American College of Physicians Ethical Guidance for Electronic Patient-Physician Communication: Aligning Expectations

Abstract

Communication is critical to strong patient-physician relationships and high-quality health care. In recent years, advances in health information technology have altered how patients and doctors interact and communicate. Increasingly, e-communication outside of in-person clinical encounters occurs in many ways, including through e-mail, patient-portals, texting, and messaging applications. This American College of Physicians (ACP) position paper provides ethics and professionalism guidance for these forms of e-communication to help maintain trust in patient-physician relationships and the profession and alignment between patient and physician expectations.

INTRODUCTION

How patients and doctors interact has changed as electronic communication (e-communication) has become commonplace.^{1, 2} While e-communication has many benefits, including supporting the patient-physician relationship and increasing accessibility to enhance patient care,³ it must be used thoughtfully and effectively to ensure ethical and professionalism standards and trust in physicians and the profession are maintained. This position paper from the American College of Physicians (ACP) offers recommendations for navigating e-communication, focusing on ethics and professionalism in patient care; privacy and confidentiality; practice considerations; and alignment of patient and physician expectations. It examines e-mail, patient-portals, texting, and messaging applications between patient and physician—not telemedicine, telephone, video (i.e., synchronous) or other applications, or communication between clinicians.

Patient-physician e-communication can take many forms, with e-mail and patient-portal communication most common; less data exists about text and messaging application utilization.^{2, 4–7} Between 16-72% of physicians report e-mail communication with patients^{5, 6} with higher utilization in academic centers, larger practices, and primary care.⁴ With the rapid expansion of electronic health records (EHRs), patient-portals to enhance patient self-management and communication are increasingly being adopted.^{4, 8} As of 2015, approximately two-thirds of office-based physicians reported using EHRs with patient-portal capabilities, a more than 50% increase since 2013,¹ but substantial variability in physician portal usage by specialty remains.⁹ As e-communication becomes more commonplace, attention should be paid to potential gaps in communication, patient safety issues, confidentiality, and disparities arising from barriers to technology use.^{7, 10}

Published guidelines on patient-clinician e-communication from the American Medical Informatics Association (AMIA), the Federation of State Medical Boards (FSMB) and the American Medical Association (AMA) focus on technical and administrative issues.^10–12 Most predate widespread portal adoption and may not reflect current technology use in clinical practice.^{10, 11} ACP has explored changing technologies and the patient-physician relationship in earlier papers on online professionalism and social media,⁷ telemedicine,¹³ and EHR ethics.¹⁴ This paper expands on those works.

For a summary of ACP positions and recommendations, see Table 1.

Table 1.

