E-mail consultation: clinical, financial, legal, and ethical implications

doi:10.1016/j.surneu.2003.09.029

Surgical Neurology

Volume 61, Issue 5, May 2004, Pages 455-459

https://doi.org/10.1016/j.surneu.2003.09.029 Get rights and content

Abstract

Background

Communication via e-mail has become widespread. Nearly every practicing neurosurgeon is confronted with numerous unsolicited e-mail requests for medical advice, guidance, or information. Neurosurgeons need to be aware of the clinical, financial, legal, and ethical implications of providing medical consultation via e-mail.

Methods

A literature review of the penetration of e-mail consultation in medical practice was performed. The data on the potential for reimbursement for provision of these services is presented. Precedents for legal liability are discussed, and issues of compliance with HIPAA regulations are reviewed.

Results

Communication between patients and physicians via e-mail is increasing in prevalence, and a substantial number of physicians are providing medical information via e-mail consultation. Billing for online consultation has been approved by the American Medical Association, and several medical insurance carriers are evaluating the economic consequences of reimbursement for e-mail consultation.

E-mail consultation raises potential medico-legal concerns, including establishment of the physician-patient relationship, malpractice liability, and HIPAA compliance.

Conclusions

The increasing prevalence of e-mail consultation raises new concerns for neurosurgeons. Some of these concerns have yet to be addressed by regulatory commissions or in the courts. If used appropriately, e-mail communication can facilitate physician-patient interactions, improve access to care, save time for each interaction, and possibly reduce costs of care.

Section snippets

The penetration of e-mail consultation into medical practice

The past decade has seen an explosion in the access to and use of e-mail through the Internet and the World Wide Web. One published survey has estimated that by September 2002, more than 600 million persons worldwide had Internet access, with the majority in the United States, Western Europe, and Japan. In the United States, more than50% of the population uses the Internet [9]. Two studies published in 1994 demonstrated that approximately 25% of patients were already using e-mail to communicate

Billing and reimbursement for e-mail consultation

Physicians frequently express concern that with improved ease of access to providers, physicians will be overwhelmed by patients requesting e-mail evaluation and diagnosis, and that this will increase their work hours, and decrease the revenues that would have been generated by office visits. However, some physicians view e-mail consultation as an opportunity and have been actively seeking to set up computer-based consultation systems in their offices. Several companies have developed aid in

Medical-legal concerns

There are a number of legal issues which are raised by the e-mail relationship between physician and patient. Although there have been a few lawsuits involving care given via online consultation, many issues have yet to be addressed by the courts. The eRisk Working Group for Healthcare is a consortium of professional liability carriers, medical societies and state board representatives, which aims to provide guidelines for physicians regarding e-mail consultations. The first question that needs

Online physician-patient relationship

The question that naturally follows is what constitutes an intention to treat, and therefore establishes the physician-patient relationship? Establishing the physician-patient relationship requires the same elements regardless of whether it takes place in person, on the telephone, or via e-mail. The duty of a physician toward a patient is not automatic, but is established by a consensual arrangement whereby the patient seeks the assistance of a physician and the physician knowingly accepts the

E-mail curbside consultations

A related issue arises in the situation where one physician communicates with another via e-mail for a “curbside consultation” regarding a patient the consultant physician has never seen or examined. The patient under discussion usually has no knowledge of the interaction, and most courts have upheld that face-to-face curbside consultations do not establish a physician-patient relationship [15]. The Illinois Court of Appeals upheld that a telephone curbside consultation between physicians did

E-mail malpractice

The foundation for any medical malpractice claim is the duty owed by the physician to the patient. Once a physician-patient relationship is acknowledged to exist via e-mail exchange, the physician is obligated to adhere to the standard of care regarding interaction with the patient. A patient seeking e-mail consultation may impart varying degrees of detail, varying degrees of accuracy, and may demonstrate varying degrees of understanding of the physician's recommendations. It remains to be

Interstate e-mail consultation

Regardless of whether the traditional legal elements of a malpractice claim are satisfied in any e-mail exchange, there are other considerations that may pose challenges for the physician. Offering medical advice or establishing a physician-patient relationship via e-mail with an out-of-state patient may be seen as practicing medicine without a license in the state in which the patient resides, unless the physician carries a valid license in that jurisdiction [3]. Such violations carry serious

Online privacy and HIPAA compliance

Security and confidentiality of private medical information is a particular concern in e-mail consultation. Even for private individual e-mail accounts, the electronic message itself is stored on a server to which the user connects to access messages. Internet service providers retain a record of the interaction, including the content of the message [12]. Patients and physicians who use e-mail in the workplace are not assured of confidentiality and may expose sensitive medical details to an

The future of e-mail consultation

A number of challenges remain to be addressed regarding the use of patient-physician e-mail consultation in clinical practice. Financial concerns are whether this will prove to be a cost-effective means of communication between patient and physician, and whether this will be reimbursed by the patients or their insurers. Legal concerns exist regarding the definition of the physician-patient relationship, adherence to the standard of care, state licensure, and professional liability coverage.

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TechnologyE-mail consultation: clinical, financial, legal, and ethical implications