REPORT 4 OF THE COUNCIL ON MEDICAL SERVICE (A-01)
Medical Care Online
(Reference Committee G)
Statistics suggest that a growing number of patients are likely to have more of their medical care
managed online in the future. The management of medical care online also has the potential to
profoundly impact how physicians practice medicine, the quality of medical care that patients
receive, as well as the patient-physician relationship. Council on Medical Service Report 4 -- the
latest in a series of Council reports addressing issues related to medical care online -- provides
statistics on current patient demand for online services and physician use of the World Wide Web.
The report also discusses some of the ways in which physicians are likely to manage medical care
online in the future, some of the potential benefits and drawbacks, and other incentives and
obstacles to medical care online. In addition, the report summarizes several current AMA e-health
initiatives and includes a series of policy recommendations.
The report finds that a significant number of patients would like their physicians to provide certain
medical services online and more than one-half of physicians currently utilize the Web for work-
related purposes. While debate exists as to the likely future impact of the Internet on medical care,
a consensus appears to exist that patients will demand quicker access to care, efficient scheduling,
and regular communications from their physicians. Physicians will increasingly use encrypted e-
mail for scheduling appointments, prescribing, sending laboratory reports, and reminding and
alerting patients about new diagnostic and therapeutic approaches and newly identified side effects
Personal digital assistants are likely to hasten physicians’ transition to the Internet because
physicians can use these devices while actually seeing patients. Physician practices will
increasingly provide highly customized and interactive Web-based services to patients. Physician
Web sites are likely to facilitate the integration of computer technology into physicians’
professional workflow and will provide a platform for patients to use the Internet for meaningful
The report recommends modifying current policy on patient-physician e-mail to ensure that such
communication does not replace the crucial interpersonal contacts that are the basis of the patient-
physician relationship. The report also recommends the development of guidelines to assist
physicians in using the Internet for legitimate electronic prescribing; that the AMA support efforts
to address the economic, literacy, and cultural barriers to patients utilizing information technology;
and that physicians advise their professional liability insurers about the practice-related activities in
which they are engaged. In addition, the report recommends that the AMA continue to examine
the legal issues associated with medical care online and make the results of this examination
available to physicians.
REPORT OF THE COUNCIL ON MEDICAL SERVICE
CMS Report 4 - A-01
Subject: Medical Care Online
Presented by: Joseph M. Heyman, MD, Chair
Referred to: Reference Committee G
(Kenneth D. Tuck, MD, Chair)
2 A significant number of patients would like their physicians to provide certain medical services
3 online and more than one-half of physicians currently utilize the World Wide Web for work-related
4 purposes. These statistics suggest that a growing number of patients are likely to have more of
5 their medical care managed online in the future. The management of medical care online also has
6 the potential to profoundly impact how physicians practice medicine, the quality of medical care
7 that patients receive, as well as the patient-physician relationship. The Council on Medical Service
8 has periodically examined issues related to medical care online, preparing six reports on electronic
9 data interchange since 1993 [CMS Reports 1 (I-93), 8 (I-95), 1 (A-96), 11 (I-96), 2 (A-97), and 7
10 (I-98)]. These reports primarily addressed the electronic submission of health insurance claims.
11 The Council also has prepared five reports on telemedicine since 1993 [CMS Reports 4 (I-93) and
12 8 (I-95), and Council on Medical Education/Council on Medical Service Reports (A-94), (A-96),
13 and (I-96)]. These reports primarily addressed the use of interactive video technology in the
14 practice of medicine. In addition, the Council has prepared two reports on electronic medical
15 records systems since 1998 [CMS Reports 1 (A-98) and 10 (A-00)].
17 This report provides statistics on current patient demand for online services and physician use of
18 the Web. The report also discusses some of the ways in which physicians are likely to manage
19 medical care online in the future, some of the potential benefits and drawbacks, and other
20 incentives and obstacles to medical care online. In addition, the report summarizes several current
21 AMA e-health initiatives and includes a series of policy recommendations. The Council is aware
22 that this report is not all-encompassing and may, in fact, raise additional issues that warrant further
23 analysis. The Council will continue to study medical care online and encourages other AMA
24 Councils to examine related “cybermedicine” issues within their respective areas of expertise.
26 CURRENT PATIENT DEMAND FOR ONLINE SERVICES AND PHYSICIAN USE OF THE
27 WORLD WIDE WEB
29 According to a 2000 survey conducted by the market research firm Harris Interactive, 83% of
30 consumers want their laboratory test results to be available online. Sixty-nine percent want online
31 charts to monitor chronic conditions, 84% want their physician to send them electronic alerts, and
32 80% want to receive personalized medical information online from their physician following an
33 office visit. Forty-three percent of the survey respondents were willing to select their physician
34 based on the availability of Internet systems.
