For further information please contact:
Jacqueline Grenon RN, BScN
University of Ottawa Heart Institute
40 Ruskin Street, Ottawa, Ontario
Email communication has been acknowledged as a resource which improves access, efficiency, responsiveness, patient focus, and the quality of health care. The use of this technology has evolved prior to the dissemination of comprehensive guidelines, leaving the Advanced Practice Nurse with a practice gap. This article proposes guidelines for Advanced Practice Nurses on email communication with patients based on the following resources: current and historical literature, documents from the Privacy Commissioner of Ontario and the College of Nurses of Ontario, existing guidelines, a review of security, and the expert opinion of an information technologist and privacy officer working in healthcare. The proposed email guidelines are comprehensive and easily applied to the clinical setting. This article may encourage further discussion within the nursing profession on the subject and has recognized the need for enhanced and feasible security options as well as future nursing research.
As technology advances so do the methods of communication. While correspondence in the past arrived with the postman, now the majority arrives as electronic mail (email). The efficiency and effectiveness of this method of communication has led to its quick adoption by society. In 1999 41% of Canadian households had access to the internet (Statistics Canada, 2005). In 2005 68% of Canadians aged 16 and over went on-line for personal reasons. This number increased to 73% in 2007 (Statistics Canada, 2008a). Email has become one of the most popular online activities completed at home (Statistics Canada, 2008a; Veenhof, Wellman, Quell, & Hogan, 2008). Based on these statistics the use of email as a method of communication will not diminish, but will continue to evolve.
Email has also become a regular form of communication in the work place. In 2007 100% of healthcare services in the public sector were using email (Statistics Canada, 2008b). Email communication not only occurs between healthcare workers, it also occurs between patienst and providers. In this author’s clinical practice as an Advanced Practice Nurse (APN) this form of communication occurs infrequently, but it does occur. Whether it occurs once a day or once a month this practice should be based on guidelines. The guidelines available in this author’s organization are limited and not specific to email communication with patients. As with most technologies, the use has advanced prior to the dissemination of comprehensive guidelines for the technology. Therefore the main purpose of this article is to propose guidelines for APNs to use in their clinical practice settings when communicating with patients via email. These guidelines were developed from a review of literatures on the: use of email in healthcare, identified research on email communication, advantages and disadvantages of email communication, various privacy regulations specific to email, liability issues for nurses with email communication, security options, and existing medical guidelines on email communication.
When examining the literature on email communication between patients and providers it was noted that the majority of guidelines have been written by physicians for physicians. Kane and Sands initially created email guidelines in 1998. In 2002 the American Medical Association developed guidelines and the Canadian Medical Association followed in 2005. These are a few of the medical resources available. Four examples of research articles on email communication in primary care include Couchman et al. (2005); Bergmo, Kummervold, Gammon, and Dahl (2005); Katz, Moyer, Cox, & Stern (2003); and White, Moyer, Stern, and Katz (2004). Examples of articles written by physicians which provide commentaries on the use of email with patients include Bauchner, Adams, and Burstin (2002); Car and Sheikh (2004a, 2004b); CAFP (2000); and Goodyear-Smith, Wearn, Everts, Huggard, and Halliwell (2005).
In comparison, the literature by nurses for nurses on email communication between patients and providers is less evident. This author was able to locate three current articles written by nurses which discuss email in a comprehensive manner. These include: Constantino, Crane, Noll, Doswell, and Braxter (2007); Dean (2008, Feb 19); and Rodriguez (2007). The College of Nurses of Ontario does not have a document that specifically focuses on email communication. There are three documents that briefly discuss email. These are: the Practice Standard for Confidentiality and Privacy, the Standard for Documentation, and the Practice Guidelines for Telepractice (CNO, 2009a, 2009b, and 2009c). Therefore, it is this authors hope that this article will stimulate supplementary discussion within the nursing profession with subsequent refinement of email guidelines and further conduction of future research.
