Much of family medicine comes down to giving patients the information they need and getting the information you need from them. It sounds like a simple transaction, but making it happen can be far from simple —just ask any patient who's spent more than a few minutes on hold with your office or who's gotten lost in the maze of instructions for your automated attendant.

A number of family physicians are taking a detour around these communication roadblocks by giving patients another option: e-mail and the World Wide Web. They're using the Internet to answer patients' medical questions, take requests for prescription refills, report some test results, monitor patients with chronic conditions and direct patients to high-quality educational material. Some of these uses may raise red flags about patient confidentiality (for example, many physicians would be uncomfortable reporting detailed test results in an e-mail message but might be comfortable sending a message that a patient's results were normal — especially if the patient had consented to receiving test results by e-mail). Despite the potential pitfalls, doctors are finding that the Internet can help them stay in closer touch with patients, keeping them happier and potentially healthier.

Timely communication

Probably the greatest benefit of communicating with patients online is that it makes the exchange of information more timely. It comes as no surprise to physicians that patients often are less than satisfied after a call to the office. “We haven't found a good way to respond in a timely fashion when patients call in and ask questions,” says Richard Neill, MD, assistant professor of family practice and community medicine at the University of Pennsylvania and an author of one of the few studies of patient-physician e-mail.¹ “E-mail and the Web allow me to have a clinical presence for my patients more of the time” and to give patients information more quickly. (For suggestions about what a practice's web site might contain, see below.)

“I tell patients that if there are things they'd like to know and they don't have a problem asking me via e-mail, then contact me that way instead of calling and waiting until the end of the day to get a call back,” says Paul R. Ehrmann, DO, a family physician in a three-doctor practice in Royal Oak, Mich. “I'm usually online three times a day. I make a habit of checking my e-mail when I first arrive in the morning, then around noon, and then before I leave the office around 6 or 7 p.m.”

Responding to general medical questions, taking requests for prescription refills and (for some) sending patients their test results are among the ways physicians are using e-mail to help keep patients out of congested phone systems. Some large practices even allow patients to schedule appointments through forms that can be submitted from the practices' web sites.

Providing helpful information via e-mail usually takes little time or legwork, says family physician Edward M. Friedler, MD, who practices with three other doctors in Annandale, Va. For example, a patient recently e-mailed Friedler to ask whether she should fast for a blood draw later that week. The reply, which took less than a minute, “saved her from spending a lot of time on hold and being aggravated — and having a 50/50 shot at getting the right answer from the receptionist,” he says.

Using e-mail with patients can also help limit unnecessary visits, something both doctors and patients appreciate. According to Neill, many of the messages he receives are “questions about nonurgent problems that have implied in them, ‘Do I need to be seen?’” This kind of self-triage hasn't led his patients to endanger themselves by not seeking care soon enough. “Let's put it this way: I've never had anyone send me an e-mail saying, ‘I'm having crushing chest pain. What do I do?’ I think it's mainly a by-product of the generic acknowledgment of the limitations of e-mail as an asynchronous method of communication.”

In addition to helping to keep patients from coming in unnecessarily, e-mail can make visits more productive when patients do need to be seen. For example, patients who regularly record blood pressure or blood glucose levels at home can e-mail their reading logs to their doctors before appointments. “This saves time in the office because it lets you spend your time reviewing data rather than having to start from scratch,” says Don Greggain, MD, a family physician in a two-doctor practice in Clarkston, Wash. “It also gives patients the opportunity to be more explicit in their details and not be in an office environment, where they feel like there are other people waiting.”

Taking out the web trash

Another way to provide better service with e-mail and the Web is to leverage their potential for patient education. Sigrid Johnson, MD, a solo family physician in Sweetwater, Tenn., puts links on her web site to information related to her monthly clinical focus, which she selects “based on what I see many of my patients going through. I'm trying to make my web site a stepping stone to medical information for patients in my remote area and make sure what they're getting is screened.”

In fact, Johnson is carving out something of a niche for her practice through her willingness to conduct web searches for her patients. Through e-mail or in person, they ask her to find information about their conditions or various alternative-medicine therapies. “I can go on the Web and pick out the good stuff and weed out the bad stuff for them,” John-son says. “People are finding me on the street, even at the hairdresser, and asking me to look things up. It's generating its own following.”

Even if you don't conduct literature searches for patients, you can use e-mail or web-site links to direct patients to high-quality educational resources on the Web. “There's no editor on the Internet, and the quality of information can be anything from absolutely marvelous to absolute rubbish,” Greggain says. “So when patients send me links to information that they want me to check out, I can let them know whether the sources are credible.”

Stronger connections with patients

Beyond these concrete ways Internet communication can help you serve patients better, e-mail and the Web offer important intangible benefits like patient convenience. Patients can review the insurance information on your web site or ask you medical questions via e-mail when they have time, even if it's 2 a.m. “If you can get something accomplished without needing a face-to-face or voice-to-voice interaction, generally speaking, patients like that,” Ehrmann says.