CMS Rep.4 – A 01 – page 2
1 The results of a 2000 survey conducted by the AMA Division of Market Research and Analysis
2 indicate that 70% of physicians currently use the World Wide Web, an increase of 33% from 1999.
3 Internet usage is greatest among physicians 40 years of age or less (86%), anesthesiologists (78%),
4 pediatricians (76%), radiologists (75%), and internists (73%). Fifty-four percent of physicians use
5 the Web at work and 38% plan to acquire access to the Web at work in the next six months. Sixty-
6 six percent of physicians who use the Web consider it to be the most useful as a medical
7 information source and 51% find the Web useful as a drug information resource. Thirty-nine
8 percent of physicians consider the Web to be useful as a resource for patient education and 21%
9 consider the Web to be useful for marketing their practice. Physicians’ perceptions of the
10 usefulness of the Web as a resource for drug information (1999, 43%; 2000, 51%), patient
11 education (1999, 30%; 2000, 39%), and practice marketing (1999, 15%; 2000, 21%) have
12 increased significantly since 1999. The majority of physicians use the Web for medical
13 information (85%), drug information (64%), and diagnostic decision assistance (52%). Only 13%
14 of physicians use the Web for posting to bulletin boards and only 8% use the Web for participating
15 in chat rooms.
17 According to the survey, one-quarter of physicians currently use the Web to send and receive e-
18 mail to and from patients. Physicians in large group practices (51+ physicians) (35%) are more
19 likely than physicians in practices with 50 or less physicians (20%) to send e-mail to patients.
20 Physicians in large group practices (33%) also are more likely than physicians in practices with 50
21 or less physicians (22%) to receive e-mail from patients. Twenty-six percent of physicians using
22 the Web have a practice-related Web site. After increasing significantly from 1997 (17%) to 1999
23 (27%), the proportion of physicians who have a site has stabilized. The existence of a site is
24 greatest among physicians in solo or two-physician practices (34%) and surgeons (43%).
25 Physicians cite patient educational information (34%) and promoting and advertising their practice
26 (32%) as the primary reasons why they have a site. Among physicians who use the Web but do not
27 have a site, the reasons given for not having a site include: no need for a site (52%), do not have
28 time to develop a site (21%), use a university and/or hospital Web site (11%), and a lack of desire
29 to advertise/promote their practice (7%). The proportion of physicians who state that the Web has
30 had a major impact on the way they practice medicine has increased steadily since 1997 (1997,
31 28%; 1999, 33%; 2000, 41%).
33 MEDICAL CARE ONLINE IN THE FUTURE
35 While debate exists as to the likely future impact of the Internet on medical care, a consensus
36 appears to exist that patients will demand immediate access to care, efficient scheduling, and
37 regular communications from their physicians. Patients with chronic conditions are likely to be
38 continuously linked to a network, their conditions monitored by sensors and computers they carry
39 as part of their clothing or themselves. Physicians will increasingly use encrypted e-mail for
40 scheduling appointments, prescribing, sending laboratory reports, and reminding and alerting
41 patients about new diagnostic and therapeutic approaches and newly identified side effects of
42 drugs. While not standard practice at this time, physicians may consider treating common diseases
43 by e-mail as they have previously done by telephone. E-mail will be used as an adjunct to direct
44 patient encounters, not instead of them.
46 Personal digital assistants (PDAs) or handheld wireless devices are likely to hasten physicians’
47 transition to the Internet because physicians can use these devices while actually seeing patients.
CMS Rep.4 – A 01 – page 3
1 PDAs currently enable physicians to check drug doses, side effects, and dangerous drug
2 interactions. Other current applications include: access to medical articles, prescription writing,
3 treatment recommendations, sending information to patients’ personal Web pages, and voice
4 dictation. In the near future, physicians will use PDAs to directly transmit prescriptions to a
5 pharmacy. Eventually, such devices will immediately alert physicians to changes in a patient’s
6 blood pressure or heart rate. However, privacy and confidentiality concerns have been raised
7 regarding the use of PDAs to store and transmit patient medical information. Federal privacy and
8 security rules, pursuant to the Health Insurance Portability and Accountability Act of 1996
9 (HIPAA), will apply to individually identifiable health information stored in and transmitted by
10 handheld wireless devices.
