American College of Physicians: Internal Medicine — Doctors for Adults ®

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Setting limits is the key to working online

How far should you go in talking to patients looking for advice at your Web site?

From the April 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.

By Jodi E. Knapp

While some physicians are allowing patients to supply their medical histories via the Web and a handful are even diagnosing minor illnesses and prescribing drugs online, most practitioners are only just getting comfortable with the idea of using electronic means to connect directly with their patients.

Those at ease offering extended Internet services say the technology's convenience helps speed communications, improve documentation and cut down on telephone tag, but most physicians are wary about going beyond offering more than just generic medical information to consumers. They cite concerns about the security of online data and the appropriateness of treating patients without the benefits of face-to-face encounters.

Experts say, however, that physicians may soon be forced to deal with the issue of direct, online doctor-patient communication as patient demand for extended services increases. While only about 2% of U.S. physicians currently communicate with their patients via e-mail, more than 43% of U.S. adult Internet users go online for medical information.

Mark E. Frisse, FACP, a member of ACP-ASIM's Medical Informatics Subcommittee, predicted that within 10 years, electronic media like the Internet will become the primary means of communication outside of the exam room. "We are so early into this that it is difficult for most people to see the enormous potential," he said. "But physicians need to ask the question of whether or not the risks and benefits of being on the leading edge outweigh taking a more cautious approach."

Creating policies

When weighing the pros and cons of working with patients through electronic means, experts say, physicians should start by examining all aspects of online communication with patients, not just cutting-edge uses. For example, even if you have set up a site to exchange e-mail with patients, you still need to create written policies for your office staff, said Jerome H. Carter, FACP, Chair of the College's Medical Informatics Subcommittee. These policies should spell out exactly who should read patient e-mail, how appointments scheduled online should be set up, how staff should handle patient emergencies that they learn about online, and what types of disclaimers your Web site should contain, he said.

Last year, the American Medical Informatics Association (AMIA) released guidelines offering practitioners advice on how to exchange e-mail with patients they have seen in the office. The guidelines also offer suggestions on how physicians should handle online prescription refills, lab results, appointment scheduling and reminders, insurance questions and routine follow-ups. (The guidelines are available at www.amia.org; click on AMIA Position Papers.)

Once you establish office procedures regulating your online communication with patients, you need to make them available to patients—and have patients agree to the terms before you begin communicating with them online. One physician even puts his Internet guidelines on the back of his business cards that he gives to patients.

"It is critically important to tell patients exactly what you will or will not provide over the Net," Dr. Frisse said. "If expectations aren't clearly articulated and met, Internet communication may do more harm than good."

Confidentiality questions

Guidelines can be a huge help when dealing with one of the more troubling issues of online communication—patient confidentiality. AMIA guidelines, for example, suggest that physicians tell patients who besides the physician might read messages. The guidelines also suggest that physicians tell patients that each message—including replies and confirmations of receipt—will become part of the medical record.

Still, physicians differ in their approach to the issue of security. "My policy is that the physician always informs the patient up front about the potential lack of security and lets them decide, to a degree, whether or not to use e-mail." said Dr. Carter, who also works in the division of general internal medicine at the University of Alabama at Birmingham. If the patient decides to proceed and the information becomes too sensitive, however, Dr. Carter said he stops the e-mail correspondence and suggests that the patient either call him on the phone or come into the office.

But other physicians, like David M. Gates, FACP, an internist with The Phoenix Center for Internal Medicine, draw the line at using e-mail to set up appointments or answer patient concerns. "We don't provide anything that is confidential over the Web because it just isn't secure," Dr. Gates explained.

"I have heard of cases across the country where people have e-mailed their physician that they are having chest pains," he said. "That is not workable. The key is communication, providing information to your patients, so they know that e-mail isn't for urgent medical care."

Slowly, however, physician attitudes are beginning to change about just how much information they will exchange over the Internet. Mark Schor, FACP, a general internist in Lake Worth, Fla., for example, allows patients not only to schedule appointments but also to provide insurance information and much of their medical history via his Web site (http://ourworld.compuserve.com/homepages/drschor), in part because it helps his office staff work more efficiently. "When patients walk into my office, the form is already filled out and all they have to do is sign it," he said.

Dr. Schor also answers questions on his site concerning simple medical questions, but does not provide diagnoses or send sensitive lab results over e-mail. "I put a disclaimer on all my answers that I am not providing medical advice," he said. "I state that I am providing only general information, and the patient still needs to see his practitioner."

Michael S. Gorback, MD, who has a private practice in chronic pain management in Houston, goes one step further and uses his e-mail (gorby@wt.net) to stay in touch with his patients from out of state while helping them establish a relationship with physicians in their area. But before he'll even talk to a patient over the Internet, Dr. Gorback requires a patient to come to his office for evaluation. Patients must then come back to the office every three months or so for a checkup.

