Ethical Questions

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Online Patient-Clinician Messaging: Fundamentals of Ethical Practice

 PDF. What are ethical implications of patient-clinician messaging? What measures/practices can health care organizations put into practice to assist clinicians with the ethical challenges of patient-clinician messaging?  Respond to at least two of your classmates’ postings.

 

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National Ethics Teleconference
National Ethics Committee Report: Online Patient-Clinician Messaging:

Fundamentals of Ethical Practice
September 29, 2004

INTRODUCTION

Dr. Berkowitz:

Good day everyone. This is Ken Berkowitz. I am the Chief of the Ethics
Consultation Service at the VHA National Center for Ethics in Health Care and a
physician at the VA NY Harbor Healthcare System. I am very pleased to
welcome you all to today’s National Ethics Teleconference. By sponsoring this
series of calls, the Center provides an opportunity for regular education and open
discussion of ethical concerns relevant to VHA. Each call features an educational
presentation on an interesting ethics topic followed by an open, moderated
discussion of that topic. After the discussion, we reserve the last few minutes of
each call for our ‘from the field section’. This will be your opportunity to speak up
and let us know what is on your mind regarding ethics related topics other than
the focus of today’s call.

ANNOUNCEMENTS

Remember, CME credits are available for listeners of this call. To get yours, go to
http://vaww.ees.aac.va.gov/ethics.
Ground Rules: Before we proceed with today’s discussion of the recent National
Ethics Committee Report: Online Patient-Clinical Messaging: Fundamentals of
Ethical Practice, I need to briefly review the overall ground rules for the National
Ethics Teleconferences:

 We ask that when you talk, you please begin by telling us your name,
location and title so that we continue to get to know each other better.

 During the call, please minimize background noise and PLEASE do not
put the call on hold.

 Due to the interactive nature of these calls, and the fact that at times we
deal with sensitive issues, we think it is important to make two final points:

o First, it is not the specific role of the National Center for Ethics in
Health Care to report policy violations. However, please
remember that there are many participants on the line. You are
speaking in an open forum and ultimately you are responsible
for your own words, and

http://vaww.ees.aac.va.gov/ethics

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o Lastly, please remember that these Ethics Teleconference calls
are not an appropriate place to discuss specific cases or
confidential information. If, during the discussions we hear
people providing such information we may interrupt and ask
them to make their comments more general.

PRESENTATION

Dr. Berkowitz:

Today’s presentation will focus on the newly released National Ethics Committee
Report: Online Patient-Clinician Messaging: Fundamentals of Ethical Practice.
This will include a discussion of the nature of online communication, explore the
ethical challenges of online communication between patients and clinicians and
offer recommendations to assure ethical practices in online patient-clinician
messaging within VHA. Joining me on today’s call is Dr. Art Derse, Chair of the
National Ethics Committee and one of the lead authors of the report. Dr. Derse
is also co-chair of the ethics committee at the Clement J. Zablocki VA Medical
Center in Milwaukee.

Also joining me today is Dr. Bette Crigger, Chief of the Ethics Communication
Service at the National Center for Ethics in Health Care. Among other things,
Bette served as project editor for the “eHealth Code of Ethics” before joining VA.

Thank you both for being on the call today. I would like to start by asking Dr.
Derse why the National Ethics Committee decided to address the issue of online
patient-clinical messaging.

Before we begin, Dr. Derse, could you tell us a little about the National Ethics
Committee and how this report on online messaging evolved?

Art Derse, MD:

I’d be happy to. The National Ethics Committee is a standing subcommittee of
the Executive Committee of the National Leadership Board. Our purpose is to
analyze ethical issues that affect the health and care of veterans. Specifically, we
are charged by the Undersecretary for Health to produce reports that address
health care ethics-related topics that relate to VHA that clarify and analyze the
issue at provide timely practical information, including recommendations. Our
topics have varied over the years, and the reports are produced in collaboration
with the National Center for Ethics in Health Care and our Ethics Committee
members are comprised of folks from the field and also from Central Office, and
I’d like to recognize them quickly: Michael Cantor, Jeannette Chirico-Post,
Sharon Douglas, Kathy Heaphy, Judy Ozuna, Peter Poon, Cathy Rick, Randy

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Taylor, and Ellen Fox is a member ex officio, and Michael O’Rourke is a
consultant to the Committee.

