surgeon and the staff."

"A few of our physicians use e-mail to communicate with patients," observed George Kellum, executive director, Orthopaedics Indianapolis, PC, Indianapolis, Ind. "Generally, they use it for appointments, prescription refills, and Q&A with established patients. The surgeons personally handle the traffic. We are currently developing written guidelines to deal with potential liability, documentation and privacy issues.

"Frankly, I believe the exposures are tremendous and while there is obvious demand for communicating via e-mail, we need to move cautiously. Over time physicians could be receiving e-mail from virtually thousands of former patients, all of whom are potential litigants should privacy be breached or care compromised in any way due to a tardy response or no response at all to a time sensitive issue."

Merrilee Greene, practice manager, office of Edward L. Garr, MD, Orange, Calif., said, "We do have e-mail, but so far only a couple of patients have used it, and it has been to ask questions regarding their condition or to send a doctor the latest jokes. I give out my e-mail address now, not his, because I am better at checking mine than he is. If it is a medical question, I give it to him for an answer and then I respond."

"We all have e-mail and the more we use it, the more we use it," said Mary Jo Blackmon, practice administrator, Metrocrest Orthopaedics and Sports Medicine, Dallas, Texas. "New patient schedulers use it to send info to the patients; patients can e-mail nonemergent questions to us, etc. E-mails are forwarded to the doctors for response only if we can’t help them. We get inquiries from people across the country that are not from patients and the docs will respond to these questions when needed. Because we still have paper charts, most e-mails are printed and attached to the chart."

Now, here are some comments from practices that choose not to use e-mail to communicate with their patients.

John Cole, CEO, Tucson (Ariz.) Orthopaedic Institute, said, "We seldom if ever utilize e-mail for patient contact. We occasionally receive an inquiry via e-mail requesting a referral to or an appointment with one of our physicians. I believe there are HIPAA [Health Insurance Portability and Accountability Act] issues surrounding the use of confidential patient information over the net that is not encrypted."

Taking a firm stand against using e-mail, William R. Hammonds, CEO, Tri-State Orthopaedic Surgeons, Evansville, Ind., said, "Our position is that we do not want to practice medicine over the web. [It’s] not good medicine. Offering to accept e-mails is opening the door for questions that would constitute practicing medicine or stating a doctor/patient relationship. Then you’re liable for the answers/advice (or lack of) and the result/outcome of that advice."

Debora Petrucci, patient care administrator, North Jersey Orthopaedic Institute, Newark, N.J., said, "We have found that it is very time-consuming. Also, patients like to utilize the e-mail system to do a consultation instead of an office visit. It is hard to give a patient more than general advice without the patient being physically present."

"I question how this developing trend will pan out financially," said Beth A. Balen, administrator, Anchorage Fracture and Orthopedic Clinic, Anchorage, Alaska. "If we spend the same amount of time e-mailing patients back and forth (which is free) instead of having them in to discuss their questions/concerns at an appointment, I see some cash flow problems. I have seen surveys where patients agreed to paying a nominal fee for e-mail info."

There are legal concerns that need to be considered when communicating with patients via e-mail, says Kristin Olds Glavin, AAOS associate general counsel. The first question you need to ask yourself is "Is the service a form of medical practice?" If your answer is "yes"—i.e., you are giving more than general medical information—then you need to be aware that you are exposing yourself to potential legal risks.

Legal concerns that need to be considered if medical advice is to be provided include:

Medical licensure. Are you licensed to practice medicine in the state in which the Internet user resides?

Specific informed consent. Do you have the Internet user’s consent to transmit personal medical information over the Internet?

Medical malpractice insurance. Professional liability insurance policies do not cover unlicensed medical practice and may also have territorial boundaries.

Errors in use or regulation of technology. If medical information or advice is incorrectly transmitted and an adverse medical outcome results, liability can be assessed against the provider.

Privacy/confidentiality. Patient medical data is protected under state law, under the federal Constitution and under the HIPAA and its privacy regulations. The regulations contain strict requirements for the transmittal of patient data over the Internet. Internet abuses and the potential for hacking, especially in e-mail transmittals that may contain confidential patient data, are real possibilities that could result in physician liability.

Reimbursement. Current Medicare regulations disfavor the practice of telemedicine.

If you decide that you want to respond to specific medical questions only from your long-standing patients, there are still several issues to consider, including:

This article is not intended to provide legal advice. You should consult your own legal advisor for legal information. More detailed information can be found in the article, "Answering e-mail may be risky" in the August 2000 Bulletin which is in the Library section of the AAOS home page www.aaos.org.

Communicate welcomes suggestions about future topics for the column on patient-physician communications. Send your suggestions to the Bulletin at AAOS, 6300 N. River Rd., Rosemont, Ill. 60018.

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