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From simple e-mail messages to integrated EMR systems, online communication can enhance your patient care.

Fam Pract Manag. 2004;11(3):93-94

Many service industries, such as banking, travel and retail, have created online platforms that provide the public with access to services 24 hours a day, seven days a week. Although health care has generally lagged behind in the Internet revolution, there has been growing interest in providing online health care ever since the American Medical Informatics Association (AMIA, released its guidelines for e-mail with patients in 1998. The Internet has an abundance of health-care-related Web sites of varying quality, but relatively few patients are receiving health care from their personal physicians online. Physicians cite reimbursement concerns, time demands and privacy issues as barriers to going online with their patients. While these problems are real, they’re also manageable, and they need to be weighed against the potential benefits of online communication – increased practice efficiency, lower overhead, and increased quality of care and satisfaction for the patient. Physicians who have been hesitant about open e-mail communication with patients may find comfort in the newer methods of secure online communication described in this article. This article reviews the current options for online communication with patients: regular e-mail, Web-based messaging and integrated online communication.


Look for the second article in this two-part series in an upcoming issue of FPM. Reimbursement options and advice about how to optimize online communication with patients will be addressed.

Regular e-mail

The use of regular e-mail between patients and physicians or office staff is the oldest and still most common form of online communication in health care. The main advantages of regular e-mail are that it’s easy to use and cost-effective. (See “A new way of practicing” to learn about my practice’s experience.) Although unencrypted e-mail does raise privacy and security concerns that may need to be addressed (see below), it does not violate the Health Insurance Portability and Accountability Act (HIPAA) as long as patients are informed of the associated risks and accept them. The Notice of Privacy Practices that you distribute to patients to comply with HIPAA should address your e-mail policies, and it’s also important to include a standard confidentiality message in each patient-related e-mail.

The unstructured format of e-mail can be both an advantage and a disadvantage. While the lack of structure allows patients to express themselves freely, which can sometimes reveal an important personal matter about their health, it can also result in uncertainty about the patient’s identity (e.g., when a patient’s e-mail address is unrevealing and only a first name is used in the message) or an incomplete message (e.g., when a prescription refill request doesn’t include all the necessary information). Setting e-mail-use guidelines, which will be addressed in an upcoming issue, can prevent these problems.

Although e-mail communication with patients isn’t prohibited by HIPAA, it does make some physicians (and patients) uncomfortable. To enhance privacy and security, encryption software can be added to the practice’s e-mail system. These software packages, which can be complicated to use and less than perfect in their application, are available from companies such as Authentica (, Hilgraeve (, Kryptiq (, Sigaba (, Tumbleweed Communications ( and ZixCorp ( They range in cost from $10,000 to $15,000 to purchase and install for up to 50 e-mail users plus $4,000 to $6,000 per year for ongoing maintenance.1

Web-based messaging

Communicating over a secure Web site, which is how most online banking and shopping sites work, is becoming more popular and is likely to replace regular e-mail in health care. With Web-based messaging, patients enter a practice’s secure Web site and send a message to the practice using an electronic form that the practice has provided. Physicians and staff are notified in their regular e-mail of messages on the Web site, and then they post a reply to the patient on the site that can only be accessed by the patient. The patient is notified of the practice’s message in his or her regular e-mail. Web-based messaging services can be incorporated into existing practice sites or can stand on their own. Medem (, Medfusion (, MyDocOnline ( and RelayHealth ( are among the vendors that offer secure Web-based messaging services.

The major advantages of Web-based messaging over regular e-mail are enhanced privacy and security (in addition to using a secure Web site, you’re partnering with a vendor who has to stay on top of HIPAA and other privacy requirements) and the ability to use templates. Templates ensure that patients’ messages include the information needed to process prescription refill requests or to adequately describe their problems and provide some clinical assessment data for the physician or nurse. They may also be designed to triage messages to the front- and back-office staff. Web-based messaging services cost $50 to $100 per physician user per month – a cost that may be offset by billing patients for use of the service.


I started giving my e-mail address to patients in 1997 as a way of avoiding a difficult telephone system in an academic practice. Inadvertently, I found that e-mail could enhance the physician-patient relationship by expanding access to communication with patients in a rapid and mutually convenient way. Eventually, I began using e-mail more frequently, both to set up and follow up a visit. In some cases, it has made visits unnecessary. It has also created a new sense of continuous care by taking the “do-it-all-now” pressure off of the episodic office visit.

Of course, some problems have come along with these unexpected benefits. Although no patients have ever raised the issue of privacy, it is a concern for me. And occasionally, despite my best efforts to educate patients on proper e-mail use, I receive inappropriate messages, such as a request for urgent care or for treatment that I really cannot provide without a visit. Some patients provide incomplete information in their e-mails, and, because I do not have an integrated EMR system yet (I will have one soon), I am not able to respond well if I am not at the office. Another frustration is that, for fee-for-service patients, I am giving away free care and sometimes preventing a reimbursable visit.

However, despite these occasional problems, I would never go back. Online communication has offered advantages for my patients and me that far outweigh the problems. Undoubtedly, online health care is coming and will become a new portal for services, replacing much of what is done over the telephone and in unnecessary office visits.

Integrated online communication

Web-enabled electronic medical record (EMR) systems now have the ability to provide integrated online communication by using the Web-based messaging model described earlier. An integrated system makes the patient’s entire medical record available to the physician during the online communication, and all of the messages are immediately made a part of the patient’s record.

The cost of an integrated system is essentially the cost of a Web-enabled EMR system, which is substantially more than regular e-mail or standalone Web-based messaging. EMR vendors that provide this type of system include such companies as Allscripts (, Alteer (, Cerner (, Epic (, GE Medical Systems (, NextGen (, Physician Microsystems ( and Siemens (, and some of these vendors offer discounts to family physicians through the AAFP’s Principled Group Purchasing Agreements – Partners for Patients.

A new platform of care

Any of these methods of online communication offer a new platform of care for physicians and patients. The second part of this series, which will appear in an upcoming issue, addresses how to successfully integrate online patient communication into a busy practice and discusses the reimbursement options available for this type of care.

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Copyright © 2004 by the American Academy of Family Physicians.

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