Secure e-messaging between patients and their doctors

Electronic communication between clinicians and patients is central to the use of Electronic Health Records (EHRs). Several Meaningful Use criteria relate to providing patients with an electronic copy of their health records in a timely fashion.

However, simply making a view of health information is a one-way method of communication. Increasingly, patients want the ability to have secure, two-way conversations with their doctors, and providing this capability will be a likely requirement for mature EHRs in the future.

The technical issues of creating such a two-way secure portal for email-like conversation is not really the roadblock here. Several companies have had secure web-based portals for doctor-patient messaging for a number of years – and similar two-way communication using the Practice Fusion PHR (Patient Fusion) is part of the vision for expanded use of our PHR.

The real issues voiced by physicians around this are a little broader, however. The concerns tend to be grouped into the following kinds of questions:

Who controls the channel?
One of the fears of clinicians is getting bombarded by messages from patients without the ability to turn the channel off. Recognizing this concern, one of the paradigms for enabling such secure emails with patients is for a patient to request permission from the clinicians to enroll in e-messaging; the clinician needs to explicitly grand permission (and can set what kinds of messages can be accepted). The clinician can also turn off a permission with a specific patient, if needs be.

What is the malpractice liability with health e-messaging?
Malpractice carriers generally prefer to have communications with patients well-documented, and secure e-messaging provides better documentation than recollection of phone calls (and their documentation by the clinician in the chart).

The bigger issue is clearly identifying what kinds of medical issues are appropriate for e-messages. Given that such messages may only be reviewed once a day (or less often), messages for urgent concerns should be conveyed with more-immediate methods (like a phone call, or even calling 911, as most clinician voice-mail messages include). Only non-urgent messages should go through e-messaging – therefore, the system should clearly state somewhere in the patient logon process what kinds of messages are appropriate for this channel, and what kinds are not.

In my own experience in using secure patient e-messaging, the kinds of messages that come through this channel are (1) “what were my lab test results,” (2) “I need a refill,” (3) “I’ve had these symptoms (described), and don’t know if I should come in, or if you can simply send in an Rx for me.” Certainly, the list can go on to considerable length, but these seem to be the most common kinds of things.

Secure e-messages are a substitute for phone calls to the office, and effective use of this should reduce the phone burden to a practice.

One more place to look…
If an e-messaging platform is separate from an EHR, then it adds to workload tedium, rather than improve it. It is simply “one more place to look” for patient data (in addition to in-EHR messages from staff about patient calls). And, if they are disconnected systems, then there is the issue of double-entry – responding to the e-message within that system, and somehow making a reference to that message within the EHR.

That is why, in our view, embedding an e-messaging system within the connected EHR-PHR system makes the most sense. A message from a patient should allow the clinician to quickly open that patient’s chart in order to respond, and capture the message thread within the patient’s chart automatically.

I’m not being paid for this
A more fundamental concern is that e-messaging represents clinical work and medical opinion-giving (with its malpractice liability risk) that is uncompensated in a classic fee-for-service environment. Fee-for-service typically only rewards (pays for) face-to-face interactions between clinicians and patients, and (even though there are CPT codes for alternative forms of service) payment for alternative engagements are slow in coming.

However, as compensation models evolve into ones that reward performance and population management – Patient Centered Medical Homes (on a practice level) and Accountable Care Organizations (on a group level) – the use of more efficient ways of delivering health care, which do not necessarily involve face-to-face interactions (and all the disruption to a patient’s daily schedule that is involved with doctor’s office visits), will make use of e-messaging as more of a center-stage activity than has been in the past.

Secure e-messaging is a tool in healthcare that will become increasingly commonly used. The technological issues of granting permissions, maintaining security of the communication, and integrating this into the ordinary workflows of an office-based EHR are being addressed in ways that minimize the burden and enhance satisfaction on both ends of the line. The healthcare organization (payment) changes needed to reward the use of such emerging technologies are starting to unfold as well – though there is still a ways to go. Over the next few years, e-messaging will become a mainstream tool that patients and clinicians will come to expect.