Other online services

As patient demand for online medical advice grows, a number of services are appearing on the Web to fill the demand. America's Doctor Online, for example, is a new service on America Online that gives consumers round-the-clock access to primary care physicians, nurses and other health care providers. The site answers basic health care questions from nearly 5,000 consumers a day on all kinds of topics. (Information about the service is available at www.americasdoctor.com.)

The site does not charge patients for the advice. Instead, sponsoring hospitals, health plans and other health care organizations financially support it. In return, the site provides information on these organizations to patients who visit the Web site.

While the service probably goes beyond the bounds of what most physicians are comfortable with, the site's founder emphasizes that the physicians do not practice medicine online but merely give patients information. "We are putting physicians online and having them answer consumer information questions only," said Scott Rifkin, MD, CEO and president of the service and an internist in Owings Mills, Md. "We are not practicing, diagnosing, prescribing, doing follow-up or keeping medical records. In short, we are not practicing medicine."

Other sites, however, are more aggressive about diagnosing patients' aches and pains. Physicians who work for CyberDocs Inc. (www.cyberdocs.com), for example, diagnose minor illnesses via the Internet. To avoid licensing problems, the service's eight physicians work only with those patients who live in the state where they are licensed. (The Web site plans to add enough physicians to treat patients in all 50 states.) Currently, CyberDocs physicians as a group handle about 20 to 30 patient consults a week.

Patients who use CyberDocs can either schedule an appointment in advance or go to the site as a walk-in patient. Patients pay for the service via credit card; initial consults cost $50.

Steven Kohler, MD, cofounder of CyberDocs Inc. and an emergency medicine physician in Nantucket, Mass., said that his service is particularly helpful for patients experiencing a minor medical emergency who can't get in touch with their regular physician. He offered the example of an American woman vacationing overseas. "She knows she is suffering from an urinary tract infection as she has had them in the past," he said. "But she doesn't want to spend several hours in an emergency room waiting for medication. I don't need to be there, touching her, to diagnose this infection. As long as she doesn't have some of the other riskier signs, such as fever, vomiting or abdominal pain, I feel very confident about getting her antibiotics."

And while Dr. Kohler readily acknowledges that the service's physicians are practicing medicine online, he emphasized that the service has clearly defined limits. CyberDocs physicians, for example, will not treat patients experiencing chest pain, flank pain, headache and neck pain.

"These symptoms are not appropriate for CyberDocs," he said. "We tell patients they need to see their doctors immediately. We generally get very simple things, or specific things, that we think we can care for."

Physicians already on the Web may staunchly defend online medicine, but they are also quick to acknowledge that the Internet will never completely replace hands-on care for patients. "You walk into an examining room where patients are waiting and you learn more about that patient in the first 10 seconds of that interaction, before you even talk to them, than at any other point of the interaction," said Dr. Rifkin.

These physicians argue, however, that the Internet can help improve patient care if used correctly. "E-mail must be viewed as something that allows greater intimacy and advances the physician/patient relationship," said Dr. Frisse.

Dr. Gates, the internist from Phoenix, couldn't agree more. When his office established a Web site (www.pcimed.com) several years ago, he never imagined that it would one day help save a patient's life. But several years ago, Dr. Gates recalled, a 51-year-old woman logged on and, using recommendations posted on the practice's site, she e-mailed the practice to set up her very first routine examination.

During that visit, the woman was diagnosed with colon cancer. Within a week, she was resected and eventually overcame the disease. "Were it not for the Web site," Dr. Gates said, "that woman wouldn't have been prompted to even see a doctor."

Jodi E. Knapp is a freelance writer and editor in Exton, Pa.


Ten ways to put your practice on the Web

As the cost of technology continues to plunge, more physicians are marketing their practices online. Here are some ways experts suggest to add additional services to cut your costs and improve physician/patient communication. However, before doing anything via electronic communication, be sure to address any patient confidentiality concerns you may have:

  • Provide information about your practice, including hours of operation, phone numbers and maps to the office.
  • Provide full descriptions of services provided and physician credentials.
  • Promote the practice to new patients and provide a physician presence when patient isn't in the office.
  • Offer standard types of patient education and information about late-breaking events.
  • Create links to other pertinent health care sites.
  • Establish templates in which patients can fill out medical histories or insurance information before coming into the office.
  • Automate appointment and scheduling features (depending on the size of the practice).
  • Provide e-mail for patients to write in questions.
  • Encourage patients to use electronic means for follow up information after patient visit.
  • Create a forum for consulting with peers.

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