The telephone and computer can be the most useful communication tools in your medical office—but practicing medicine by phone and e-mail is risky. Telecommunications healthcare cannot replace face-to-face healthcare.

Diagnosing medical conditions without examining a patient does not allow assessment of the person’s appearance, body language, severity of symptoms or other factors normally considered during a physical exam. Some patients—or some of the individuals who call in on their behalf—may be unreliable or inaccurate when assessing a problem or describing symptoms. Such inaccuracies can have serious consequences.

Only a few years ago, telemedicine appeared to be healthcare’s next big trend; a number of companies and solo physicians rushed to offer telemedicine services. Even though the companies advertised that they would provide over-the-phone medical care (including prescriptions) 24 hours a day, seven days a week, many of them had trouble convincing patients that remote consultations were a good idea.

A significant segment of the medical community remains deeply skeptical that doctors can adequately treat patients they have never seen in person. The American Academy of Family Physicians strongly opposes the idea, and the American Medical Association has expressed concern that patients who are treated over the phone could get shortchanged and even harmed. The Medical Board of California asserts that companies offering telemedicine services may be violating state law by allowing doctors to treat patients by phone.

Despite all that, it is undeniably true that the telephone and computer have become indispensable tools for today’s medical practices. Given the potential risks involved, however, it is essential that these tools be used properly.

Documenting Patient Phone Calls
When it comes to phone conversations with patients—whether they involve you or members of your staff—what information needs to be recorded in the patients’ charts?

Calls are made to physicians’ offices for a variety reasons—from making, canceling or rescheduling appointments to inquiring about test results to checking on the status of an outstanding bill. It is not necessary to record details of all of these calls in the medical record, but a system should be in place to confirm that each call was responded to.

Documentation requirements do kick in,however, whenever a call focuses on conditions of medical care. This type of call must be documented in the medical record; the notation should include the nature of the inquiry, the person to whom the caller was referred, a tentative diagnosis and the action plan established to resolve the issue.

A brief note should be jotted down even when the call comes in the middle of the night—or, say, when you’re attending your child’s school pageant. A more extensive note can be written or dictated into the medical record the next day.

If a prescription is given via the telephone, it is critical that there be a well-documented notation in the permanent medical record. The amount of the prescription should be minimal, and the patient should be instructed that an office visit is imperative prior to any further prescribing.

Patients who view telephone calls as a convenient alternative to office visits can be a substantial risk to your practice. The following guidelines can minimize the potential liability:

• Inform patients in writing about when to seek telephone advice. Give examples of the types of complaints—for instance, minor headaches, cuts and bruises—that may be dealt with adequately over the phone. Also give examples of problems—such as shortness of breath and abdominal pain—that are likely to require a visit to the office or emergency room.
• Only physicians or qualified staff such as RNs, NPs, and PAs should provide telephone advice. Written protocols need to be prepared for the office staff; the protocols should include what questions to ask, recommended responses for minor problems, and which calls to refer immediately to a doctor or schedule for an office appointment.
• Give callers ample time to explain their problems. Avoid leading questions. Instead of asking, “Do you have any chest pain?” ask “Exactly where do you feel pain?”
• Be careful about prescribing by phone for new complaints. If your diagnosis is wrong, the medicine could be ineffective or even harmful.
• Document calls for advice in the medical chart, using the caller’s own words whenever possible. If one of your staff members handles and documents calls, review the notes to make sure the adviser followed written guidelines and dispensed appropriate advice.

Best-Practice E-mail Guidelines
Although e-mail has all but replaced telephone conversations in some medical offices, many physicians remain reluctant to incorporate this communication tool into their practices. That’s too bad, because e-mail can be an easy and effective way to communicate with patients. Still, certain basic guidelines should be followed:

• Be careful what you write. Always follow this rule of thumb: Never put in an e-mail what you wouldn’t say in person.
• Get to the point. Don’t ramble in your e-mails; be focused and concise. No one wants to sift through pages of text to get to the heart of a communication.
• Incorporate your contact information. Use the automatic signature function in your e-mail software to provide, at a minimum, your full name, your practice’s name and your phone number in every message you send.
• Check your spelling and grammar before clicking “Send.” Even in e-mails, misspelled words and bad grammar reflect poorly on you as a professional.
• Don’t use all caps. Not only is it difficult to read e-mails typed using all capital letters, it’s equivalent to screaming at the intended recipient.
• Use “emoticons” sparingly. The smiley faces and other graphical representations of emotions—called emoticons—that often pepper e-mails may be cute for friends, but they’re rarely appropriate for professional communications.
• Never use abbreviations. When communicating with patients, abbreviations can lead to dangerous misunderstandings. Limit your use of abbreviations in e-mails to close friends or associates.
• Include a disclaimer. Communicate upfront your ground rules for e-mail exchanges. A standard disclaimer might read as follows: “Electronic mail is not secure, may not be read every day and should not be used for urgent or sensitive issues.”
• Pick up the phone. If you cross e-mails with another party two or three times, or if there is an emotionally charged issue involved in what you want to communicate, stop e-mailing and place a phone call instead.

Guidelines developed by the eRisk Working Group for Healthcare urge physicians to offer e-mail “visits” only to existing patients whose medical history they are familiar with, rather than to patients they’ve never treated before. The guidelines—available online at http://www.medem.com/phy/phy_eriskguidelines.cfm—carry no formal legal authority but reflect a growing consensus about the safest way to practice online medicine.

Adopting good telephone and e-mail practices is vital to enhancing quality of care while simultaneously decreasing liability exposures that can occur.