All of these folks discuss these issues, and then we, with assistance from
staff of the National Center for Ethics in Health Care, including Bette Crigger and
Leland Saunders, craft a first draft and then craft second and third and ultimate
drafts of these reports. So, that is how these reports come to be, and this one on
online interactions is particularly timely, and not only is Bette Crigger someone
who has expertise in this area, but your moderator and host Ken Berkowitz also
has expertise in this area and has thought and written about this topic.

The NEC decided to address this issue for several reasons. First, surveys show
that patients want to be able to communicate with their clinicians online. Patients
want to use email to schedule appointments, refill prescriptions, get test results
and ask questions that don’t require an office visit. It is also widely held that
online patient-clinician messaging enhances patient-clinician relationships and
also promotes a greater involvement by patients in their own care. But many
doctors and patients have jumped into online messaging without thinking through
its ethical implications as carefully as they should. The NEC wanted to provide
guidance, especially because VA’s My HealtheVet will soon offer VA patients the
ability to communicate with their clinicians using online messaging through a
secure website.

Dr. Berkowitz:

We’ll want to hear more about My HealtheVet, but I’d like to examine the ethical
aspects of online messaging first. Dr. Derse, what are some of the advantages of
online patient-clinician messaging?

Dr. Derse:

Well, one advantage for both the patient and the clinician is greater efficiency
and convenience. It helps to alleviate problems of “telephone tag” and also helps
overcome barriers related to geographic distance. Another advantage is that it
can promote more effective communication in that it enables clinicians to convey
complex information more clearly than is often possible by telephone or even in
face-to-face conversations. Additionally, online communication helps to create a
written record of the communication between the patient and the clinician. Many
studies, such as one sponsored by Blue Shield of California, also suggest that
online communication can promote more efficient utilization of health care
resources and help reduce costs.

Dr. Berkowitz:

With all the advantages that online patient-clinical messaging offers, can you tell
us how clinicians have responded about this new opportunity?

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Dr. Derse:

Well, some clinicians have been reluctant to adopt the practice. Most concerns
are related to patient privacy, possible impact on the clinician’s workload, and
lack of reimbursement for time spent online as well as liability and licensure
issues. Despite these concerns, the reality is not whether online communication
will be accepted but how to assure that good communication practices are
adopted so that all parties’ interests are protected and also enhance rather than
hinder the patient-clinician relationship.

Dr. Berkowitz:

Dr. Crigger, can you explain for us what features of online communication can
raise ethical concerns?

Bette Crigger, PhD:

Sure Ken. It’s important to understand the nature of online exchange as a mode
of communication. Online health communication can occur through different
channels, such as encrypted or unencrypted email and/or web-based messaging;
it can also serve different purposes—for example, making an appointment versus
asking a question about a particular symptom. And it can take place in different
kinds of patient-provider relationships, from patients and clinicians who already
know each other well, to those who encounter one another through an advice
function on a health website. All of those can pose different ethical challenges.

The features that make online communication attractive are often the same ones
that raise concerns. For example, online communication is asynchronous. While
asynchronous communication is efficient, this can also create an ethically
troubling situation in an urgent message to a clinician from a patient may not be
received right away. Anonymity is another issue. While online communication
offers patients some level of anonymity that can make it easier for them to
communicate more openly about an embarrassing or sensitive subject, it also
presents opportunities for patients and/or clinicians to disguise their identities.
Additionally, online messaging is often seen as informal and many people often
neglect the fact that messages are self-documenting and are verbatim records of
communication. If electronic messages are incorporated into the medical record,
they would represent one of the few occasions in which a patient’s own words
become directly part of his or her medical record.

Also, the way we tend to think about online communication can raise concerns.
Some patients might expect that online communication will give them immediate
access to their clinician, while clinicians may feel that online communication
presents them with demands for immediate responses and additional
requirements upon their time and attention.