A literature search was conducted using the following databases: Proquest Nursing and Allied Health; EBSCOhost; Science Direct; BioMed Central; Proquest; PubMed Central; professional and government websites; and Google. The search terms entered into the databases included: “email”, “electronic mail”, “email between patient and provider”, “email and nurses”, and “email guidelines”. Literature earlier than 2002 was used only if it was cited frequently by current articles or published by professional organizations. Articles were limited to those that discussed “email” communication and not “web based” communications, such as professional websites, WebCT platforms, or chat rooms. Information requests on email communication with patients were sent via email to the College of Nurses of Ontario and the Information and Privacy Commissioner of Ontario. An information technologist working at the University of Ottawa Heart Institute provided information on the security of email systems. The privacy officer at The Ottawa Hospital also provided some information on encryption and email communication. Permission was requested from both of these individuals prior to citing them as references.
Email is a system for sending and receiving a digital message over a computer network, between two personal computers. An email message contains two sections, the header and the body of the email. The header contains the sender’s address, the receiver’s address, the subject heading, and attachments, if included. The body of the email contains the main message and the signature block.
The literature identifies primary care, family practice, and specialized clinics as the health care settings where email communication is primarily used (Bergmo et al., 2005; Car & Sheikh, 2004a; Couchman et al., 2005; Dunton & Robertson, 2008; White et al., 2004). Email in these clinical settings are used for the following: appointment schedules (booking, cancelling, and automated reminders), billing questions, health questions for the physician, prescription refills, referrals or non-urgent consults, test results, sick note renewals, preventative health care reminders, counseling, and education (Bergmo et al., 2005; Car & Sheikh, 2004a; Constantino et al., 2007; Couchman et al., 2005; Dunton & Robertson, 2008; White et al., 2004).
Despite the ability of email to manage a wide range of practice issues communications, healthcare workers tend to be reluctant to use it in their practice. Goodyear-Smith et al. (2005) noted that only 4% of physicians communicated with patients through email. Rodriquez (2007) noted that approximately half of the nurses sometimes provided patients with their email address while the other half never did. These low percentages are not reflected in the trends or needs of the general public. The literature indicated that anywhere from 70 to 90% of the general public would be interested in communicating with their physician via email (Car & Sheikh, 2004b; Virji et al., 2006).
The use of email for communication between patients and providesr and the concerns that arise from this practice have stimulated the completion of research on the topic. One such concern is that email communication will add more work to the providers’ already busy schedules. An early study by Katz et al. (2003) found that email communication with patients added to the workload of physicians. There was an increase in the number of patient emails with no decrease in the number of office phone calls. The results of this study were only partially supported by Bergmo et al. (2005) who found that merging email systems with patient records and using an efficient triage system did reduce the number of office visits over time. However, this study also did not demonstrate a decrease in telephone consultations.
Another common concern noted in the literature was the proper use of email by patients. White et al. (2004) examined whether there was an inappropriate and inefficient use of email by patients. Their findings demonstrated that the majority of email content and tone was appropriate. It also demonstrated that patients adhered to provided guidelines which requested that they: focus the content of their email, limit one request per email, and avoid using email for urgent or highly sensitive requests. This study did not review the expectations patients had for email communication. Couchman et al. (2005) found that patients had high expectations for quick responses from providers. Fifty percent wanted responses for medical questions within eight hours. This short response time was unrealistic if the question was associated with a test result that takes longer than eight hours. The authors emphasized the need to set guidelines for response times with patients.
What type of information do patients want communicated via email? The study by Couchman et al. (2005) found that patients wanted to use email to make or cancel appointments, obtain routine lab results or tests reports, consult on simple medical questions, request prescription refills, and communicate directly with their doctor. Katz et al. (2003) similarly found that patients were more willing to use email for less-complex or sensitive issues and preferred the phone or face-to-face visits for complex, sensitive issues which required discussion.