ACP Recommendations for Electronic Communication Between Patients and Physicians

ACP Position/recommendation	Actions	Rationale
1. Electronic communication can supplement in-person interactions between patient and physician	• Communicate electronically with patients who have established care in person and maintain an ongoing in-person relationship • Be aware of local laws and institutional policies regarding the use of electronic communications	• E-communication should only occur within an established patient-physician relationship to ensure adherence to professional standards • Regulations pertaining to e-communication and consultation vary by state
2. Electronic communication should only take place after discussion with the patient about expectations and appropriate uses, and with the patient’s consent	• Discuss risks, benefits, and expectations with patients. Patients should consent to use • Share a printed or electronic copy of your practice or institution’s policies and procedures with your patients • Know and follow your practice or institution’s communication, medicolegal, and administrative guidelines	• Try to align patient and physician expectations for communication (i.e., response time for messages, appropriate topics) • Patients should be aware of clinic policies • Adherence to policies may also minimize liability concerns
3. E-communications with patients should occur through a method that is patient-centered and secure such as patient-portals	• Respond to e-mail correspondence with a request that the patient sign up for the portal and include a brief rationale for why portals enhance e-communication	• Portals are preferred over e-mail due to enhanced security, documentation, and workflow capabilities and for HIPAA (Health Insurance Portability and Accountability Act) compliance
4. All electronic communications should be documented in the medical record	• E-communication should be uploaded into the EHR	• Ensure accurate documentation of medical care provided via e-communication • Complete records enhance care
5. Clinical and ethical standards for relationships should be applied to electronic communication contexts	• Do not disclose personal elements in professional communication • Consistently apply clinical standards and ethical principles for maintaining the relationship, trust in the profession, confidentiality, privacy, and respect for persons to online settings and communications • Use clinical judgment in what is discussed via e-communication, for example, do not discuss sensitive test results (i.e., HIV results) or break bad news	• Keep professional and social spheres separate • Professionalism applies in all settings
6. Electronic communication between patients and their physicians, if done with attention to ethical and other concerns, may help improve patient care, patient satisfaction, and clinical outcomes	• Use e-communication (i.e., reminders, etc.)to manage chronic conditions (i.e., hypertension, diabetes, etc.) between in-person visits	• Some preliminary studies suggest that patient-portals may be a promising tool to help patients with disease management
7. Physicians and institutions should use electronic communication to promote health equity and proactively address the socioeconomic and demographic factors that may lead to disparities in uptake and utilization	• Promote health equity by encouraging patients to engage in portal use across all age, race and ethnic groups, with focused efforts on patient populations with low uptake and utilization rates • Use mobile devices to reach underserved patient populations for portal enrollment to reduce disparities	• Portal enrollment and use are lower among lower socioeconomic, older, and rural patients • Black and Hispanic patients may be more likely to access portals on their mobile devices than non-Hispanic white users; mobile technology can be used to improve portal access
8. Health care institutions should have policies on electronic communication methods. Medical schools, training programs, and institutions should educate trainees, physicians, and clinical team members and physicians about principles of electronic patient-physician communications	• Train and educate physicians, trainees and all involved in patient care on appropriate and effective use of e-communication, including integration into clinical workflows	• Clinicians and trainees should be taught evidence-based skills and behaviors for and ethics of e-communication • Training on e-communication skills with opportunities for feedback and continuous practice improvement can improve patient care in the digital age
9. Physicians, institutions and patients should recognize and address increased workload associated with management of electronic communication and implications for physician well-being	• Align patient and physician expectations for e-communication • Implement team-based care approaches to manage increasing demands of e-communication and EHR workload • Consider workflow protocols that appropriately delegate tasks and best utilize the team (i.e., message triaging by nurses based on standardized policies)	• E-communication may significantly increase the volume of physician work • Patient and physician expectations about using e-communication methods may not align and should be explicitly discussed • Physician well-being concerns and burnout have been linked to burdens associated with EHR work

METHODS

This position paper was developed on behalf of the ACP Ethics, Professionalism and Human Rights Committee (EPHRC). Committee members abide by the ACP’s conflict-of-interest policy and procedures, and appointment to and procedures of the EPHRC are governed by the ACP’s bylaws.^{15, 16} After an environmental assessment to determine the scope of issues and literature reviews, the EPHRC evaluated and discussed several drafts of the paper; the paper was reviewed by members of the ACP Board of Governors, Board of Regents, Council of Resident/Fellow Members, Council of Student Members and other committees and experts. The paper was revised based on comments from these groups and individuals. The ACP Board of Regents reviewed and approved the paper on 3 November 2018.

POSITIONS

Position 1: Electronic Communication Can Supplement In-Person Interactions Between Patient and Physician

E-communication between patient and doctor can be an addition to an established patient-physician relationship, but should not take the place of in-person communications. It should strengthen, not impede, ongoing relationships grounded in interactions with “active listening and discussion, eye contact, and thorough physical examination” in building “therapeutic alliances”.¹⁴

Outside of cross-coverage, patient-physician e-communication should only occur within a patient-physician relationship that has been established in-person or through a valid telemedicine encounter¹³ to ensure standards of practice, confidentiality, ethics, and professionalism are upheld.⁷ This allows physicians to utilize clinical context, physical exams, and clinic conversations to advise patients.¹⁴ An individual who otherwise initiates e-communication for clinical advice should be advised to make an appointment or as appropriate, seek emergency care.⁷ Clinicians should be aware of institutional policies and laws and regulations on e-communication and consultation which may vary by state.¹⁰