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One last, but very important, concern is that electronic messaging is a “thin”
communication medium. By “thin,” I mean that it’s a poor channel for conveying
emotion or psychological state. Online messaging doesn’t allow for “nonverbal”
cues that tone of voice, expressions or body language do.

Dr. Berkowitz:

Often we hear the words “email” and “web messaging” as if they are
synonymous. Can you tell us if there is a difference between email and web
messaging?

Dr. Crigger:

Currently, most online communication between patients and clinicians usually
takes place through Internet email using commercial services. Often, additional
software to encrypt messages or authenticate a user is not available. Web
messaging or secure messaging, however, allows users to exchange information
on a single, protected computer. Web messaging requires the additional step of
logging on to a password-protected website before posting or receiving
messages, but is still relatively easy to use and provides greater protection
because the message never travels over the Internet (where it might be
intercepted), and the only people who have access to it are those who have
passwords to the message server.

Dr. Berkowitz:

Despite the benefits and enthusiasm for online communication between patients
and clinicians, there are several ethical challenges that need to be addressed
with this method of communication. The most notable concerns are related to
privacy and confidentiality, access, effects on patient-clinician relationships,
voluntariness of participation, informed participation, boundaries of online
professional practice, and fairness with respect to workload and compensation.

Let’s discuss the area of privacy and confidentiality. We all know and understand
that privacy and confidentiality are extremely important in health care. Patients
have the right to determine who has access to them and their personal
information and also expect that clinicians will not share their personal health
information inappropriately outside of the patient-clinical relationship. Breaches
of privacy and confidentially can have extremely harmful results and clinicians
have the ethical obligation to respect patient privacy and assure that health
information is kept confidential. But how does this play out when patients and
clinicians communicate online? Dr. Derse, can you tell us about privacy
practices in online messaging?

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Dr. Derse:

Yes. Online messaging requires good privacy practices specific to this
environment. Since it’s easy to share electronic information whether intentionally
or inadvertently, it’s important that clinicians be vigilant in protecting patient
information. Just like a patient’s computerized medical record, patient-clinician
messages should never be left open to casual view on a computer monitor. It is
also important that clinicians explain to their patients who will have access to
message—for example, other members of the care team—and under what
conditions messages will be forwarded to a third party. Equally important are
technical issues related to electronic security and authentication. HIPAA sets
very strict standards for preventing unauthorized access to electronic health
information in transmission, protecting the integrity of information that is stored
and transmitted, and assuring that both the sender and recipients of an electronic
message are who they represent themselves to be

VA has created this kind of secure environment in My HealtheVet, which plans to
launch an online messaging function in the near future. I know that some of the
people from My HealtheVet planned to be on the call today, so perhaps we could
ask Ginger Price who spoke to the NEC about the initiative, to tell us more about
it.

Dr. Berkowitz:

Great idea. Ginger, could you tell us briefly about MyHealtheVet and the plans for
making secure online messaging available in VA? I should say, for those of you
who don’t know, that Ginger Price is the Acting Director of Health Informatics
Strategy at the VA Office of Health Information and Acting Director of the My
HealtheVet Program. Could you please tell us briefly about the My HealtheVet
initiative, and the plans for making secure online messaging available in VA?

Ginger Price, ACIO:

I’d be happy to Ken. This is of course, a work in progress. About a year ago we
went to the National Leadership Board with two proposals. One was to give
electronic access to information to veterans and the other was to investigate a
secure messaging function between clinicians and patients. The second was
unanimously decided upon that a secure messaging function should take place
within My HealtheVet. This would alleviate many of the issues that have been
alluded to earlier about the identification of the patient, encryption of the
information, and keeping patient information very safe. I just came today from
talking with a company that offers an identity authentication service, and we may
well be instituting that as well, which would give us some added security on the
front end of My HealtheVet that would then extend to online messaging as well.