Email has the possibility of improving access and health outcomes. A study by Constantino et al. (2007) reviewed the benefits of email for women and children in abusive relationships. Email provided these women with 24/7 access and was a non-judgmental format which served as a device for providing individualized care, education, information, and social support. In the conclusion of the article the author briefly reviewed security issues. There was no discussion of email guidelines.
Rodriguez (2007) acknowledged the need for email guidelines in the clinical setting. A nurse working in a cancer clinic was contacted by a patient via email raising concerns and resulting in the implementation of an email policy. The author noted that the email guidelines mitigated the fears associated with email communication but did not guarantee its use. Brooks and Menachemi (2006) assessed physician adherence to recognized physician-patient email guidelines. What they found was a lack of use of email guidelines by physicians with email communication. The authors hypothesized that infrequent use may have resulted from a lack of knowledge of the existing guidelines, disagreement with the guidelines, or the impracticality of their implementation. Suggested solutions included: education on email communication, assessment of barriers to guideline implementation, and the need for further study on the guidelines themselves.
Prior research provides the APN with existing knowledge on email communication that can facilitate the creation and implementation of guidelines for use. Additional factors which require consideration include: disadvantages, advantages, privacy regulations, professional regulations, liability issues, security options, and existing guidelines.
Recurring themes on the disadvantages associated with email communication were noted in the literature and are summarized below in Table 1. Knowledge of these disadvantages enhances guideline development which can support efficient use of email by APNs and their patients.
(Bauchner, Adams, & Burstin, 2002; CAFP, 2000; Car & Sheikh, 2004a; Dean, 2008; Goodyear-Smith et al. 2005; Rodriguez, 2007; Katz et al. 2003; White et al. 2004)
There were also recurring themes in the literature on the advantages associated with email communication which are included in Table 2 below. The following advantages assist the APN in choosing whether to adopt or decline the use of email communication with patients.
(Bauchner, Adams, & Burstin, 2002; CAFP, 2000; Car & Sheikh, 2004a; Dean, 2008; Goodyear-Smith et al. 2005; Rodriguez, 2007; Katz et al. 2003; White et al. 2004)
Technology has created a heightened awareness for the Privacy Rights of individuals. These rights have been repeatedly emphasized through media reports of misplaced personal information by organizations, such as credit card numbers or stolen laptops. The Personal Health Information Act (PHIPA) of 2004 provides health information custodians, such as nurses, with practice expectations for improving security when using electronic technologies. Health information custodians should take steps to ensure that personal health information (PHI) is protected against theft, loss and unauthorized use or disclosure. Custodians should also ensure that this information is protected against unauthorized copying, modification or disposal. These responsibilities may be upheld with use of the following points noted in documents obtained from the Information and Privacy Commissioner of Ontario:
(Cavoukian, 2007; Wright, 1994)
The CNO has three documents which review the issue of email communication. These include the: Practice Standard for Confidentiality and Privacy (CNO, 2009a), the Standard for Documentation (CNO, 2009b), and the Practice Guidelines for Telepractice (CNO, 2009c). These three documents do not exclusively discuss email but do identify important points that relate to email communication for nurses to utilize in practice. These points include:
The use of email communication with patients creates additional liability issues for APNs. One such concern is whether there are practice issues for the APN when the patient resides outside of the APN’s jurisdiction. The CNO (2009c) telepractice guideline states that, “Nurses working in Ontario, but in contact with clients outside the province, are considered to be practicing nursing in Ontario and are accountable for maintaining the College’s practice Standards” (p. 8). As a result of using email to communicate with a patient outside of their jurisdiction, the APN may become professionally accountable and liable in another jurisdiction as well (CNO, 2009c). If an allegation is made against the APN from another jurisdiction the APN may need to travel to this location to defend their practice.