12 As the aforementioned survey results indicate, one-quarter of physicians currently have a practice-
13 related Web site. Many of these sites provide basic practice information, including: office hours;
14 photographs and brief biographies of the physicians and staff; information about how to contact the
15 practice; a list of participating insurers; instructions for requesting prescription refills; information
16 about fees and billing policies; procedures for referrals; patient-oriented health information; and
17 references to other educational sites. Physician practices will increasingly provide highly
18 customized and interactive Web-based services to patients, such as disease management tools,
19 patient care protocols, e-mail to staff and physicians, and physician-supervised online support
22 Web-based communication can provide for more secure channels to enter information online and
23 allows for a more structured form of communication than simple e-mail. For instance, templates
24 for appointment requests, a medical history, and prescription refills can be created for patients to
25 complete online. Messages also can be sorted according to the type of correspondence a visitor
26 selects and distributed to the computer workstations of the staffers designated to handle them.
27 Physician Web sites are likely to facilitate the integration of computer technology into physicians’
28 professional workflow and will provide a platform for patients to use the Internet for meaningful
29 health activities.
31 In addition, some medical Web sites offer Internet users free or paid online diagnosis. Many other
32 non-secure sites encourage anonymous patient communication with an anonymous expert or
33 interaction among site users forming self-help groups. The proliferation and popularity of these
34 sites indicate patients’ desire to share personal information, concerns, and fears, even if they may
35 be reluctant to do so in person with their own physician.
37 The AMA has established a number of policies related to medical care online. Policy H-478.997
38 (AMA Policy Database) outlines communications and medicolegal and administrative guidelines
39 for patient-physician e-mail. Policy H-390.859 states that physicians should be compensated for
40 their professional services, at a fair fee of their choosing, for established patients, whether the
41 consultation service is rendered by telephone, fax, electronic mail, or other form of communication.
42 Policies H-390.859 and H-480.974 state that the AMA will press the Health Care Financing
43 Administration and other payers for separate recognition of such supplemental communication
44 work. Policy H-480.974 encourages the CPT Editorial Board to develop CPT codes or
45 modifiers for telemedical services.
CMS Rep.4 – A 01 – page 4
1 AMA policy also supports the use of the Internet as a mechanism to prescribe medications with
2 appropriate safeguards to ensure that the standards for high quality medical care are fulfilled
3 (Policy H-120.956). Policy 120.957 encourages the Drug Enforcement Administration to
4 accommodate encrypted electronic prescriptions for Schedule II controlled substances, as long as
5 sufficient security measures are in place to ensure the confidentiality and integrity of the
6 information. Policy H-160.933 opposes the transmission of test results via electronic mail and
7 Policy H-120.956 states that the AMA will keep pace with changes in technology by continually
8 updating standards of practice on the Internet.
10 POTENTIAL BENEFITS OF MEDICAL CARE ONLINE
12 Improved Quality of Care
14 Proponents of patient-physician electronic communication cite improvements in the quality of care
15 that patients receive as a reason to manage medical care online. They note, for example, that e-
16 mail can serve as a way for physicians to clarify medical advice that the patient forgot or did not
17 fully understand. E-mail can be especially useful for information the patient would otherwise have
18 to commit to writing if it were given orally, such as addresses and telephone numbers of other
19 facilities to which the patient is referred, test results with interpretation and advice, instructions on
20 how to take medications or apply dressings, pre- and post-operative instructions, and other forms of
21 patient education. Clarity and legibility of patient instructions, especially instructions regarding
22 medications, can be helpful in improving patient outcomes, and automated reminders and
23 information may increase patient compliance.
25 In addition, e-mail can allow for a more detailed and considered response to a patient's query than a
26 telephone call generally permits. Linking patients and physicians through e-mail also may increase
27 the involvement of patients in supervising and documenting their own health care, processes that
28 may contribute to improved health. Proponents note that computerized prescription writing has the
29 potential to reduce errors by preventing a physician’s handwriting from being misread.
30 Computerized drug references also increase the likelihood of patients receiving proper dosages, as
31 well as preventing side effects and dangerous drug interactions. Electronic clinical decision
32 support systems assist with diagnosis and treatment, alerting physicians to clinical guidelines.
34 AMA policy supports the need for cooperation among all sectors of the health care industry to
35 design, carry out, and analyze the results of scientifically rigorous studies to measure the benefits
36 (in effectiveness and quality of care, and in efficiency and costs of its provision) and the costs (in
37 time use, behavioral, and organizational change, as well as in monetary costs) of physician use of
38 computers in all health care settings (Policies H-405.971 and H-480.974). Policy H-405.982
39 states that the AMA will develop appropriate strategies to foster the identification and continuing
40 development of activities designed to make the computer a useful tool for creating a more efficient
41 work environment for the physician, while at the same time improving patient care.