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For that past year we have had an implementation working group meeting on the
clinician-patient messaging issue, discussing many of the issues that have been
brought up today about workload credit, what kind of business model should be
in place, etc. We have that report in, and we are about to start with the first
simple steps to arrange a point-to-point patient-clinician messaging function. That
will, of course, be secured, encrypted, and available on an opt-in basis. That
means that both patient and clinician both agree that they wish to enter into a
sort of contract, and the implementation working group has suggested what this
contract might look like. We should have the results of that out and ready to send
to people, and then we will start to construct the messaging function. We are
going to be able to use basically a listserv function in a way which is messaging,
but does not need to be secure, which will channel health information and health
awareness information to patients this November. So, that’s the first step.

Dr. Berkowitz:

Thanks very much. But let’s turn to some of the other ethical challenges of online
messaging. Access is also an important issue. Will encouraging online
communication between patients and clinicians exacerbate existing inequalities
in health care by discriminating against those who have no or limited access to
the technology?

Dr. Crigger:

Many of those who are most in need of health care services are also among the
most disadvantaged segments of the American population and might benefit
most from having online access to clinicians. At the same time though, they are
also less likely to be online or to utilize online communication when they have
access. The so called “digital divide” is closing, but members of minorities, and
those who have lower income and/or less education, as well as older individuals,
are still less likely to be online than other segments of the population. Providing
free access through libraries, schools, or communication centers can help, but
doesn’t really solve the problem because information may be too personal for a
public arena and/or there are restrictions in access because of operating hours.

In addition, when we think about access it’s important to consider not just
physical access, but a patient’s ability to use the technology. Difficulty using a
computer or poor reading and writing skills can be just as big a barrier as not
having access to a computer at all. The most important point is to assure that
patients, who don’t communicate online, whatever the reason, receive the same
clinically appropriate care as their online peers.

Dr. Berkowitz:

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That’s right. One standard of care whether online or off is the bottom line. But,
even if the quality of care is the same, moving from a face to face interaction to
an electronic relationship, it simply has to change the patient-clinician
relationship. There seems to be a real divide among clinician. Some think
communicating with their patients online is great. But others worry that something
valuable is lost in the patient-clinician relationship when it isn’t face to face.

Dr. Derse:

Yes, some clinicians are concerned because online communication does not
allow for the nonverbal communication that plays an important role in the patient-
clinician relationship. All the things that you get the sense from seeing the
person, from seeing how they speak and talk, and move. All of that is lost when
someone’s online. I should also point out that all that is often lost on the
telephone too, so it’s not that big a jump. They feel they won’t have the same
contact with their patients. Many clinicians don’t agree with that, however. Many
are able to have satisfying relationships with patients utilizing online
communication. Patients also have different opinions about the experience.
Some feel that it enhances the relationship because they are able to speak more
freely. Regardless, online communication has the potential to change the
dynamics of the patient-clinician interaction and individual patients and clinicians
will respond differently.

Dr. Berkowitz:

Art, could you elaborate a little on these concerns about how the patient-clinician
relationship could change?

Dr. Derse:

The concerns really are that the relationship can change for both the better and
for the worse in a number of ways. One is that patients can, of course, be more
directive about the relationship—they can contact their clinician when they want
to. It could, thereby, contribute to a more consumerist approach toward health
care, that is, the patient lets you know when they want your care, rather than you
telling them that they need to come in for a visit.

The other way that I think it can change the relationship is one that we really
don’t have great data to show how it will change, and this in the area of the
clinician’s ability to communicate compassion and care, and engendering trust
with patients. Those kinds of things occur through all sorts of ways through the
ways that doctor and patient interact, and through that thin medium of online
communication where so many things are filtered out. It’s possible that the
relationship will perhaps lose some of that. How best can you display
compassion and caring in an online interaction? I think those are still open
questions.

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Dr. Berkowitz:

There is also voluntariness of participation. Patients should always be able to
refuse online communication with their clinicians just like clinicians who are
concerned that communicating online will diminish the quality of their interactions
with patients should be permitted not to engage in this mode of communication.

This option, allowing some patients and clinicians to choose whether to
communication online, could create two classes of patients. We must be careful
to assure that opting out of online communication does not diminish access to or
quality of care.

