The changing face of patient–doctor interaction online

As publisher of OBGYN.net (http://www.obgyn.net), I see a lot of online interaction between doctors and patients, and I never cease to be amazed at how it has changed and evolved over the last few years. In 1996, the World Wide Web was beginning to be adopted by patients and the medical professional community, yet there was still a great barrier between the two groups. There were websites for women and websites for doctors, but there was little or no online interaction between the two. What interaction did exist at that time was usually a disincentive for change, as many patient groups were eager to jump on the first doctor they met in cyberspace to either get free medical advice or take out frustrations from prior bad experiences with other physicians. 

Conversely, doctors found themselves facing Internet Printout Syndrome: patients would come to their offices armed with reams of paper about their conditions. It was impossible for the doctor to sort through all this information during the diminishing time allotted for an office visit. There was also a justifiable mistrust of those who had written the material, with regard to its authenticity. Some of it was misinformation being presented as the truth by people trying to sell products or promote individual agendas. 

“The number of women online has now surpassed that of men, and the most common topic 
women seek on the Web is health care information.” 

Over the last four years, the Internet has become a major educational force and communication tool for many patients, and this trend has become even more significant for the practicing obstetrician/gynaecologist. The number of women online has now surpassed that of men, and the most common topic women seek on the Web is health care information. For these women, the most rapidly expanding areas of Internet usage are interactive forums, e-mail lists, bulletin board postings, and live online discussions (or ‘chat rooms’). Forums and bulletin boards give them access to other patients and health care professionals on their own individual time schedules, while chat rooms allow an instantaneous, real-time interchange of information. These venues allow women to interact and receive support from other like-minded patients, as well as from medical professionals. 

Women who suffer from chronic ailments such as endometriosis, polycystic ovarian syndrome, breast cancer and similar long-term conditions are finding that online support in patient support groups has become necessary to both their mental and physical well-being. Patients are finding that support from these groups is becoming an irreplaceable part of the battle against these conditions. Our own endometriosis@ obgyn.net forum consistently logs between 2000 and 4000 individual messages each month. The ease and convenience for these women to be able to plug in any time, day or night, from the privacy of their own computers is a significant reason for such high usage of the World Wide Web. The discussion topics on these patient-only forums range from serious medical issues to light-hearted, anecdotal topics shared among friends. Additionally, the likelihood is that these interactions will become an even greater part of the practice of medicine as easier access to the Internet and video-conferencing evolves. 

“By providing a practice website for patients that helps educate them with solid, evidence-based 
information or links to respected Internet resources, the physician can actually cut down on the 
amount of time spent on patient education in the office.'

Other venues exist where the interplay between physicians and patients takes the form of question-and- answer bulletin board postings or interactive discussions. In these interactive sessions, it is important that the proceedings are moderated for medical accuracy, and that the patients have the opportunity to remain anonymous if they choose to do so. There have been examples of insurance companies or employers searching mailing lists for their patients’ e-mail addresses in order to review their medical questions. Also, the credentials of the physicians answering the questions should be detailed and easily accessible. These physician/patient questions and answers should also be catalogued and archived for future reference by others who might have similar concerns. Both physicians and patients can then tap into this wealth of information with a high degree of reassurance as to the accuracy of the advice offered. Despite all this online activity, many physicians are just now coming online and learning how to integrate e-mail and the Internet into their practices. However, since it is impossible to add more hours to the day, how can one avoid becoming bogged down in an overload of information and still respond to patients’ needs, both in person and online? 

These are tough questions and, unfortunately, there are no easy answers. We find ourselves in an evolutionary period characterized by widespread technological advances. This means that there is a great increase in effort to meet the needs of both online and offline patients. It is tempting to stick with the tried-and-tested offline methods in the hope of meeting everyone’s needs, but this is an approach that might very well be near-sighted and eventually regretful. The field of medicine will continue to adopt online advances, while communication will move ahead at a momentous rate. Now is the time to start integrating these new processes into medical practice. According to a recent study that we conducted of 3000 consumers on OBGYN.net, 43% said the number one most important thing they wanted online was access to expert physician opinions, opposed to 16% who wanted access to their own individual physician. 