In-person communication techniques (i.e., asking open-ended questions, providing frequent summaries, etc.) are not always directly transferrable to e-communication where the absence of in-person conversation, brevity, and non-verbal cues challenge assessment of understanding. While e-communication may enhance connectivity, time between and expectations for responses, potential typographical errors, or misinterpretation raise concerns. Secure e-communications may be most useful for making or canceling appointments; medication refills; raising brief questions; or “checking in” regarding current care (e.g., if the physician asks at a visit, “let me know if you are tolerating this new medication”). E-communication may result in a clinician suggesting a visit is needed when it pertains to a new condition or for questions raising lengthy discussions.

Position 2: Electronic Communication Should Only Take Place After Discussion with the Patient about Expectations and Appropriate Uses, and with the Patient’s Consent

Physicians and patients should review limitations, benefits, and risks and patient consent given prior to initiation of e-communication.⁷ They should set shared expectations, including about response time and appropriate uses¹¹; giving specific examples and clarifying how and urgent symptoms and emergencies should be handled would be helpful. Practices should communicate policies clearly, including that messages become part of the medical record and are viewed by other team members (e.g., nurses, front desk staff) who may assist in message triage.¹¹

Position 3: E-communications with Patients Should Occur Through a Method that Is Patient-Centered and Secure Such as Patient-Portals

ACP recommends secure patient-portals for e-communication for privacy, confidentiality, documentation, access, and workflow reasons. Portals can best ensure patient confidentiality and privacy. Confidentiality, rooted in respect for patient autonomy, applies in all medical settings and is critical to maintaining trust and strong relationships.¹⁷ Physicians should be aware of relevant state and federal law, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy rule and the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) when engaging in e-communication.

E-mail use can entail confidentiality risks, especially if a patient’s e-mail address is shared by multiple individuals or when passwords are not kept secured. Portal use is also superior to multimedia messaging services (MMS) and short message service (SMS) or text messaging services for patient-physician communication about clinical matters. Text messaging’s abbreviated format can lead to missed or misunderstood messages, and the logistical challenges of transferring text exchanges into the EHR and the risk of third-party access to the information are problematic.⁷ ACP/FSMB guidelines also note that “Physicians and patients should be discouraged from communicating on health matters through social media tools that are publicly viewable, do not ensure patient confidentiality and are not readily recordable or admissible to the medical record”.⁷ Physicians should maintain professional online boundaries; they also “should not ‘friend’ or contact patients through personal social media”.⁷

Physicians should consider responding to patient e-mails with requests that patients use the portal with a brief rationale for why portals enhance e-communication. Exceptions for patients who would be better served by secure e-mail or who face barriers accessing portals could be made.

Position 4: All Electronic Communications Should Be Documented in the Medical Record

Medical records must be accurate and complete, including about patient-physician communications.^{7, 14, 17} E-mail and text messaging also create additional work, necessitating transfer into the medical record¹¹ and expanding administrative work for physicians that may quickly become prohibitive for full-time primary care physicians who typically have a 1200–1900 patient panel.¹⁸ Portal use allows for automatic capture and saving of messages in the EHR.

Position 5: Clinical and Ethical Standards for Relationships Should Be Applied to Electronic Communication Contexts

The ACP Ethics Manual says physicians must act in the patient’s best interests and take care “to extend standards for maintaining professional relationships and confidentiality from the clinic to the online setting”.¹⁷ Physicians should keep their professional and social spheres and communications separate and “comport themselves professionally in both”.⁷

The AMA also states that when physicians e-communicate, “they hold the same ethical responsibilities to patients as they do during other clinical encounters”.¹² Clinicians should use clinical judgment to determine which topics are appropriate for e-communication or for in-person or phone communication (e.g., sensitive test results, breaking bad news).