With that, now is good time to discuss informed participation. Can you elaborate
on this?

Dr. Derse:

Sure Ken. Patients should be able to make well-considered decisions whether to
communicate online with clinicians. So clinicians have an obligation to explain
their online communications practices with their patients. This discussion should
include the limitations of web messaging, for example, that messages will not be
exchanged in real time as in instant messaging or that messaging cannot convey
some potentially important kinds of information. Clinicians should also explain
their offices’ and/or organizations’ practices for handling online messages.
Current professional guidelines recommend that clinicians enter into an
agreement with patients (orally or in writing) regarding the terms and conditions
that will govern their online communication. Privacy risks, security risks,
discussing whether and how messages will be incorporated in the medical
records and provisions for terminating the option of online messaging should also
be discussed.

Dr. Berkowitz:

What about written informed consent to participate in online communication? Is
that relevant?

Dr. Crigger:

That is still debated. The AMA recommends that patients sign agreements
regarding the terms of online communication and that it be documented in the
medical record. While it’s agreed that patients should be informed about the
opportunities and limitations of online communication, it isn’t clear ethically that
formal signature consent should be required.

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Dr. Berkowitz:

Dr. Derse, are there any boundaries of online professional practice that you
believe are relevant to mention?

Dr. Derse:

Well, the nature of online communication means that it can poses challenges
with regard to professional competence and quality of care. Clinicians need to
be clear with patients about what kinds of health concerns that can be addressed
via online communication and which health concerns should be handled in other
ways is an issue that must be considered. For example, it would be reasonable
to use online communication for questions about ongoing care for a problem
that’s already been diagnosed, or discuss new symptoms that aren’t severe,
such as a minor sore throat or cough. But patients should be warned not to try to
communicate online about emergency health concerns—you don’t want to post a
message to a website when you’re having chest pain! Drawing a bright line can
be difficult, however; both clinicians and patients have to use good judgment.
That’s another reason agreeing up front how they will use online communication
is important.

Otherwise, online communication is probably not best suited for initiating the
patient-clinician relationship for example. Things that occur in the first encounter
such as the physical examination cannot be accomplished online. Online
communication is probably not well suited for exchanging highly sensitive
information either. Also, both patients and clinicians should make efforts to
assure that they understand one another. Potentially problematic are messages
that are poorly organized, omit key pieces of information, or are carelessly
worded. Providing a template for messages can help assure that patients
provide the information clinicians need to respond appropriately.

Dr. Berkowitz:

And to pick up on of the things you mentioned about not initiating patient-clinician
relationships this way, that similar to all aspects of telemedicine, that online
messaging is really an attempt to enhance, not replace, face to face interactions.
So, it’s an augmentation device, not a replacement device.

Bette, you can talk about workload issues and time spent on this new clinical
activity?

Dr. Crigger:

Well, compensation for professional activity is an important one. Some clinicians
believe that communicating with patients online would be just one more activity

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that they will have to complete and that they will not be compensated by insurers
or health care plans for their efforts. In some cases, this may be true. Reading
and responding to patient messages can, in fact, add another level of work for
clinicians. Other clinicians who actively use online communication don’t believe it
is burdensome and believe it has been a good experience overall.

As far as reimbursement, to date, most clinicians have not been reimbursed for
their time handling patient online messages—any more than they have been for
telephone conversations. However, some third-party payers see potential for
cost savings and improved quality of care, and are exploring ways to reimburse
for online services (with or without patient copayment).

Dr. Berkowitz:

I think it is interesting that in a managed care environment, which we are one that
it is really workload recognition, not just compensation that clinicians might seek
as this activity might start to take up a lot of time. On the other side, if it makes
you more efficient, then you might be able to see more patients face to face.

As we can see by the discussion, online messaging has many advantages and
also presents some ethical challenges in the process. We all know that VA has
been in the forefront in utilizing and adopting information technologies in health
care delivery and in the improvement and quality of patient care, for example, the
CPRS system (computerized patient record system). My HealtheVet is another.