The very nature of email communication presents inherent risks. The lack of visual, auditory and physical cues from the patient during email communication creates risks which are reduced if the patient is known or will become a prospective patient (CMA, 2005). These risks may also be minimized by matching the medium to the message. This medium of communication is appropriate for non-complex or non-urgent issues. The task of matching the medium to the message may be accomplished through guidelines establishing limits for use which are known to both patient and provider (Goodyear-Smith et al. 2005). The immediacy associated with email also creates its own concerns. Email implies a quick response. It is important to establish turnaround times for email. Providing patients with clear response timeframes avoids inappropriate patient expectations and reduces levels of frustration. The usual turnaround time for email is two to three business days (Kane & Sands, 1998; Rodriguez, 2007). Patients will also need to know what to do if their email message has not been answered within the set time limit.
Lastly, communication with patients through this medium requires some extra knowledge on the part of the APN. They require knowledge of email technologies and the issues surrounding them. They should also be aware of proper email etiquette. As practice leaders, APNs should advocate for the creation of email guidelines along with the use of secure technologies for this form of communication.
Encryption is recognized by the Privacy Commissioner as a requirement for the transmission of very sensitive information by means of email (Cavoukian, 2007). Attaining this requirement is difficult for providers since encryption is not readily available in public email systems (Wright, 1994). It is also not user friendly (CAFP, 2000). This lack of availability and impracticality with encryption was also recognized by Kane and Sands (1998) and by the CAFP (2000). Encryption is available at this author’s institution for email messages within the organization, but once it leaves the organization it is no longer encrypted. This occurs because different public email systems do not have compatible encryption programs (Wright, 1994).
A potential solution for adequate and attainable security is the use of a secure encrypted email tunnel between two organizations. However, this is not possible if patients are using multiple email providers. Patients would be required to set up an account with a specific email provider (for instance, Google’s Gmail) which would then become an email partner with the hospital. The hospital would set up an email tunnel (point-to-point security) with this partner (Marc Charbonneau, personal communication, October 20, 2009). Setting up a partnership with a public email provider requires approval from the hospital because it increases vulnerability to outside privacy and security threats (Marc Charbonneau, personal communication, October 20, 2009).
If encryption or a secure email tunnel is not available, what option does the APN have for secure email communication? Email communication between patient and provider and the transmission of PHI may still occur if the patient provides the APN with informed consent for such (Anne Lavigne, personal communication, October 26, 2009). Expressed written consent helps to avoid any confusion surrounding the practice email communication with patients (CNO, 2009a). If the patient does not consent to transmission of PHI without encryption, and encryption is not available, PHI should not be transmitted outside of the organization through email (Anne Lavigne, personal communication, October 26, 2009).
Guidelines for email communication between patient and provider were established by Kane and Sands in 1998 as part of a task force for the American Medical Informatics Association. This white paper provided physicians with comprehensive guidelines which are still applicable to clinical practice today. The American Medical Association (2002) created guidelines for email communication reflecting those of Kane and Sands which are divided into three sections: communication, medicolegal and administrative, and ethical guidelines. Lastly, the Canadian Medical Association (2005) also created guidelines for online communication between physicians and patients. Concepts for email guidelines from these three documents are summarized below in Table 3.
(AMA, 2002; CMA, 2005; Kane & Sands, 1998)
The proposed guidelines for email communication include the following points: patient selection, type of PHI transmitted, authentication, response times, escalation of communication, email system adaptation, patient acknowledgment of messages, forwarding or copying patient emails, records of email communication, encryption, and consent forms.
Online communication should only be used with known or prospective patients. APNs do not have to limit their communication to patients who reside in the same jurisdiction, however, it is recommended that they communicate only with known patients or prospective patients in a different jurisdiction. During the course of email communication with a patient the APN may need to terminate this form of communication if the patient does not abide by requested guidelines.
