You and Your Patient Email

Case History

This issue's case history provides some useful information to guide you in the use of email with your patients. I believe it will help you enhance the provider-patient relationship, and the communication skills between you and medical providers.

C.M. is a 78-year-old right-handed Caucasian male patient. His daughter contacted me because her father had complained of dizziness during the a.m. hours when arising from bed. The daughter said it was difficult to get her father to go to a doctor, as she and the father resided in different states.

Initial consultation with C.M. was by telephone, and it became apparent that he was overdue for his routine annual physical examination. Further questioning revealed he had been a hypertensive patient controlled by prescription drugs for a great number of years. He had not been feeling right the previous two weeks, and had even refrained from socializing.

With his permission, I personally made contact with his medical generalist, describing the symptomatology and reporting a need for urgency in evaluation, because I felt that the differential diagnosis to be excluded included stroke in evolution (an impending cerebral vascular accident).

On initial contact with the GP's office, the secretary told me the doctor would return to the office at nine o'clock the following morning. I advised her that I couldn't wait that long, and that this pertained to a mutual patient.

"Just find him for me. This is Dr. Molina calling," I entreated.

I didn't know if my name would mean anything to the GP, but I suspected it might be in the best interest of this patient if I pushed a little. There was a pause of several seconds while I waited. The secretary advised me that the doctor was just leaving, but would speak to me now. The GP agreed to examine the patient the next morning.

Just to be on the safe side, I confirmed availability of the patient and daughter and called to follow-up the next afternoon. The GP reported that the patient was in "good shape," but ordered some laboratory testing and an electrocardiogram based on my suspicions. The tests were scheduled within the next three days.

On the day he was preparing to report for the scheduled tests with the GP, C.M. suffered a stroke. He found himself stumbling and falling to the left side. He noticed a sudden onset of left-sided weakness in the upper and lower extremities, causing him to fall. He managed to call 911 and was taken to a local hospital. He arrived in atrial fibrillation (a regularly irregular heart rhythm, generally slow), with rapid ventricular response (this faster rate makes the atrial fibrillation heart rhythm dangerous, because the patient throws emboli that can lead to stroke). He was cardioverted (a method to restore the normal heart rhythm by cardioshock) and placed on prescription. A CAT scan was done, and the doctor confirmed that he had had a stroke.

After a horrific four-month hospital stay and neurorehabilative recovery, C.M. was left with residual weakness of the left lower extremity and a left-upper-limb hemiparalysis with medical shoulder subluxation (anterior deformity is a type of dislocation). He went home and was fitted with an orthotic to prevent foot drop, and a shoulder stabilizer. His home was modified for wheelchair access, with a ramp and safety grip bars.

He received companion care, and some outpatient rehabilitation offered through his insurance company.

The symptoms and physical deterioration have been gradually and slowly reversed, but the patient has suffered from numerous ailments over the past year: depression; myofascial pain syndrome; pneumonia; mid-back squamous cell carcinoma (excised without further incident); an infected G-tube; intermittent diarrhea with constipation (irritable bowel syndrome); and intermittent and various side effects of medications. Approximately one month ago, the patient was successfully weaned off all prescription medications under medical monitoring and advisement. The patient subsequently has undergone further MRI work-up and evaluation of the brain, circle of Willis, and carotids. Results indicate evidence of an old right-side parietal stroke, with narrowing of the left external carotid with vertebral artery patency.

Discussion

The patient presented with a very interesting, complex and challenging case. All the more difficult was that this case necessitated long-distance management. Electronic communication has enabled me to assist in the primary care of this elderly patient since the advent of his stroke and other untoward events relating to that accident. The family, consulting physicians, and patient were made aware that as a doctor of chiropractic, my practice is based upon a drug-free and surgery-free foundation. I did emphasize my focus in physical medicine and rehabilitation. Careful and educated communication allowed more of an academic challenge that later succeeded in gaining the mutual respect of the various specialists encountered.

C.M.'s neurologist recently emailed the following communication to me:

"I have found the patient to be mentally competent using nationally recognized objective testing. He is consistently oriented and has increased his interaction with all providers since his depression was medically treated with short-term and limited drug therapy. He scored a 30 out of 30 on a mini-mental examination. He has made progress with performing his activities of daily living. He is able to feed himself, use the restroom, and requires less help bathing and dressing than was previously necessary.

"He is less hampered by chronic pain and appears more motivated to pursue his own course to independent living. He has also regained the skills required to make his own appointments, and is able to communicate on the telephone without assistance. His recent successes in using a home computer provides further evidence of his ability to function independently.* I believe him to be currently in a state where he is physically and mentally able to direct his own affairs with a limited amount of assistance."

I continue to communicate with C.M., the family, companions, and the family physician and specialists via email. Today, with technological advances in web communication, two goals are foremost: effective interaction between the chiropractor and patient, and observance of medicolegal prudence. An important point to remember is that in contrast with telephone conversations, email is self-documenting and instantly reproducible: Copies of email can be printed or attached to the patient's chart. Often malpractice claims can be traced to faulty communication; so good communication is part of good insurance.

According to the paper "Guidelines for the Clinical Use of Electronic Mail with Patients," published in the Journal of American Medical Informatics Association (vol. 5, no. 1 Jan/Feb 98, Hanley and Beltus, Inc., Philadelphia, PA), technical, electronically equipped health care consumers have accelerated the demand for email access to their health care providers.

Summary of Communication Guidelines

• Establish turnaround time for messages. Do not use email for urgent matters. Inform patients about privacy issues. These messages are to be included as part of the medical record.

   

• Establish types of transactions (appointment scheduling, etc.) and sensitivity of subject matter (mental health, etc.) permitted over email.

   

• Instruct patients to put the category of a transaction in the subject line of messages for filtering, such as: "appointment," "medical advice," or "billing question."

   

• Request that patients put their name and patient identification numbers in the body of the messages.

   

• Configure an automatic reply to acknowledge the receipt of messages.

   

• Print all messages, with replies and confirmation of receipt, and place then in your patient's paper chart.

   

• Send a new message to inform a patient of the completion of a request.

   

• Request that patients use the "auto-reply" feature to acknowledge reading the provider's message.

   

• Maintain a mailing list of patients, but do not send group mailings where recipients are visible to each other. Use the "blind copy" feature in software.

   

• Avoid anger, sarcasm, harsh criticism, and libelous references to third parties in messages.

   

• Healinx (www.healinx.com) is a service that connects patients to their doctors, and doctors to doctors, via secure email. It also permits patients to place their own medical records securely on the Web so that in times of emergency or convenience, patients can permit other doctors to view their records. There is no charge to the patient or chiropractor for this service.