43 Increased Efficiency and Decreased Administrative Costs
45 Medical care online may result in increased office efficiency and reduced administrative costs.
46 Currently, office staff conduct most transactions on the telephone or by paper, which can be time-
47 consuming. The Web site’s ability to route incoming messages to the right person may reduce
CMS Rep.4 – A 01 – page 5
1 routine phone traffic and other assaults on practice productivity. Given the flexibility afforded by
2 connectivity, the patient could be given the option of receiving automated responses to certain
3 routine queries. The electronic interface also can passively encourage brevity by offering only a
4 small window for text entry, thereby suggesting the appropriate length of a message. In addition,
5 information can be retrieved or messages sent and read, at times convenient for the retriever. The
6 sender does not have to be available simultaneously with the reader, which may result in more
7 timely responses. It should be noted, however, that electronic communication with patients may
8 require the addition of staff to respond to e-mail messages.
10 E-mail also may result in fewer office visits, and visits may be more productive when patients do
11 need to be seen. For example, patients who regularly record blood pressure or blood glucose levels
12 at home can e-mail their reading logs to their physician before appointments. Time spent
13 communicating electronically with patients may prevent the unnecessary utilization of health
14 services -- a potential advantage for physicians with large populations of capitated patients.
15 Medical care online, therefore, has the potential to allow physicians and their staffs to respond to
16 the daily needs of many patients electronically, freeing precious time for physicians to interact with
17 those who require a more intimate level of care.
19 POTENTIAL DRAWBACKS OF MEDICAL CARE ONLINE
21 Decreased Face-to-Face Care
23 Critics cite the danger of losing essential benefits of the patient-physician relationship if e-mail
24 takes the place of some face-to-face interactions. E-mail exchanges lack context, so the multiple
25 clues during a direct patient encounter can be lost if online care is inappropriately substituted for
26 face-to-face care. Many physicians also have been quite reluctant to diagnose and prescribe by
27 telephone, due in large part to liability concerns, and they are likely to be even less willing to do so
28 by e-mail.
30 Liability Concerns
32 Use of electronic communication in medicine implicates a number of legal issues, including, but
33 not limited to, a patient's right to informed consent, the components of a medical record, a
34 physician’s duty of confidentiality, state licensing, and product endorsement. Previously
35 mentioned Policy H-478.997, which provides guidelines for patient-physician e-mail, includes the
36 development of a patient-physician agreement for informed consent for the use of e-mail. The
37 guidelines state that this agreement should be discussed with the patient and documented in the
38 medical record. Most jurisdictions also require physicians to maintain appropriate medical records
39 and most states define a medical record in broad terms. Guidelines developed by the American
40 Medical Informatics Association (AMIA) for the clinical use of e-mail with patients state that
41 patients should be made aware that e-mail messages will be included as part of the medical record.
42 In addition, appropriate privacy and security safeguards for digital information storage must be
43 carefully maintained, particularly when a third party audits a practice.
45 If the degree of e-mail interactivity is sufficient to create a patient-physician relationship, it then
46 becomes important for the physician to ensure that the patient to whom advice is given resides in
47 the same state in which the physician is medically licensed. Otherwise, the physician may be at
CMS Rep.4 – A 01 – page 6
1 risk for illegally practicing medicine in a jurisdiction in which he or she does not hold a license to
2 practice. In addition, providing links to other Web sites may imply an endorsement of the service,
3 information, or products found on the linked site. This is particularly problematic because the
4 content of a Web site can be constantly altered or updated, making monitoring of its contents
5 difficult. A physician’s e-mail messages also are legally discoverable and, therefore, can be used
6 against him or her in a professional liability case. However, proponents of electronic patient-
7 physician communication counter that because e-mail exchanges, when stored and filed in the
8 patient’s record, provide a self-documenting trail, they are more likely to come to a physician’s
9 defense in a lawsuit. Proponents contrast this with the poor documentation that frequently
10 accompanies telephone transactions.
12 Furthermore, professional liability insurance applications usually require the applicant to set forth
13 the location or locations of the medical practice in order to be insured. This provides full
14 disclosure to the insurer and affords the company’s underwriters an opportunity to assess the risk
15 associated with the jurisdiction involved. Professional liability underwriters may determine that
16 the risks of practicing in one state are different than in another due, in part, to differences in
17 statutes of limitations, rules of procedure and evidence, existence or absence of professional
18 liability damage caps, and the scope of medical practice acts. Insurers also are normally required
19 to be licensed to offer insurance in each state in which they conduct business. Covering a claim for
20 an incident in a jurisdiction that was not previously disclosed may, therefore, present a serious
21 problem for the insurer. It should be noted that final federal privacy and pending security rules,
22 pursuant to HIPAA, have the potential to significantly impact patient-physician electronic
25 AMA policy supports exemption from state licensure requirements for telemedicine practiced
26 across state lines in the event of an emergent or urgent circumstance, the definition of which for the
27 purposes of telemedicine should show substantial deference to the judgment of the attending and
28 consulting physicians as well as to the views of the patient (Policy H-480.969[1c]). Policy H-
29 480.974 states that the AMA will work with the Federation of State Medical Boards and the
30 state and territorial licensing boards to develop licensure guidelines for telemedicine practiced
31 across state boundaries.