Email communication should not be used to transmit complex or sensitive PHI. What is or is not sensitive PHI needs to be defined by both the organization and the patient. Patients will have different views of what is or is not sensitive information (CMA, 2005). Once the patient identifies the PHI that they would like to have transmitted with the use of email, the APN will have to ensure that transmission of this information is acceptable to their organization (CMA, 2005). The patient’s choice of the type of PHI they would like to transmit via email may alter according to who will be reading the email messages (Kane & Sands, 1998). Patients may not want to send sensitive information to an office clerk, yet they may feel more comfortable sending this information to the APN.
Not only is it important to determine what type of information will be transmitted it is also important to request that patients focus their email messages by including only one request per email. This will make it easier to manage the messages.
Passwords should be used for email accounts and computer desktops to minimize unauthorized access to email accounts. Passwords should be carefully created, changed frequently, and never shared. Additionally a case sensitive log-on and automatic log-off for email accounts will also minimize unwanted access. Once logged on, computers should not be left unattended. Emails should not be stored in remote areas (home computers, laptops), nor should email accounts be shared with others (coworkers, family members). The address in the “TO” field should be verified prior to sending the email. If electronic addresses are being used for easy retrieval of patient email addresses providers should ensure the patient addresses are correct. Patient group emails are not recommended unless using the “blind copy” function. Avoid the use of wireless systems which are more vulnerable to interception of messages. Lastly, incorporate confidentiality warnings in email messages. These are recommendations for both the APN and the patient.
A two to three day turnaround time for emails should be established and communicated to patients. Of course within this specified time frame there may be emails which need to be answered on day one while another, which is less urgent, can wait until day three. The use of clear email subject headings will assist in determining which should be answered on day one or day three.
Patients need to know what to do if their email has not been answered within the three day timeframe. If they have not received an answer within three days they should call the office. If the topic they need to discuss will require numerous emails back and forth, or is lengthy in nature, they should call the office. If they need to be assessed by the physician they should call and make an appointment for a clinic visit. Patients should be reminded that emails are not for urgent situations, and should be provided with options such as office visits for such events.
A separate email account should be set up for nurse-patient email communication. This facilitates the automatic reply option for patient emails without creating too many rules. It also provides the APN with increased privacy for work emails just in case access is required by a third party for patient emails. The current email system at this author’s organization is Novell GroupWise 7. This system allows one to create ‘auto replies’ to emails. The ‘reply’ sends a prepared message to the sender when certain conditions are met (Novell GroupWise, 2008). This reply action is activated when a newly received item, the patient’s email, is placed in the GroupWise mailbox. A recommended reply message includes: a statement of receipt of the patient email, the expected response time, proper use of email, directions for communication escalation, a short note on privacy and security, and the providers contact information. A second reply should be created for vacation alerts and activated when the APN leaves for vacation. The message in this reply acknowledges receipt of the email, informs patients of the expected time out-of-office, and who to contact for what issues.
When providing patients with medical advice, such as the adjustment of a medication dose, a request receipt should be selected by the provider prior to sending the email (Kane & Sands, 1998).The receipt request is brought to the patient’s attention when they receive the email. The patient’s response assures the APN that instructions have been received. Further correspondence may be needed to clarify if they are understood, and have been implemented.
Forwarding or copying patient email to a third party without their permission is not recommended, even if this individual is involved in their circle of care (AMA, 2002; Kane & Sands, 1998). When the text is forwarded to a colleague it should not contain the patient’s name or email address (Kane & Sands, 1998). This recommendation is due to the issue that once an email has been sent the sender has no control over its final destination. Also, the further the PHI becomes from its original source the less likely fair information practices will be upheld (Wright, 1994).
Patients should be informed that a hard copy of the nurse-patient email communication will be kept in their office chart. In this author’s practice there is an ‘other letters’ section for such communication. Each email communication should be printed in full. This means including the full text of the patient’s query(ies) and the providers response(s) (Kane & Sands, 1998).
Patients should be informed by the APN when encryption is not available and the risks associated with the lack of encryption. The patient’s wish to continue communicating via email without the use of encryption should be documented on the consent form and a copy kept in the patient’s office chart.
