But email acceptance and use isn't universal, and some areas are slower to adopt it. While I routinely exchange email with my stock broker, accountant, car dealer, veterinarian, realtor, and nearly all my service providers, my healthcare professionals are much less uniformly available electronically. In fact, there's no uniformity of opinion among patients, doctors, ethicists, insurance companies, the medical establishment, and government about how this new-fangled technology should be handled and regulated.

My primary care doc, an internist emphasizing cardiac health, gave me the idea for this article by being available via email starting about two years ago. He finds it -- as I do! -- great for direct, simple communications, and reports that email decreases phone calls and phone tag, achieving office efficiency and economy. I've asked simple questions such as how often it's advisable to give blood and what kind of blood pressure monitor to purchase. He makes email contact available to all his patients with the understanding that if specific therapies are required after email contact, an office visit is needed. Before any emailing, he ensures that a patient is using a private home computer, rather than a workplace system. And he considers email conversations to be informal, not necessarily entering patient records, with any recommendations requiring specific therapeutic intervention warranting a carefully documented office visit.

It's clear that there aren't yet standards for high-tech medical communications, and healthcare providers are individually exploring and defining opportunities. Some doctors use email for administrative matters only, such as booking appointments and handling prescription refills. Some respond to email with telephone calls. Still others won't accept or send any patient email, citing concerns about privacy and security, or email's cold ("low touch") nature as inappropriate for something as important and personal as healthcare.

There are valid technical concerns: email is not private or secure, or even completely reliable: email can be forged, sender and receiver are usually not authenticated, email containing a warning or diagnosis can be delayed in transit, etc. And risks such as incomplete recordkeeping, misunderstandings and miscommunications -- even a patient denying that a note was received -- add to the already sadly high risk of litigation.

An ethics expert draws a sharp line, commenting that he's "been around this issue in several professional settings". He continued, "The legal profession has OKed email for confidential communications IF the client requests/approves it and if the system is secure. Work computers are often monitored, so it is not reasonable to regard them as secure. I'd say the same standards apply to doctors." And he identifies an additional risk; "Unlike with lawyers, simply communicating with an oncologist (for example) gives information with confidential overtones." He suggests that doctors avoid email communications with patients, patients avoid communication with doctors from work, and patients avoid research from work on medical Web sites.

The American Medical Association (AMA) offers resources describing advantages and risks of healthcare-related email. Guidelines for Physician-Patient Electronic Communications http://www.ama-assn.org/ama/pub/category/2386.html notes that "Email has taken on increased significance as a mode of communication that is readily available to patients and health care professionals" and strongly recommends that email must never replace crucial interpersonal contacts. And it provides a number of clear/specific and mutual guidelines for patient/doctor email.

Ethical Guidelines for Use of Electronic Mail Between Patients and Physicians http://www.bioethics.net/journal/infocus.php?vol=3&issue=3&articleID=120 includes a longer discussion of email issues, including a brief history of doctor/patient communications from the 17th century. Perhaps its most crucial recommendation is that email "should not be used to establish a patient-physician relationship, but rather to supplement personal encounters".

The government endorses use of email; William Pierce, Deputy Assistant Secretary of HHS, said that the HHS Secretary encourages use of information technology for efficiency and to improve health. He notes that under HIPAA's new healthcare privacy rules, use of email is permitted, with informed patient consent and control, and responsible patient usage.

Another issue may be more challenging than deciding whether and how to email: working out a way for doctors to be paid for added value services such as access-by-email. In the era of managed care, my doc notes, many patients feel entitled to administrative services -- FAXing referrals and prescription refills, copying records, filling out forms for handicapped parking and travel insurance, etc. -- because they have health insurance. Since insurers don't presently reimburse those services, some medical practices have tried to establish fee structures to cover their costs. Of course, new fees aren't popular with patients or insurance companies. So a new administrative services package may emerge, including emailing, FAXing, form completion, etc. for a modest annual fee. And the AMA has defined temporary codes "for identifying emerging technology, services and procedures", such as online medical evaluations.

A middle ground is outlined by Jim Harper, editor of Privacilla.org, a Web-based project that seeks to capture "privacy" as a public policy issue: "A physician should strike the balance carefully between the security risks involved in emailing and the importance of quick, effective communication. Email is fine for ordinary treatment information about conditions that carry no stigma. More sensitive conditions, or diagnoses and so on, probably deserve better than e-mail". He notes that the relatively new HIPAA law may have lawyers advising doctors to avoid using email with patients. If this happens, he feels that this "probably needlessly degrades communication with patients who would benefit from getting written information quickly".

And a bit of practical reality comes from my doc, who notes that "This is the 21st century. If patients want my time (which unfortunately is finite) they have to get it any way that works for me". So taking appropriate cautions and precautions, requiring informed patient consent regarding email's tradeoffs and limitations, and recognizing the potential need to pay for the enhanced service, email complements other technologies -- telegraph, telephone, and FAX. These, after all, were new in their time and not accepted without reservations by both patients and physicians, but are now routine rather than threatening.

This article appeared originally on AARP's Computers and Technology Web site, www.aarp.org/computers. (c) AARP 2004. Permission is granted for reprinting and distribution by non-profit organizations with text reproduced unchanged and this paragraph included.

There is no restriction against any non-profit group using this article as long as it is kept in context with proper credit given the author. The Editorial Committee of the Association of Personal Computer User Groups (APCUG), an international organization of which this group is a member, brings this article to you.

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