Electronic Patient-Centered Communication (e-PCC) Resource Page

Note: I’ve long been an advocate of communicating with patients in ways that sometimes are more efficient and effective than just face-to-face visits and telephone calls. In fact, back in the 1990s I created a site called e-PCC.org dedicated to the use of e-mail and related technologies to communicate with patients. Here are some of its most popular resources — and some new ones in the same vein.

---

I’ve been using e-mail to communicate with patients in my primary care practice since I arrived at Beth Israel Hospital (now Beth Israel Deaconess Medical Center) in 1991 (where e-mail had been a part of the culture since 1978). In 1998, just a few short years after the advent of the World Wide Web and the democratization of its resources, I helped lead a working group of the American Medical Informatics Association to make the case for the use of electronic communication between clinicians and patients and promote best practices governing its use. This culminated in the very first national guidelines for the use of electronic communication in clinical care, which was published by the Journal of the Medical Informatics Association in 1998. Surprisingly, almost everything we said and did here so many years ago is still valid, almost 15 years later. I have a downloadable PDF here for ease of access:

AMIA Clinical E-mail Guidelines

In 1999, I developed a derivative document following input from a variety of stakeholders convened by the Massachusetts Health Data Consortium:

MHDC Guidelines for the Use of Patient-Centered E-mail

---

Tips on Using E-mail (not all applies to secure messaging) with Patients

Daniel Z. Sands, MD, MPH 3/6/2000

The use of e-mail in the patient-clinician relationship is useful to enhance communication, patient education, and both patient and provider satisfaction when used properly. Here are some guidelines which may help increase your comfort level and allow you to better manage the risks and benefits of electronic patient-centered communication. For more information see http://www.e-pcc.org.

• You may choose to offer this service to all of your patients, some of your patients, or none of them.
• Always discuss guidelines for appropriate use. The major points can be summarized on a rubber stamp or sticker, which you may place on the back of your business card. Your discussion with your patient about the use of e-mail is an informed consent discussion, and as such the discussion and the patient’s assertion of their understanding should be documented in the patient’s record, for example “We discussed the risks, benefits, and appropriate uses of e-mail for our communications. The patient expresses an understanding of the risks and agreement to our standard guidelines. Her e-mail address is: …”

The guidelines are:

• Use alternative forms of communication for:Be concise
  • emergencies and other time-sensitive issues
  • sensitive information (do not assume e-mail is confidential)
  • situations in which my response is delayed (I may be away)
• Put your name and identification number in the subject line
• Keep copies of e-mail you receive from me
• I may save e-mail I send and receive in your record
• I may share your messages with my office staff or with consultants (if necessary)

Additional points worth mentioning to patients:

• E-mail sent using an employer’s e-mail system could legally be read by the employer. An alternative is to sign up for a personal e-mail account.
• E-mail is sent across an open computer network and is generally unencrypted. It is thus accessible to prying eyes much as a postcard is.
• The biggest threat to the confidentiality of e-mail is not hackers intercepting messages, but:
  • messages that are misaddressed
  • messages containing confidential information that are inadvertently forwarded to others
  • messages read using shared e-mail accounts
  • messages left on computer screens when one forgets to log off

• Always quote the full text of the e-mail that is being sent to you when responding (to provide the context for your replies).
• Append a standard block of text to the end of all your e-mail messages to patients, which contains your full name, contact information, and reminders about security and importance of alternate forms of communication for emergencies. An example is at the website above.
• Save all e-mails that you send and receive in an e-mail folder for each patient. Ideally you should file these in the patient’s medical record, either by printing them out and filing them or by copying and pasting or filing them directly in the patient’s computerized record.
• Record your patient’s e-mail addresses in your address book and in their electronic or paper record. Ideally, you can have a field in the registration system that you can use for this.
• In general, be careful about sending e-mail messages to more than one patient at a time, since they will see the other recipients’ e-mail addresses (or worse). If you wish to send group mailings, do the following:
  • Address the message to yourself.
  • Use the “bcc” field to list each of the intended recipients. This way your patients will not be able to see who else received the message (other than you).
• You may choose to maintain a policy of only replying to but never initiating e-mail messages.
• Do not deliver bad news via e-mail.
• When e-mail messages get long or the volley is prolonged, tell the patient you’d like them to come in to discuss (or call them).
• Remind patients when they do not adhere to the guidelines.
• For repeat offenders, it is acceptable to terminate the e-mail relationship. 

---

The Back of my Business Card, Circa 1999:

---

Electrons in Flight — E-Mail between Doctors and Patients

For a more recent perspective on this topic, read this paper that I wrote with Tom Delbanco for the New England Journal of Medicine: Delbanco-Sands NEJM Perspectives on ePCC.

---

Meaningful use

Stage 2 Meaningful Use has a new core objective for eligible providers to “Use secure electronic messaging to communicate with patients on relevant health information.” I’ll update this section with relevant resources as I come across them.

---

Literature Search

Here is a reasonable literature search on PubMed for relevant papers on this topic. It’s more sensitive than specific, but may be useful.