The Web also gives you a good opportunity to ask patients for input about their care. Ehrmann and Greggain have posted patient satisfaction surveys on their web sites in addition to making them available in the office. The web format lets patients complete the surveys in a convenient setting and return them with a single click of a mouse. Greggain estimates that about 15 percent of his practice's surveys are completed online.

But Internet communication doesn't have to stick to business to be productive. Even when they aren't specifically related to patient care, e-mail and web interactions make your patients feel that they're more closely connected with you. Greggain says patients sometimes send him e-mail about “web sites they just think are cool, and that's another way of linking me to them.” Ehrmann agrees: “I've got some funny, nonmedical things on my web site just to let people know that I'm a regular guy, too. I think it's been fairly well-received.”

The cost of keeping in touch

Establishing a web presence is a relatively low-cost venture, whether you choose to set up and maintain your own site or hire someone to do it for you.

For example, Greggain and his son, Joel, developed and maintain his practice's site. Greggain bought SoftQuad's HoTMetaL PRO site-development software for about $100 (other programs include Microsoft's FrontPage, Filemaker's Claris Home Page and Symantec's Visual Page, and prices range from about $50 to $200). Greggain registered his site's address, or uniform resource locator (URL), through site host GeoCities for $75, which included a fee of $70 to InterNIC, the organization that registers all addresses on the Web, for two years of registration. He also pays GeoCities a $5 monthly hosting fee. “Joel spent 25 or 30 hours taking pictures for the site, gathering information and setting it up, and we spend probably a couple of hours a month updating it,” he says. “So it's really economical.”

Even paying a third party for site development and maintenance isn't prohibitively expensive. Friedler hired a local developer to create and register his practice's site in 1997 at a cost of about $650, and he pays a $45 per month maintenance charge.

E-mail access often is included in site-hosting arrangements. In addition, local Internet service providers and national services like Juno and America Online offer e-mail accounts for prices ranging from no charge to about $20 per month.

Guidelines for e-mail

Although Internet patient communication offers new benefits, it also presents new challenges because the standards for managing telephone calls and “snail mail” don't adequately cover communication using the new medium. In addition, the prospect of reporting test results and medical conditions over an unsecured Internet raises concerns about protecting patient confidentiality and about physicians' legal liability related to electronic patient interaction.

In response, the American Medical Informatics Association (AMIA) last year released a white paper offering detailed guidelines for the clinical use of e-mail, addressing both effective patient-physician communication and “medicolegal prudence.”² The AAFP is incorporating the AMIA guidelines into a monograph, “The Doctor Will E-Mail You Now,” that relates them more specifically to family practice. The Academy plans to have the monograph available in February.

The AMIA guidelines recommend that physicians ask patients how they want to communicate with the practice and document in the chart which form of communication patients prefer for different purposes. The guidelines also recommend that physicians consider obtaining formal informed consent for the use of e-mail, a view seconded by a health care attorney recently in the Journal of the American Medical Association.³

Although he agrees with the need to safeguard patient confidentiality and to consider e-mail messages official doctor-patient communication to be included in the medical record, Neill believes physicians shouldn't wait for absolute security before using e-mail with patients. “It's good for us as a profession to have guidelines for how these communications should occur in a sensitive and secure fashion, but the reality is that how this springs up is going to be driven by individual patients and physicians and may or may not include a lot of attention to security,” Neill says. “Should it? Absolutely. But I don't think we should wait to use e-mail until we have completely secure systems in place when the communication systems we use now don't have that type of security.”

Getting patients to use it

Internet communication between doctors and patients is still relatively new, and it's something that patients have yet to embrace in large numbers (all the doctors we spoke with reported 10 or fewer e-mail interactions with patients per week). As a result, you'll probably need to make an effort to get patients to take advantage of your online access.

Business cards, stationery, newsletters, waiting-room posters and advertisements are good places to display your web site's URL or your e-mail address. Friedler also suggests asking managed care organizations to list your site's URL in their provider directories. But one-on-one communication is probably most effective. “For those patients who use my e-mail address, they're very happy,” Friedler says. “They're able to bypass the front desk, communicate with me directly and get an answer promptly. But it's taken personal encouragement from me for them to do that.”

Better care in less time?

Of course, the best way to improve patient relations is to provide excellent care cost-effectively, and connecting with patients via the Internet may help on that score, too. Reading and replying to patients' e-mail messages does take some time, but “how does that compare with how we usually do things — playing phone tag and being unable to reach patients?” Neill asks. “E-mail has the potential to save time when compared with how we do things now, and it will enrich what we do now.”

Ehrmann agrees: “E-mail has definitely enhanced my ability to keep in contact with patients and, in the long run, to deliver better patient care in less time. If you have patients who are compliant and who touch base with you, you can be on top of things a lot more.”