33 Physician Time Constraints
35 Many physicians considering communicating electronically with their patients, understandably,
36 fear that such communication will place additional demands on their already busy schedules.
37 Specifically, they raise concerns that they are likely to become overwhelmed by the volume of e-
38 mails they receive, particularly if patients attempt to substitute office visits for the convenience of
39 free e-mail exchanges. Critics also note that e-mail requires continual monitoring and that patients
40 are likely to demand immediate responses to their messages. Previously mentioned Policy H-
41 478.997, which provides guidelines for patient-physician e-mail, attempts to address this by
42 including the establishment of a turnaround time for messages. While a study published in the
43 October 21, 1998, issue of JAMA found that the time required for clinicians to read and respond to
44 incoming queries was not overly burdensome, more patients currently utilize e-mail than when this
45 study was conducted. In March 2001, the University of Michigan initiated a study to measure the
46 effects of electronic patient communication on practice efficiency, accuracy, and satisfaction for
47 both physicians and patients.
CMS Rep.4 – A 01 – page 7
1 ADDITIONAL INCENTIVES AND OBSTACLES TO MEDICAL CARE ONLINE
5 Patient demand for having portions of their medical care managed online will likely serve as an
6 incentive for physicians to provide such services. This demand also is not likely to abate as
7 members of the “baby boom” generation, the oldest of whom are now approaching their mid-50s
8 and who are more technologically savvy than the generation that precedes them, begin to require
9 more medical services. Since physicians are increasingly being judged by patients' satisfaction
10 with their health care experiences, proponents contend that it makes good sense to offer services
11 that work towards that end. In addition, the high rate of computer literacy among young and future
12 physicians is likely to increase the degree to which physicians manage medical care online in the
13 future. Finally, employers may place increasing pressure on health care organizations to deliver
14 certain medical services online. For example, approximately 60 companies, including General
15 Motors Corp. and Boeing Co., formed the Leapfrog Group to mobilize employer purchasing power
16 to initiate improvements in the safety and value of health care. Members of the group favor
17 medical plans in which the hospitals use special computerized systems for medical reports and
22 A major obstacle to physicians managing medical care online is that, like telephone transactions,
23 few insurers compensate physicians specifically for e-mail use. Clearly, paying physicians for “e-
24 visits,” as the Downers Grove, Illinois-based national health benefits company, First Health,
25 decided to do as of January 2001, is likely to hasten physicians corresponding electronically with
26 their patients. First Health, which has more than 270,000 member physicians, 7.7 million
27 enrollees, and counts many of the nation’s largest employers as clients, pays physicians
28 approximately $25 for what it terms “structured Internet visits.” Initially, the program will be
29 available only to the patients enrolled in First Health’s chronic disease programs. The e-visit
30 program will be offered first to patients with diabetes, asthma, depression, and three specified
31 cardiac conditions and to the physicians who treat them. Later, the program will be offered to
32 pregnant patients and those with HIV. The intercommunication must occur using First Health’s
33 Web server and meet certain criteria -- the patient must initiate the visit, actual clinical data must
34 be exchanged, and the patient and physician must agree that the visit is “completed” before a claim
35 is generated. It should be noted, however, that concerns have been raised regarding the privacy and
36 confidentiality of patient medical information transmitted on Web sites like First Health.
38 Sufficient technical support and the costs associated with that support also may serve as barriers to
39 physicians managing medical care online. This may explain the disparity between the number of
40 physicians in large group practices who currently e-mail their patients, compared to the number
41 who e-mail their patients in practices with 50 or less physicians. Many groups are developing
42 online capacities to conduct day-to-day administrative and business functions using the group or
43 health plan as the organizer and the source of funds. In addition, poorer and less educated
44 Americans, who suffer higher rates of disease, are less likely to have access to computers and the
45 Internet. According to a February 2001 report by the Pew Internet & American Life Project, 82%
46 of those living in households with more than $75,000 in income now have Internet access,
47 compared to 38% of households earning less than $30,000. However, those at the lower end of the
CMS Rep.4 – A 01 – page 8
1 economic scale are coming online relatively rapidly -- only 28% of those in lower-income
2 households were online in May-June 2000.