As we’ve heard My HealtheVet will solve some of the ethical challenges of online
patient-clinician communication by providing a secure environment and putting in
place ways to authenticate users. In VA as elsewhere, online messaging will
likely become a significant channel for communicating between patients and
clinicians. Even with My HealtheVet, however, there are potential ethical pitfalls.
Dr. Derse, can you outline the recommendations that VHA’s National Ethics
Committee developed for ethically sound online communication between patients
and clinicians?

Dr. Derse:

Sure Ken. Following are the seven recommendations from the report.

1) Clinicians and health care organizations should ensure that online
communication takes place only when the confidentiality and security of
personal health information can be reasonable assured. Once implemented
nationally, My HealtheVet will provide the foundation for a secure environment
required for responsible online communication between patients and clinicians.

2) Clinicians should ensure that patients who do not interact electronically
receive the same quality of care as their online peers. Online communication

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should not be allowed to exacerbate existing inequalities in health care by
discriminating against those who have no or limited access to online
communication.

3) Clinicians should be aware of the potential effects of online messaging
on the patient-clinician relationship and take steps to avoid
“depersonalization.” Just how online interaction affects patient-clinician
relationships is an empirical question that is still unsettled.

4) Participation in online messaging should be voluntary for both patients
and clinicians. As VHA gains more experience with this medium, requiring
clinicians’ participation may some day be justified. However, patient participation
should remain voluntary.

5) Clinicians should assure that patient participation in online
communication is well informed. Clinicians should enter into an explicit
agreement with patients, either orally or in writing, regarding the terms and
conditions that will govern their online communication. However, there is no
need to require patients to sign an informed consent form.

6) Clinicians should limit their online communication with patients to
appropriate uses. Online communication should not be used to initiate a
patient-clinician relationship, to handle situations of an urgent nature, or to
convey information that is highly sensitive. Messages should be carefully worded
and organized to ensure effective communication, and should conform to
organizational standards with regard to message handling.

7) Health care organizations should recognize online interactions with
patients as part of clinicians’ professional activities in institutionally
appropriate ways. This may be accomplished, for example, by formally
scheduling time for messaging, or by adopting, the recently proposed AMA CPT
code for online evaluation and management of patients to capture data regarding
online patient communication, evaluation, and management as a professional
activity.

MODERATED DISCUSSION

Dr. Berkowitz:
Thank you Dr. Derse and Dr. Crigger for discussing the topic of online patient-
clinician messaging, presenting the ethical challenges involved and giving us the
recommendations of the National Ethics Committee. Now that we have had an
opportunity to discuss online patient-clinician messaging, I would like to hear if
our audience has any response or questions.

Julia Haggerty, Phoenix VA:

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Regarding a patient who may type into My HealtheVet questions regarding
something like nausea, and get a rather generic answer from his doc that he is
bright yellow with jaundice. How are we going to replace the actual assessment
of the patient visually?

Dr. Berkowitz:

I don’t think that this is attended in any way to replace the visual assessment if
the visual assessment or physical exam is something important that has to be
done for the interaction.

Dr. Derse:

I think that’s a perfect example of how clinicians will have to think differently
about this. That is, that kind of visual cue that as soon as you walked into the
room you’d be able to tell is now lost. There is also the opportunity to ask the
patient, have you noticed a change in your skin color or in the whites of your
eyes, there might be some other questions that might be able to help. But, it is
true, that those cues that are right in front of you in the face to face interaction
are now gone, and things we may think of as general medical problems now
need to be rethought, as far as we are going to help sort out the serious from the
non-serious problems. That is a problem, no question, and we are going to have
to create new ways of asking those questions online, or categorizing nausea and
vomiting that persist that you have to come in.

Dr. Crigger:

There’s also been the suggestion that you use message templates. So, instead
of just letting the patient type in whatever message he types in, use a template to
help guide him, and maybe find some way to prompt him or her to give you more
information. It won’t solve the problem, but it might contain it in a certain way. But
designing appropriate templates is going to be a challenge too.

