Be sure to provide accurate Web links and current telephone numbers for all referral information. Such standard responses may be set up in a variety of ways, depending on the sophistication of your e-mail software. One simple method is to prepare a variety of e-mail “signatures,” each with a different response.
Practice tip No. 9. Steer unknown e-mailers seeking medical advice to a local physician or medical center. Increasingly sophisticated e-mail filter technology can advise you of who is and who is not a current patient. In all instances, it is your ethical obligation to provide referral information to all those who contact you.
Practice tip No. 10. Before sending an e-mail, always scroll down to the very bottom of your almost-ready-to-send e-mail. This step is good general practice because not only can you learn important information in a potential e-mail thread but there may be confidential information that you do not want to pass on.
Cost and reimbursement
Reimbursement policies for psychiatric treatment remain largely based on the volume and duration of face-to-face visits. Despite years of debate, neither phone assessments nor online encounters are reimbursed in industrialized countries—with the exception of a few demonstration projects and very few insurers. In some Canadian jurisdictions, notably Ontario and British Columbia, there exist “chronic disease management” fee codes, but it is difficult to “box” a psychiatric encounter into one of these codes. And yet, psychiatrists can spend valuable time responding to e-mail messages, just as they do responding to phone calls. E-mail adds to the daily workload, even though office staff can intercept messages, much as they answer the telephone.
There does appear to be a demographic divide: younger physicians embrace and appreciate the need to be in almost constant dialogue with clients. Medicine is changing and will become more participatory. The reality is that few patients abuse e-mail, for example, by attempting to contact the office after hours. Clear expectations about after-hour “e-access” need to be communicated to all patients.
Keep the relationship first
The telephone was once accused of dehumanizing the physician-patient relationship, just as electronic communication is today. But readers may remember that on March 10, 1876, Alexander Graham Bell’s first words over the telephone were, “Mr Watson, come here, I want you.” Bell was calling for medical assistance because he had just spilled sulfuric acid on his clothes and needed help.12 Since those early days, the telephone has saved countless lives.
E-mail is perhaps an even more powerful medical tool. It empowers patients by increasing their means of gaining access to health care. It enhances the management of chronic diseases, improves patient education and joint decision making, and facilitates continuity of care. It increases the frequency of interaction with the system from acute encounters to more regular ongoing interactions that enable patient self-management.
As Katz and Moyer13 have noted,
Navigating schedule systems, parking lots, waiting rooms, nursing stations, and checkout counters to spend an average of 10 minutes with a physician is no small price to pay for issues that, in many instances, could be better addressed through other, less burdensome modes of communication. Despite advances in phone system technology, automated message systems frustrate many patients. Largely due to the frustration with communicating with physicians, patients remain dissatisfied with access to their health care providers. For many patients, using online communication appears a better option than more traditional modes.
Instant messaging and other Web-based communications
Patients are also concerned that their words not be misunderstood and that they do not misinterpret the words of the doctor. E-mail and IM “conversations” are recorded so that they can be compared and meanings discussed; recommendations can be better remembered, and doctors can be held accountable for their advice.
Many health care organizations are increasingly turning to Web-based communication tools and solutions that make it possible to exchange or store information in an easily retrievable manner and to track and document communication.14 Such systems are more secure than regular e-mail because they can be authenticated and messages cannot be easily forwarded. See the Table for safety and audit trail comparisons among various media.
Conclusion
We are in the midst of an explosion of information on the Web, and the most dominant forms of expression on online blogs and communities relate to health care. Discussions about mental health, in particular, are the most frequently active of all patient conversations in chronic illness groups on social media platforms, such as MySpace. Many of the most discussed topics in these communities relate to high-stigma illnesses, such as depression, bipolar disorder, and HIV/AIDS.14
As modern patients, or e-patients, express their needs, wants, and expectations of the health care system, it is incumbent on psychiatrists to take these issues seriously. E-communication is just communication by another name—even if fraught with distinct liability and security risks. The more psychiatrists can do to advance the ease of reciprocal communication and reduce barriers, the better. Psychiatrists are an ideal group to lead the e-revolution.
