USPSYCH: From the Couch to the Laptop: The Age of Psychiatrist-Patient Email

NEW ORLEANS, Nov. 22 -- These days a psychiatrist may see an email from a patient that says, "I'm feeling suicidal."

This hypothetical scenario -- "which is not that farfetched" -- illustrates that the rules governing doctor-patient communication lag behind the latest technology, said Stuart Gitlow, M.D., M.P.H., of Beacon Health Strategies in Providence, R.I.

Furthermore, as e-mail, instant messaging, and online chat rooms have become a routine part of life, patients are demanding that doctors be electronically available, Dr. Gitlow said at the U.S. Psychiatric & Mental Health Congress here.

They pose other interesting scenarios, he said. Imagine that in the future you are using your laptop to videoconference with a patient. You are on an airplane flying between New York and California. You are over Kansas. Your patient, as it happens, is on another airplane over Arizona. In what state are you practicing medicine?

Moreover, physicians may be concerned about running afoul of data privacy and security rules of the Health Insurance Portability and Accountability Act (HIPAA).

The rules governing electronic communication between doctors and patients are far from clear in many cases, but some organizations have issued guidelines concerning email. Dr. Gitlow presented highlights of such guidelines from the American Medical Association (AMA), the American Psychiatric Association (APA), and the Federation of State Medical Boards (FSMB), as well as a brief look at the HIPPA rules covering emails.

The AMA suggests the following:

• Establish a turnaround time for emails.
• Inform patients about the privacy status of emails with you. For example, patients should know who -- other than you -- might see the message they send. This information can be included in the usual disclosure statements that new patients receive, Dr. Gitlow suggested.
• When possible, retain copies of emails with patients.
• Patients should be instructed to include their full name and patient ID, if any, in their emails. This avoids confusion between patients who have the same or similar names, Dr. Gitlow said. Patients should also understand the need for their messages to be concise.
• When sending group messages to patients, be sure to put the addresses in the "blind copy" address field. Otherwise, every patient will be able to see the email address of every other, Dr. Gitlow said.
• Avoid sarcasm, anger, harsh criticism, or libelous references to third parties in your e-mails.
• Append your name, contact information, and reminders about privacy (or lack thereof) to your e-mails to patients.
• Never forward patient e-mails or patient information.

Dr. Gitlow suggested that mental health care professionals establish with patients what kinds of communication are appropriate for e-mails and other electronic communication. For example, some doctors might not want to receive emergency information electronically because they don't check their e-mail often. For others, an email or instant message might be the preferred way to receive information about acute problems, Dr. Gitlow said.

The APA further suggests that doctors have specific policies in place about how frequently they check their email, about vacation coverage of their e-mail, and about automatic responses, such as the out-of-office reply, Dr. Gitlow said.

Dr. Gitlow advised that out-of-office replies should give patients specific instructions as to what to do or whom to contact next.

Finally, HIPPA rules state that if you are a covered entity, your emails should be encrypted to be secure. If they are not encrypted, they should not contain patient identity information. Patient identity information includes name, address, birth date, admission date, discharge date, phone number, fax number, email address, social security number, and medical record number, Dr. Gitlow said.

"Interestingly, there are no similar guidelines as to how to interact with patients by telephone or by letter mail," Dr. Gitlow said. To doctors who are as comfortable with electronic communication as they are with telephones, the guidelines might seem as obvious as the instructions on old telephones: "wait for dial tone," he said.