4 Medical care online also is largely inaccessible to patients with limited literacy skills. According
5 to the 1992 National Adult Literacy Survey, 40 to 44 million Americans, or approximately one-
6 quarter of the US population, are functionally illiterate and another 50 million have marginal
7 literacy skills. AMA policy recognizes limited patient literacy as a barrier to effective medical
8 diagnosis and treatment (Policy H-160.931). Policy H-160.931 states that the AMA will
9 work to make the health care community aware of the number of adults who have limited literacy
10 and difficulty understanding both oral and written health care information. In addition, electronic
11 communications may not facilitate physicians delivering culturally competent care to patients,
12 including those with limited English proficiency. Policy H-295.897 directs the AMA to engage in
13 series of activities to enhance the cultural competence of physicians. Finally, as the
14 aforementioned survey results suggest, older physicians may have less facility using computers
15 than their younger counterparts and, therefore, may be reluctant to manage medical care online.
16 Policy H-480.971 states that the AMA will work, in cooperation with state and specialty
17 associations, to bring computer education and information to physicians.
19 It should be noted that the AMA has established an extensive policy base related to the privacy and
20 confidentiality of patient medical information. In the last few years, the House of Delegates
21 adopted a series of reports that outline and clarify AMA policy on this issue (Policies H-315.983,
22 H-60.965, H-315.978, H-460.919, and H-140.927). Most notably, Policy H-315.983 outlines key
23 principles to evaluate any proposal regarding privacy and confidentiality of medical information.
24 The AMA also has drafted model state legislation to establish safeguards for maintaining the
25 confidentiality, security, and integrity of health care information. In addition, the AMA has sought
26 modifications to proposed federal rules, pursuant to HIPAA, to adequately protect patient
27 confidentiality and privacy, without substantially increasing administrative burdens for physicians.
29 AMA e-HEALTH INITIATIVES
31 The AMA has implemented a number of e-health initiatives, including, but not limited to, Your
32 Practice Online, the Internet Health Road Show, and the AMA Internet ID. Established in October
33 1999 by seven national medical societies, including the AMA, Medem offers physician members of
34 affiliated societies the opportunity to build a free Web site with Your Practice Online. The Your
35 Practice Online service allows physicians to build their own personalized sites with clinical
36 information from partner medical societies, as well as from their own practices. At the time that
37 this report was written, 25 medical societies had partnered with Medem and nearly 22,000
38 physicians had built their own Your Practice Online Web sites. It should be noted that Medem, in
39 collaboration with more than 30 malpractice carriers and a dozen of the nation’s medical societies,
40 created the eRisk Working Group for Healthcare, along with a series of documents to help guide
41 patient-physician communications on the Internet. One such document, “eRisk for Providers,”
42 from March 2001 recommends that providers develop and maintain a staff policy that includes
43 procedures to incorporate copies or printouts of provider-patient online messages into the existing
44 medical record. The document also advises providers to store copies or printouts of the electronic
45 messages in a manner that is consistent, in terms of information security and confidentiality
46 protections, with their treatment of medical records.
CMS Rep.4 – A 01 – page 9
1 In addition, the AMA, Intel Corporation, and Medem have collaborated to create the Internet
2 Health Road Show. This one-day course provides participating physicians with the opportunity to
3 learn from leaders in medicine and technology what Internet tools are currently available to
4 physicians and patients and the latest cutting-edge Internet health care technology. The AMA and
5 VeriSign Inc. also have collaborated to provide AMA Internet IDs to physicians for use on the
6 Internet. AMA Internet IDs uniquely identify physicians over the Internet and provide a more
7 reliable authentication technique than passwords for secure Internet transactions. AMA Internet
8 IDs also protect physician and patient privacy and confidentiality whenever online medical
9 information is sent or received. At the time that this report was written, the AMA had issued more
10 than 800 AMA Internet IDs to physicians since December 2000.
14 The introduction of the telephone into medical practice in the last decades of the 19th century was
15 greeted with both celebration and trepidation. Invented in 1876 by Alexander Graham Bell, the
16 telephone was commercially introduced in the late 1870s. It was not until World War I, however,
17 that the telephone became a common utility. Although some physicians heralded the advantages of
18 efficiency and accessibility that the telephone provided, others expressed concerns about being
19 overwhelmed by patients seeking over-the-telephone care, the safety of telephone diagnosis, and
20 problems of privacy. By the mid-1920s, however, the telephone was fully integrated into physician
21 practice, as it was in broader society. The telephone had become a mandatory medical technology,
22 as central to practice as the stethoscope and sphygmomanometer.
