Dr. Grohol, you frequently speak on the use of e-mail in clinical practice. Can you give us some guidelines for how we should most appropriately use e-mail with our patients?
The first thing I recommend is that physicians and therapists give a good amount of thought to their own boundaries around e-mail communication with patients. One of the crucial questions is, under what circumstances should patients e-mail you? Some clinicians limit e-mails to administrative issues, such as appointments and prescription refills. Others allow patients to ask significant questions about treatment. Another important issue is how quickly patients should expect you to respond. Many patients expect that e-mail should be responded to immediately, but that isn’t feasible in most practices. So you may adopt a policy of reading and responding to all your patient e-mail on one or two specific days per week.

Responding to e-mail can take a lot of time. Are we allowed to charge for e-mail contact?
Yes, you can certainly charge a fee. In fact, there is an AMA CPT code for e-mail consultation, 0074T, but most insurance companies will not reimburse for this code yet. Many practitioners set an out-of-pocket fee for e-mail contact, and this will typically be in the range of $20 to $25 per consultation. Patients are very often willing to pay this in order to have some clinical contact between face-to-face sessions. The key is to develop your own electronic communication practices, and to discuss them with your patients ahead of time.

What can go wrong with e-mail therapy?
The worst case scenarios have to do with confidentiality issues. Unless you use a paid service to encrypt clinical e-mail, such as Medem (see side bar), e-mail is not secure. In many households there is only one computer, and if everybody in the family has access to it, spouses and children might read messages to and from a therapist. Some people also worry about strangers hacking in and reading confidential e-mail, but in my experience this is rarely an issue, because hackers are unlikely to spend much energy in order to read someone’s e-mail to a doctor. They’re usually trying to get into bank accounts!

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Medem: A portal for confidential clinical e-mail
Medem is an electronic healthcare company that allows physicians to quickly set up a website for their patients to access, and sets up an encrypted system for patient-doctor email communication. The yearly cost for the service is $295 – see www.medem.com for details.

HIPAA and E-mail
Contrary to common belief, HIPAA (the Health Insurance Portability and Accountability Act) does not require that you encrypt email to patients. You must take “reasonable” precautions to preserve the privacy of e-mail  communication, such as not sending it to the wrong person, not allowing unauthorized personnel to view your monitor, and adding a confidentiality
statement at the end of your message. See TCPR July 2005 for details on HIPAA.