By providing a practice website for patients that helps educate them with solid, evidence-based information or links to respected Internet resources, the physician can actually cut down on the amount of time spent on patient education in the office. Patients want to work with their trusted physicians in finding the right information for themselves online. This is definitely a way that physicians can reach their patients effectively, with lower costs and minimal impact on office staff. E-mail communication between the doctor and the patient represents another opportunity to provide better care. 

Guidelines for using e-mail in a clinical setting address two interrelated aspects: effective interaction between the clinician and patient (Table I), and the observance of medico-legal prudence (Table II). These guidelines are published in a white paper by the American Medical Informatics Association (http://www.amia.org/pubs/other/email_guidelines.html). 

It is important that you send all of your online patient communication from a designated office e-mail address that can also be supported by your staff. Naturally, it is a mistake to publish or respond with your personal e-mail address, because it can result in tremendously increased email traffic to your personal account. You must be as protective of your online time and space as you are of the privacy of your personal life and residence. 

Any information you can include in your website, including office directions, a map, registration, medical history forms, office policies, insurance information and contact information will be appreciated and taken advantage of by your patients. It will also cut back on the office staff’s workload, allowing them to stay focused on more important services and reduce overhead costs. Starting with a basic website and adding new online patient services to it over time will definitely add to your practice in the future. 

The future of electronic health care communication looms on the horizon with the promise of online medical records, prescription services, integration of office and hospital information services, scheduling, patient education, and an ever-expanding list of exciting opportunities. Unfortunately, with these opportunities also comes the problem associated with online medical records - patient privacy issues. However, the future is clear, and change is imminent. Those who do not embrace this change will likely become victims of it. The opportunity to help your patients navigate the wealth of information on the World Wide Web and better educate themselves is now in your hands. You owe it to yourself and to your patients to meet the challenge that lies before us all. 

Table I: Summary of communication guidelines. 
• Establish a turn-around time for messages; do not use e-mail for urgent matters 
• Inform patients about privacy issues: patients should know who, besides the addressee, processes messages: 
- during the addressee’s usual business hours 
- during the addressee’s vacations or illness 
That message is to be included as part of the medical record
• Establish types of transactions (prescription refills, appointment scheduling, etc.) and sensitivity of subject matter (HIV, mental health, etc.) permitted over email 
• Instruct patients to put the category of transaction in subject line of message for filtering: ‘prescription’, ‘appointment’, ‘medical advice’, ‘billing question’ 
• Request that patients put their name and patient identification number in the body of the message 
• Configure automatic reply to acknowledge receipt of messages 
• Print all messages, with replies and confirmation of receipt, and place in patients’ paper charts 
• Send a new message to inform patient of completion of requests 
• Request that patients use auto-reply feature to acknowledge reading providers’ messages 
• Maintain a mailing list of patients, but do not send group mailings where recipients are visible to each other (use blind copy feature in software) 
• Avoid anger, sarcasm, harsh criticism and libelous references to third parties in messages 

Table II: Medico-legal and administrative guidelines. 
• Consider obtaining patients’ informed consent for use of e-mail; written forms should: 
- itemise terms in communication guidelines 
- provide instructions for when and how to escalate to phone calls and office visits 
- describe the security mechanisms that are in place 
- indemnify the health care institution for information loss due to technical failures 
- waive encryption requirement, if any, at patient’s insistence 
• Use password-protected screen savers for all desktop workstations 
in the office, hospital and at home 
• Never forward patient-identifiable information to a third party without the patient’s express permission 
• Never use patients’ e-mail addresses in a marketing scheme 
• Do not share professional e-mail accounts with family members 
• Use encryption for all messages when encryption technology becomes widely available, user-friendly and practical 
• Do not use unencrypted wireless communications with patient-identifiable information 
• Double-check all ‘To:’ fields prior to sending messages 
• Perform at least weekly backups of mail onto long-term storage; define ‘long-term’ as that applicable to paper records 
• Commit policy decisions to writing and electronic form.