24 The Council believes that medicine is again on the threshold of a dramatic expansion in
25 communications technology that is likely to have profound effects on how physicians practice
26 medicine, the quality of medical care that patients receive, and the patient-physician relationship.
27 However, the Council believes that new communication technologies must never replace the
28 crucial interpersonal contacts that are the very basis of the patient-physician relationship. Rather,
29 e-mail and other forms of electronic communications should be used to enhance such contacts.
31 The Council also believes that it is important to distinguish between electronic communication
32 within an existing patient-physician relationship and communication between physicians and
33 consumers in which no ongoing professional relationship exists. Physicians who participate in
34 online discussion groups or public support forums, for example, must avoid the appearance of
35 creating a professional relationship or the rendering of medical advice within the parameters of the
36 patient-physician relationship. In the event a court finds the patient-physician relationship to exist,
37 the dynamics of the resulting legal responsibilities change considerably.
39 As previously noted, most jurisdictions require physicians to maintain appropriate medical records
40 and most states define a medical record in broad terms. The Council believes, therefore, that,
41 consistent with AMIA and eRisk Working Group for Healthcare guidelines, e-mail messages
42 should be stored electronically or printed in hard copy and placed in a patient's medical record.
43 Indeed, there is no advantage to simply deleting e-mail messages, as even deleted messages are
44 recoverable and legally discoverable.
46 In addition, the Council believes that it is imperative for patients to be reminded of the importance
47 of security and that they avoid using e-mail in cases of an emergency. To that end, the Council
CMS Rep.4 – A 01 – page 10
1 believes that a standard block of text should be appended to the end of e-mail messages to patients,
2 which contains the physician’s full name, contact information, and a reminders about security and
3 the importance of alternative forms of communication for emergencies. The Council also is
4 concerned that e-mail not be inappropriately substituted for face-to-face care and that physicians
5 not become overwhelmed by the volume of messages they receive. The Council believes,
6 therefore, that physicians should explain to patients that their messages should be concise and when
7 e-mail messages become too lengthy or the correspondence is prolonged, physicians should notify
8 patients to come in to discuss or call them. Patients also should be reminded when they do not
9 adhere to agreed upon e-mail guidelines. For patients who repeatedly fail to adhere to such
10 guidelines, it is acceptable for the physician to terminate the e-mail relationship. In addition,
11 patients should sign the agreement to acknowledge their acceptance of its terms and should receive
12 a copy for future reference. The Council recommends that Policy H-478.997, which provides
13 guidelines for patient-physician e-mail, be modified accordingly.
15 Furthermore, the Council believes that the AMA should develop guidelines to assist physicians in
16 using the Internet for legitimate electronic prescribing of pharmaceuticals for established patients.
17 Such purposes include the computer order entry and online transmission of prescriptions, ordering
18 refills -- either patient to pharmacy or physician to pharmacy, and electronic consults between
19 physicians and patients where the outcome is an ordered prescription. In addition, the Council
20 believes that the AMA should support efforts to bridge the “digital divide” by supporting efforts to
21 address the economic, literacy, and cultural barriers to patients utilizing information technology.
22 To ensure coverage, the Council also recommends that physicians advise their professional liability
23 insurers about the practice-related activities in which they are engaged, including the use or
24 sponsorship of Web sites, e-mail, Internet discussion groups, and mailing lists.
26 Although the AMA published a book in 1999 that discusses the legal issues associated with using
27 the Internet for health information, the Council believes that the AMA should continue to fully
28 examine these issues and make this information available to physicians. This will be particularly
29 important in assisting physicians in achieving compliance with federal rules pursuant to HIPAA.
30 Medical care online poses a number of challenges to physicians in fulfilling their duty of
31 confidentiality and to patients in protecting the confidentiality of their medical information. The
32 Council also notes its concern regarding the degree to which medical care online enables others --
33 outside the traditional patient-physician relationship -- to access a patient’s medical information.
34 Finally, the Council recognizes that HIPAA regulations, combined with technological advances
35 such as secure messaging and digital certificates, may necessitate modifying Policy H-160.933,
36 which opposes the transmission of test results via e-mail.