Position 6: Electronic Communication Between Patients and Their Physicians, if Done with Attention to Ethical and Other Concerns, May Help Improve Patient Care, Patient Satisfaction, and Clinical Outcomes

E-communication has the potential to improve patient care, patient satisfaction and outcomes when used with attention to ethical guidance.⁷ Some preliminary studies showed that patients who consistently used the messaging feature in a patient-portal had better diabetes control than patients who did not,^{19, 20} and portal use was associated with improved outcomes for patients with hypertension²¹ and depression²²; however these studies looked at portal use in conjunction with case management.⁹ While more work is needed to understand the impact of portal messaging on clinical outcomes, initial studies suggest it may be a promising disease management tool.⁹

Position 7: Physicians and Institutions Should Use Electronic Communication to Promote Health Equity and Proactively Address the Socioeconomic and Demographic Factors that May Lead to Disparities in Uptake and Utilization

The ACP Ethics Manual states that, “The physician has a duty to promote patient understanding and should be aware of barriers, including health literacy issues for the patient”.¹⁷ While e-communication may become a tool to foster patient engagement through improved access, empowerment, and communication, concerns have been raised about the “digital divide” and differential uptake of technology among patient populations which may contribute to disparities in care.¹⁴

Patients who e-mail their physicians are twice as likely to have a college degree, are younger and less frequently ethnic minorities.²³ Portal enrollment and use are less prevalent among lower socioeconomic, older, and rural patients.²⁴ Black, Hispanic, and Asian patients have been found to have lower rates of portal enrollment/use compared with non-Hispanic white patients, even after adjusting for internet access and use, suggesting that other patient, physician, and system-level factors may be involved.^{9, 25–27} Interestingly, while enrolled Black and Hispanic patients are less likely to access the portal overall, a greater proportion accessed the portal with mobile devices.⁸ Given these findings, physicians and institutions can work to promote health equity by encouraging patients to engage in portal use across all age, race, and ethnic groups.

Position 8: Health Care Institutions Should Have Policies on Electronic Communication Methods. Medical Schools, Training Programs, and Institutions Should Educate Learners and Physicians About Principles of Electronic Patient-Physician Communication

Just as clinicians and trainees are taught skills and behaviors for in-person communication with patients, standards need further development for application to e-communication^{28, 29} Providing education and training on e-communication skills, social media behavior and etiquette and institutional policies for all involved in patient care with opportunities for feedback and continuous practice improvement can further optimize patient care in the digital age. More research is needed on how to effectively integrate e-communication into clinical workflows.

Position 9: Physicians, Institutions, and Patients Should Recognize and Address Increased Workload Associated with Management of Electronic Communication and Implications for Physician Well-being

Despite many advantages, e-communication has been found to increase the volume of physician work³⁰ and patient and physician may not share expectations about its use. E-communication can seem to patients to provide 24/7 access to physicians, but for the physician, this can be challenging to manage. Patients may not be aware of the number of patients in a practice and the amount of e-communication. Patients and physicians will need to work together to align appropriate expectations.

Physician well-being and burnout have been linked to burdens associated with EHR work.^{31, 32} To manage the increasing demands of the e-communication, team-based care approaches and new strategies for reimbursement are needed.³³ Institutions should consider workflow protocols and standardized policies to optimize team-based care management and triage of EHR work^{34, 35} (e.g., preapproved protocols for nurses to triage requests for refills, appointments, clinical concerns, etc.).³⁶

For general tips on patient-physician electronic communication, see Table 2.

Table 2.

General Tips for Patient-Physician Electronic Communication (Including E-mail and Portal Use)

