You feel sluggish, dizzy, distracted. In fact, you’ve been at work all morning and haven’t gotten a thing done. You e-mail your doctor, describing your misery in excruciating detail.
Your employer, quite legally, reads it, and concludes you’re not really sick, just goofing off. Now you’re in deep yogurt.
Or, you run out of Prozac. You e-mail your shrink, who calls in a prescription. You’re fine – until your employer gets sued for something unrelated and all company e-mail within certain dates, including yours, winds up in court.
Or how about this scenario? You seek a second opinion on line from a doctor you’ve never met. You explain the diagnosis from the first doctor. The on-line doctor recommends a different treatment. You do it. It makes you worse. You sue. You lose; turns out there was no real doctor-patient relationship.
In its own way, the Internet may be changing the practice of medicine as much as antibiotics, anesthesia or immunizations.
The wealth of health information – and misinformation – on line is unimaginably vast. There are 40 million Americans on line and 15,000 to 25,000 web sites for health matters, says Dr. Helga E. Rippen, a physician-engineer who runs a health information institute at Mitretek Systems, a nonprofit technology think tank in McLean, Va.
Nearly 40 percent of Americans with on-line access use the web to search for health information, a survey by Princeton Survey Research Associates and the Institute for the Future, a California think tank found.
Through the web, people find new medicines, needle-in-a-haystack experts and support. But they are also finding, or soon will, that cyber medicine has pitfalls as well as promise.
Like e-mail.
“This is a technology that, like it or not, we are all going to be using,” says Dr. Daniel Z. Sands of Beth Israel Deaconess Medical Center, a co-author of new guidelines on doctor-patient e-mail put out by the American Medical Informatics Association (www.amia.org).
Both patients and doctors tend to be naive about the dangers of medical e-mail. It’s inappropriate in emergencies, for instance – you should call your doctor or 911. In fact, it often takes 48 hours for a busy doctor to answer e-mail.
Confidentiality is another huge risk. E-mailing your doctor from work is dicey because your employer may see it. At home, especially if you share a computer with your spouse or kids, e-mail from your doctor may wind up on a screen everybody can see. In the doctor’s office, a nurse or others may be deputized to read e-mail – and put a copy in your patient record.
In between, in the vastness of cyberspace, your e-mail is vulnerable to busybodies hacking their way. So it’s wise to encrypt medical e-mail, which you can do through a number of “applications” (software) says Alissa Spielberg, a medical ethicist at Harvard Medical School.
Be careful if you fill out any medical forms on line, or otherwise divulge personal medical information, too. Make sure there’s a lock icon in the lower left corner, which means whoever has designed the form has included encryption, says Rippen.
Even with these precautions, be careful about discussing sensitive information such as psychiatric problems, HIV status, abortion decisions or disability claims on interactive web sites or by e-mail.
That said, doctor-patient e-mail is expected to grow because patients like the fact that e-mail helps them get through to doctors, bypassing secretaries, nurses, switchboards, and busy signals.
Doctors appear more reluctant. So far, only 1 to 2 percent use e-mail to communicate with patients, estimates Dr. Tom Ferguson, a health informatics professor at the University of Texas and editor of the Ferguson Report, an industry newsletter about on-line health information.
In part, this is because doctors fear that answering patients’ e-mail will take them time and pay nothing.
That’s true, but even so, it may be worth it, some say.
In a study published in October in the Journal of the American Medical Association, Dr. Stephen M. Borowitz, a pediatric gastroenterologist at the University of Virginia Health Sciences Center in Charlottesville, analyzed more than 1,200 e-mails from worried parents over a three-year period.
He found that it takes only four minutes, on average, to read and respond to an e-mail and that most can be answered within 48 hours. Parents also seem to feel freer on e-mail to ask questions they fear are “too basic or too stupid” to ask in person, he adds. To help with just such basics, he’s developed a number of online “tutorials” to which he directs parents with sick kids.
To help doctors cope with the inevitable growth of patient e-mail, Dr. David Stern, an internist at the Ann Arbor Veterans Affairs Medical Center and the University of Michigan Health System, is studying more than 50 young doctors.
Half of them will communicate with patients only in traditional ways, and half will add e-mail to their interactions, and he’ll compare the outcomes. The results aren’t in yet, he says, but he hopes to find out whether e-mail helps or hurts overall communication with patients and whether it saves or costs time.
And what about getting medical advice from on-line docs?
So far, there are about 10 on-line medical consult services. But while there are benefits to such cyber consults – such as getting detailed opinions about a proposed treatment plan – there are also questions:
Can you get personalized care from a doctor you’ve never met? How do you know your consultant is really a doctor? Does an on-line consult constitute a doctor-patient relationship? Can doctors, licensed state by state, practice on line across state lines? Do cyber doctors increase their risk of malpractice?
“People should be very cautious,” says Bill Silberg, new-media editor at JAMA. Even if you hook up with top authorities, it’s not clear the advice would be as tailored to you as what you’d get from your own physician. “That personal connection in extremely important, but this is an evolving field,” Silberg adds.
“I’d be quite wary,” adds Spielberg of Harvard. Despite doctors’ disclaimers, she notes, “Once money is exchanged, you’d have a good argument that a doctor-patient relationship exists. If harm occurs, you may have a claim for malpractice.”
Dr. James Winn, executive vice president of the Texas-based Federation of State Medical Boards, agrees, adding that his group has written model legislation – adopted by a dozen states – stipulating that when the patient and doctor are in different states, the patient’s jurisdiction should prevail.
The group also recommends that states issue a limited license to doctors from other states who offer electronic consultations.
Massachusetts has not adopted the model law, but is working on the issue, says Alexander Fleming, executive director of the state board of registration in medicine.
At Mediconsult.com, which offers consults from doctors in various states through a service called MediXperts, medical director Michel Bazinet and his staff say they have taken great pains to tiptoe through this legal minefield.
They say their services – $195 per consult – do not constitute a doctor-patient relationship or second opinion because the doctor never knows the patient’s name, only the case number. The patient also pays the service, not the doctor. The company insists that it does “not practice medicine with this service.”
Maybe. But the bottom line is that cyber medicine – whether e-mail, health-oriented web sites or on-line consults – is such an exploding field that lawyers, legislators and ethicists, let alone average patients, aren’t keeping up.
Which means: Think before you type.
Cyber tips for patients and doctors
For patients:
- Don’t use e-mail for emergencies or other situations in which you need a timely response. Call your doctor or 911.
- Don’t assume e-mail is confidential. Don’t discuss psychiatric problems, HIV status, abortion, disability claims or other sensitive issues by e-mail.
- Double-check the e-mail address you’re sending to.
- Identify yourself by name in the subject line. Don’t expect the doctor to decipher a cutesy e-mail address.
- Assume that whatever you write to your own doctor will end up in your medical record. Keep copies of all medical e-mail.
- If you e-mail your doctor from your workplace, know that your employer is legally entitled to read it.
- If you e-mail your doctor from home and you share your computer with family members, be aware that your e-mail may be read by others.
- Encrypt your medical e-mail.
- If you fill out forms on line with personal medical information, make sure the web site encrypts this information.
- Ask if the doctor will send your e-mails to insurers.
- Getting second opinions or other medical consults on line may be helpful, but use caution about taking medical advice from a doctor you have never met.