A 39-year-old woman has started using the encrypted email within her hospital's electronic health record system to contact her primary care physician about health concerns. She works as an attorney and has a history of sarcoidosis, gastroesophageal reflux disease, and tension headaches. The patient frequently sends long updates on her symptoms to her physician with medical questions referencing articles she finds on the internet, often 5-10 times a day. Her physician, who has treated her over the past 5 years, has been spending increasing amounts of time responding to her concerns. During this time, she has also no-showed for 2 of her scheduled in-person appointments. When the physician is suddenly called out of the office due to a family emergency, the patient becomes frustrated by the lack of response to her emails and sends the physician several messages complaining about lack of availability. On returning, what would be the best response for the physician to give the patient?

Question

A 39-year-old woman has started using the encrypted email within her hospital's electronic health record system to contact her primary care physician about health concerns.  She works as an attorney and has a history of sarcoidosis, gastroesophageal reflux disease, and tension headaches.  The patient frequently sends long updates on her symptoms to her physician with medical questions referencing articles she finds on the internet, often 5-10 times a day.  Her physician, who has treated her over the past 5 years, has been spending increasing amounts of time responding to her concerns.  During this time, she has also no-showed for 2 of her scheduled in-person appointments.  When the physician is suddenly called out of the office due to a family emergency, the patient becomes frustrated by the lack of response to her emails and sends the physician several messages complaining about lack of availability.  On returning, what would be the best response for the physician to give the patient?

Quizplus · Accepted Answer

Explanation: According to the American Medical Association, "Patient-physician electronic mail is defined as computer-based communication between physicians and patients within a professional relationship, in which the physician has taken on an explicit measure of responsibility for the patient's care." Many health care systems have implemented encrypted email for patients to use in Health Insurance Portability and Accountability Act (HIPAA)- compliant communication with physicians. Efficient and convenient, email provides the opportunity for basic follow-up care and clarification of medical advice provided in the office setting, with ease of documentation of communication. Suggested educational resources and websites can be easily referenced in the context of an email, allowing patients to better understand pertinent health care issues. However, it is important for physicians to set clear boundaries regarding the use of email communication prior to engaging in these exchanges with patients. The parameters should include prohibiting the use of email for urgent or emergency situations, and discouraging overuse to circumvent office visits or emails containing abusive or inappropriate content. Patients should be informed that email is most useful when managing simple health care issues (eg, medication refills, basic questions about pre- or post-operative care, appointment scheduling, advice clarification). This physician should inform the patient that her email use is not appropriate and outline the parameters for their email contact. (Choice A) Discontinuing the patient's email privileges would not be the best next step. This would be more appropriate if the patient has repeatedly failed to respect set boundaries or is abusive or threatening harm. (Choice B) Mandating that all concerns be addressed in office visits would be recommended for a patient who continues to use email in lieu of office visits following a clear discussion of email parameters. (Choice C) Although some concierge practices may bill for time spent on email, currently insurance does not cover this type of service. It would be more reasonable to first discuss appropriate emailing parameters. (Choice D) Offering an explanation for why the physician was away avoids addressing the main issue, which involves the patient's lack of understanding about the appropriate use of email. Educational objective: Patient-physician email communication regarding simple, nonurgent health care issues is useful in clarifying instructions, improving rapport, and increasing patient satisfaction. Physicians should set clear parameters early on with patients regarding appropriate use of email. References: Guidelines for the clinical use of electronic mail with patients. The AMIA Internet Working Group, Task Force on Guidelines for the Use of Clinic-Patient Electronic Mail. (http://www.ncbi.nlm.nih.gov/pubmed/9452989)

A 39-Year-Old Woman Has Started Using the Encrypted Email Within