40 The Council on Medical Service recommends that the following be adopted and the remainder of
41 the report be filed:
43 1. That the AMA modify Policy H-478.997 by addition and deletion to read as follows: “New
44 communication technologies must never replace the crucial interpersonal contacts that are the
45 very basis of the patient-physician relationship. Rather, electronic mail and other forms of
46 Internet communication should be used to enhance such contacts. Patient-physician electronic
47 mail is defined as computer-based communication between physicians and patients within a
CMS Rep.4 – A 01 – page 11
1 professional relationship, in which the physician has taken on an explicit measure of
2 responsibility for the patient’s care. These guidelines do not address communication between
3 physicians and consumers in which no ongoing professional relationship exists, as in an online
4 discussion group or a public support forum. (1) For those physicians who choose to utilize e-
5 mail for selected patient and medical practice communications, the following guidelines be
8 Communication Guidelines:
10 (a) Establish turnaround time for messages. Exercise caution when using e-mail for urgent
11 matters. (b) Inform patient about privacy issues. Patients should know: (c) Who besides
12 addressee processes messages during addressee’s usual business hours and during addressee’s
13 vacation or illness; and (d) That the message may be included as part of the medical record, at
14 the discretion of the physician. Whenever possible, electronic and/or paper copies of patient e-
15 mails and corresponding responses will be retained as parts of the patient’s medical record. (e)
16 Establish types of transactions (prescription refill, appointment scheduling, etc.) and sensitivity
17 of subject matter (HIV, mental health, etc.) permitted over e-mail. (f) Instruct patients to put
18 the category of transaction in the subject line of the message for filtering: prescription,
19 appointment, medical advice, billing question. (g) Request that patients put their name and
20 patient identification number in the body of the message. (h) Configure automatic reply to
21 acknowledge receipt of messages. (i) Send a new message to inform patient of completion of
22 request. (j) Request that patients use autoreply feature to acknowledge reading clinicians
23 message. (k) Develop archival and retrieval mechanisms. (l) Maintain a mailing list of patients,
24 but do not send group mailings where recipients are visible to each other. Use blind copy
25 feature in software. (m) Avoid anger, sarcasm, harsh criticism, and libelous references to third
26 parties in messages. (n) Append a standard block of text to the end of e-mail messages to
27 patients, which contains the physician’s full name, contact information, and reminders about
28 security and the importance of alternative forms of communication for emergencies. (o)
29 Explain to patients that their messages should be concise. (p) When e-mail messages become
30 too lengthy or the correspondence is prolonged, notify patients to come in to discuss or call
31 them. (q) Remind patients when they do not adhere to the guidelines. (r) For patients who
32 repeatedly do not adhere to the guidelines, it is acceptable to terminate the e-mail relationship.
34 Medicolegal and Administrative Guidelines:
36 (a) Develop a patient-clinician agreement for the informed consent for the use of e-mail. This
37 should be discussed with and signed by the patient and documented in the medical record.
38 Provide patients with a copy of the agreement. Agreement should contain the following: (b)
39 Terms in communication guidelines (stated above). (c) Provide instructions for when and how
40 to convert to phone calls and office visits. (d) Describe security mechanisms in place. (e) Hold
41 harmless the health care institution for information loss due to technical failures. (f) Waive
42 encryption requirement, if any, at patient’s insistence. (g) Describe security mechanisms in
43 place including: (h) Using a password-protected screen saver for all desktop workstations in
44 the office, hospital, and at home. (i) Never forwarding patient-identifiable information to a
45 third party without the patient’s express permission. (j) Never using patient’s e-mail address in
46 a marketing scheme. (k) Not sharing professional e-mail accounts with family members. (l)
47 Not using unencrypted wireless communications with patient-identifiable information. (m)
CMS Rep.4 – A 01 – page 12
1 Double-checking all "To" fields prior to sending messages. (n) Perform at least weekly
2 backups of e-mail onto long-term storage. Define long-term as the term applicable to paper
3 records. (o) Commit policy decisions to writing and electronic form.
5 (2) The policies and procedures for e-mail be communicated to all patients who desire to
6 communicate electronically.
8 (3) The policies and procedures for e-mail be applied to facsimile communications, where
9 appropriate.” (Modify Current HOD Policy)
11 2. That the AMA develop guidelines to assist physicians in using the Internet for legitimate
12 electronic prescribing of pharmaceuticals for established patients. (Directive to Take Action)
14 3. That it is the policy of the AMA to support efforts to address the economic, literacy, and
15 cultural barriers to patients utilizing information technology. (New HOD Policy)
17 4. That the AMA educate the physicians to be aware of clauses in their professional liability
18 insurance coverage which may require them to report changes or additions to their practice-
19 related activities, including the use or sponsorship of Web sites, e-mail, Internet discussion
20 groups, and mailing lists. (Directive to Take Action)
22 5. That the AMA continue to examine the legal issues associated with medical care online and
23 make the results of this examination available to physicians. (Directive to Take Action)
References used in this report are available from the AMA Division of Socioeconomic Policy