Before initiation of e-communication	• Discuss risk, benefits, expectations and appropriate uses of e-communication • Discuss security, confidentiality and record keeping • Help ensure policies and procedures are clearly communicated with patients and practice shares a printed or electronic copy with patients • Clarify how urgent and emergent situations should be handled • If multiple electronic exchanges are needed or there is any confusion about the electronic message, an in-person or telephone consultation should be initiated • Patient consent to e-communicate should be documented in medical record if possible
Establish appropriate topics	• Prescription refill requests • Appointment requests • Short questions that can be answered briefly • Questions or updates about non-urgent clinical treatment matters (i.e., medication side effects, etc.) • Reporting health data for chronic disease management (i.e., blood pressure, blood sugars, etc.) • Inquiries about laboratory or study results
Establish inappropriate topics	• Clearly define urgent and emergent conditions that are not appropriate for e-communication (i.e., chest pain, shortness of breath, etc.) • Time-sensitive requests • Use clinical judgment in what is discussed • Set parameters for when to ask patient to come in for an office visit
Maintain professional standards	• Separate personal elements from professional communication • Avoid anger, sarcasm, jargon and disparaging comments as with any communication
Set expectations for responses	• Set clear expectations regarding turn-around time for responding to messages (i.e., between 2 and 3 business days) and whether messages are checked on weekends • Establish maximum turn-around times (e.g., 72 h) • Establish clear coverage plan for when physician is out of office • Establish that if patient does not receive response in timely fashion, patient should call clinic to discuss issue
Acknowledge receipt of message	• Acknowledge receipt of e-mail or portal messages and ask patients to acknowledge that they have read messages; this process may be automated through specific e-mail or portal functions
Security	• Patient information should not be shared over connections with inadequate security, which may include residential internet connections; use multifactor authentication to verify user identity when accessing portals or e-mail • Public unsecured wireless networks and cellular device networks are inherently publicly accessible and should not be used; access portals and e-mail through a work-based encrypted virtual private network when available to enhance security • Use a practice dedicated e-mail address that utilizes encryption software to secure messages
Clarify expectations for response	• Include a summary of when e-mail or portal messages will be answered and remind patients to seek immediate help for urgent matters • Set up automatic away message when on vacation or not checking portal messages or e-mail regularly with information on how to contact covering physician
E-mail specific communication tips*
Document e-mail communication in the EHR	• Relevant e-mail communication should be uploaded into the EHR to document the exchange
Encourage transition to patient-portal	• Respond to patient e-mail correspondence with a request for patient to sign up for the patient-portal and include a brief rationale for why portals enhance e-communication
Patient-portal Specific Communication Tips
Confidentiality	• Patients should know that messages will be included as part of their medical record and other members of care team (i.e., nurses, physician assistants, front desk staff) may read and assist in message triage
Other
Text messaging and social media	• Text messaging, multimedia messaging services (MMS) short message service (SMS), and social media applications should not be used for patient-physician communication about clinical matters

Acknowledgment: Some tips in this table were adapted from¹¹ Kane B, Sands DZ. Guidelines for the clinical use of electronic mail with patients. J Am Med Inform Assoc. 1998;5:104–11

*While we recommend patient-portals as the preferred method for e-communication for high-quality care, security, confidentiality, documentation, and workflow reasons, we recognize that physicians may continue to use e-mail to communicate with select patients

CONCLUSION

Patients and physicians increasingly e-communicate outside of in-person clinical encounters. Here, ACP provides guidance for e-communication to help maintain strong and trusted patient-physician relationships and alignment between patient and physician expectations. Recommendations may need revisiting as new technologies emerge.

E-communication is a powerful tool that when used appropriately and with attention to ethics and professionalism, has the potential to help improve quality, patient satisfaction, and patient access to health information and clinicians. It must be used with care, in facilitating the care of the patient.

*This paper, written by Wei Wei Lee, MD, MPH and Lois Snyder Sulmasy, JD was developed for the American College of Physicians Ethics, Professionalism and Human Rights Committee. Members of the 2018–2019 ACP Ethics, Professionalism and Human Rights Committee at the time the paper was approved by the Committee were: Thomas A. Bledsoe, MD (Chair); Omar T. Atiq, MD (Vice Chair); John B. Bundrick, MD; Betty Chang, MDCM, PhD; Lydia S. Dugdale, MD; Andrew Dunn, MD, MPH; LT COL Joshua D. Hartzell, MD, USA; Thomas S. Huddle, MD, PhD; Janet A. Jokela, MD, MPH; Diana Jung; Mark A. Levine, MD; Ana María López, MD, MPH; Neena Mohan, MD; and Paul S. Mueller, MD, MPH. Approved by the ACP Board of Regents on 3 November 2018.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.