Consent should be obtained from the patient prior to initiating email communication. A copy of the consent should be kept in the patient’s chart, with a copy given to them. Patients should have the option to withdraw consent at any time. The consent should review:
(AMA, 2002; CMA, 2005; Kane & Sands, 1998)
The email guidelines proposed in this article are comprehensive in nature. They are based on extensive information obtained from: literature and research on email communication, various privacy regulations, liability issues, expert opinion, and established email guidelines. The guidelines are all inclusive and will meet the clinical practice needs of the APN. The proposed email guidelines can fill an identified practice gap.
The guidelines are easily adapted to the clinical practice setting of the APN. The need for adaptation is a given in that each clinical practice has its own unique characteristics. These adjustments are not insurmountable and are not required for all of the guidelines. An example of a guideline which may require revision is the type of information sent by email. Organizations will need to specify what should or should not be transmitted by email. Email systems vary between organizations and response messages may need to be tailored to fit the email system. As well, privacy policies differ between organizations as do security options. These differences need to be incorporated into the guidelines. The remaining guidelines should not require much, if any alterations and could be readily implemented into diverse settings.
The guidelines are also feasible. The initial setup of a second email account, the patient response replies, and the consent will take some effort on the part of the APN. Ensuring that these functions are set up properly will save the APN time in the long run. There will be less time spent dealing with inappropriate email messages from patients. However, having a second email account will require that the APN check his/her own personal email plus the patient email.
The proposed guidelines are a new concept for the nursing profession. This novelty may hinder their adoption by APNs. The recognition that encryption is not an absolute necessity for email communication may cause doubt on the part of APN resulting in the rejection of the guidelines. Other issues may include lack of knowledge of the guidelines, the viewed impracticality of the guidelines, a required change in practice, and the lack of nursing research included in the guidelines.
A noted limitation of these guidelines is the fact that they were created from the research and perspective of one person. Input from more than one APN in various practice settings would enhance their generalizability. A second limitation arises from the fact that the information used to generate the guidelines was mostly written by physicians for physicians. Despite this fact, the guidelines are still applicable to the APN’s clinical practice.
Ultimately it is the choice of the individual APN to initiate this form of communication with patients in their clinical practice. Ever-increasing patient demand may make it difficult for APNs to opt out of this form of communication. Additionally, email is progressively being recognized as a method of improving the access, efficiency, responsiveness, patient-focus, and quality of health care (Bauchner & Burstin, 2002; Car & Sheikh, 2004a). If and when APNs decide to adopt the use of email communication with their patients this practice must be based on guidelines. If there are no guidelines specific to email present in the APN’s clinical setting he/she should advocate for the development of such guidelines. The guidelines in this article are a starting point for that development. They will assist APNs with the efficient and effective use of email in their clinical setting.
The development of these guidelines demonstrates that there are many issues which have to be considered when using this form of communication with patients. This paper reveals important issues which need further exploration, one of which is the necessity for further dialogue on security concerns. There is a need for both adequate and feasible security options for this form of communication. Simply stating that encryption is a must is not realistic. This requirement will either limit the use of email or promote improper use. The paper has also exposed the paucity of available nursing literature in this area of practice. There is a need for additional publications from nurses on email communication, whether they are general comments or research papers.
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Jacqueline Grenon is the Advanced Practice Nurse for the Heart Transplant Program at the University of Ottawa Heart Institute. She recently finished the Masters of Health Studies from the University of Athabasca. She has accumulated many years of experience in various nursing roles. Her current role as an Advanced Practice Nurse has exposed her to the use of email communication with patients. She is in a perfect position to research, test, and share her experienced with patient-provider email communication.
PEER EDITOR: Mrya Gasner RN, BScN
CJNI EDITOR: June Kaminski
Grenon, J. (Fall, 2010). Nurse-Patient Email Communication: Comprehensive Guidelines. CJNI: Canadian Journal of Nursing Informatics, 5 (4), Article One. http://cjni.net/journal/?p=1009