Melissa Brown, Greater Los Angeles VAMC:

Have you looked at guidelines for maybe working with groups of patients, and
how that may play out? I’m in mental health, so I’m thinking you might work with
caregivers support group.

Gary Christopherson:

I’m the Senior Advisor to the Undersecretary and have been a long champion of
the My HealtheVet program with Ginger. In the area of group work, we are
looking at how to build into My HealtheVet using a range of tools in which
messaging would be one, whereby we could have a group of individuals in a
moderated discussion to use these tools to interact and provide programming

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there as well. There may be areas outside of mental health, but mental health is
one of the areas that we are trying to work very early on, working with Fran
Murphy and others to make sure we can actually deliver that kind of capability.

We also, want to thank the Center and the Committee as well for the work that
was done on this report. It is very helpful for what we are trying to accomplish
with My HealtheVet, and what we are trying to accomplish with the messaging.
One thing that this group should be aware of, and Ginger mentioned it early on,
is that we went to the National Leadership Board, and got approval. There was a
lot of pre-work before we went to the National Leadership Board with groups like
the Chief Medical Officers, the Health Systems Committee, to make sure we are
doing this very well.

Lynn, Milwaukee VAMC:

My question is that with My HealtheVet that there is a real strong correlation with
the nurse advice line. Maybe we could triage some of these e-mails. Has
anything like that been looked into?

Mr. Christopherson:

What you are seeing right now is that there are two parts to the messaging
relationship. One is that we are really trying to build a relationship with whomever
is the primary provider, so there is a relationship issue as well as a content issue.
So the first goal of online messaging is to create a relationship with who the
patient is working with, and that can be a physician, a nurse, preferably it is a
person they regularly work with there. It is very important to look at this as a
supplement to the relation between a patient and the clinician that they see on a
regular basis.

Sue Ward, Reno:

For development of your templates to help channel down what information the
patient sends to clinicians, you might use what the telephone advise nurses use
in their algorithms, because that could help channel and focus the patient’s
energy. There might be prompts that if you have this then you need to not send
this e-mail but call the provider or go to the emergency room.

Another question: Is any of this going to go into CPRS, because in dealing with
our tort claims if the patient says one thing and the provider says something back
and their ends up being a tort claim, it’s very nice to have documentation as to
who said what when.

Mr. Christopherson:

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That’s what we are working on right now. We do believe, by the way, that this is
going to need to be either in the record, or patched to the record. For many
reasons, you want this information built in, especially over time as this
information becomes richer in content, where the patient is giving you information
that you don’t want to be part of the medical record. You clearly can do the cut-
and-paste route, and that’s one option. We are looking at ways to automate
entering that information into CPRS. Part of what you get with automated is how
much of this message do you want to put in the record, and does it start to clutter
because some of the information is really critically to the record, some is
probably not so much there. So, cut-and-paste allows the clinician to put
whatever is important in there; the automated makes sure you don’t miss
something, so we are looking at both options.

Dr. Derse:

With online communication there are many analogies to telephone
communication. The idea of an algorithm is a great idea, but the analogy with the
telephone breaks down a little bit when you think about liability issues, because
of course there is liability for giving advice to patient’s over the telephone, but
then there is no record of it. With written a record of some kind, there could be
the possibility of seeing what someone actually did say, so that a clinician who
said, “I told patient such-and-such, “ now over the telephone has merely him or
herself as a witness, but with the written record it might be something that could
be used to strengthen the defense from liability.

FROM THE FIELD

Dr. Berkowitz:
Now I want to turn to our “From the Field” segment, where we take comments
from our listeners on ethics topics not related to today’s call. Please remember,
no specific consultation requests in this open format, but I invite you now to make
your comments on other ethics-related topics, or to continue our discussion on
online patient-clinician messaging.

Diane Galski:
I think the obligation of the Ethics Committee is to protect the doctor-patient
relationship at all costs, and I think that online messaging, by definition, is
depersonalization of that important relationship. It is a far cry from the old time
house calls, where it’s not just face to face, but also hands on. The potential
advantages are much out-weighed by the disadvantages. I think one of the
potential abuses of the system, for example, is if you are online and the patient
decides to put you into his buddy system, and start chatting with you. I think
when you say it’s going to be voluntary, hopefully a lot of consideration has been
put into even going forward with this. I don’t know if any research has been done

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if physicians are supportive, how many veterans are supportive, how many
veterans have computers, etc.

Dr. Berkowitz:

I would challenge your premise that the obligation of the Ethics Committee is the
preserve the doctor-patient relationship. I think that’s true, but it doesn’t
necessarily has to stay in the form that it has. I don’t think that we need to be
resistant to change. Having said that I am an extremely staunch patient
advocate, and am very skeptical for the most part about change, and I agree with
many of the things you said, but I think that changing this relationship to add this
kind of interaction can increase access to doctors, break down barriers, and
increase efficiency. So, I think there is a lot of good that can come out of this
integrating this into our practices, and we’ve certainly talked about the things on
this call to be wary of.

Dr. Derse:

I don’t think that online messaging is an unalloyed good. Surveys show that
patients want this, and if you have to wait a long time to get a doctor’s
appointment, you call. And if they could send a message that they could get a
response to from their clinician, they would like to do that. I do think there are
some good things from it. That said, I think one task of the National Ethics
Committee is to tease out the good and the bad of this new technology. That is,
we want to protect the doctor-patient relationship, but this thing is coming down
the pike, and here are the good things about it and here are the bad things about
it. I’d love to say the doctor-patient relationship should only be in person, and in
fact, we shouldn’t even accept phone calls, just come on in so I can take a look
at you. But we sacrifice some of the interaction to be able to interact on the
phone, we don’t think about that all the time. Though our nurses who triage those
calls do think about it, and they know that it is sub-optimal, but it is timelier. And I
think that e-mail is a technology of this kind.

Mr. Christopherson:

E-mail is already going on, but it’s not being done securely, which is why we
have to do something about it. So, there is experience already in the VA system
already there. There is also substantial experience outside of the VA as well,
such as the Partners in Care group in Massachusetts who have been using
messaging systems for quite some period of time. I was just in Utah with another
speaker, Danny Sands, a physician who has been doing messaging for a long
time. You are absolutely right, this is not meant to take away from the patient-
clinician relationship, it’s just one more way for that to occur, and it can never be
treated as a substitute for a face to face encounter when that is what is needed.

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I indicated early on, that in VA this has gone through a very deliberate process, a
lot of discussion, and lots of different venues. Obviously work done by the Ethics
Committee and the Center as well has all been part of what we in this
organization have been doing more than anyone else has ever done, which is
really making sure we understand what it is, what we hope to accomplish with it,
how to do it right, and how to continue to titrate it as we get experience with it.

CONCLUSION

Dr. Berkowitz:

Well, as usual, we did not expect to conclude this discussion in the time allotted,
and unfortunately we are out of time for today’s discussion. We will post on our
Web site a very detailed summary of each National Ethics Teleconference. So
please visit our Web site to review today’s discussion. We will be sending a
follow up email for this call that will include the links to the appropriate web
addresses for the call summary, the CME credits, and the references referred to.

We would like to thank everyone who has worked hard on the development,
planning, and implementation of this call. It is never a trivial task and I appreciate
everyone’s efforts, especially, Dr. Art Derse, Dr. Bette Crigger, Nichelle Cherry,
and other members of the Ethics Center and EES staff who support these calls.

 Let me remind you our next NET call will be on Tuesday, October 26 from
12:00 – 1:00 pm EST. Please look to the Web site at vaww.va.gov/vhaethics
and your Outlook e-mail for details and announcements.

 I will be sending out a follow-up e-mail for this call with the e-mail addresses
and links that you can use to access the Ethics Center, the summary of this
call and the instructions for obtaining CME credits, and the references that I
mentioned.

 Please let us know if you or someone you know should be receiving the
announcements for these calls and didn’t.

 Please let us know if you have suggestions for topics for future calls.

 Again, our e-mail address is: vhaethics@hq.med.va.gov.

Thank you and have a great day!