More Opinions on Practice Management

The decision to add laser procedures to your current practice can be daunting yet exciting. Realistically, this is unlike Field of Dreams, as patients do not materialize just because you have a new laser. Certain questions are important to answer in making this decision.

Read more

The largest asset on your balance sheet is almost certainly, believe it or not, accounts receivable. Collecting balances due has always been a problem for physicians.

Read more

The word "volunteer" is unusual in that it may be used as a noun, verb, or adjective. As a noun, it identifies a person who performs a service of his or her own free will, and, importantly, as a verb, it means to do charitable or helpful work without pay.

Read more

Film is dead, it has gone the way of the daguerreotype and calotype. As DVDs have replaced VHS, digital cameras have replaced film cameras and for pretty much the same reason; digital cameras are easier to use.

Read more

Opinions on Practice Management

Joseph S. Eastern, MD, FAAD

How to Handle E-mails from Patients

Joseph S. Eastern, MD, FAAD

Tuesday, January 12, 2016

I recently received a lengthy e-mail from a very worried woman. She claimed to be an established patient in my office - though, because she had not signed her message, I had no way of confirming this. She asked many questions about sexually transmitted diseases, and how they might affect her and a new boyfriend.

I was undecided on how to reply - or even whether to reply at all - so I queried several dermatology colleagues around the country, as well as a few physician friends and acquaintances in other specialties.

Responses varied from "I never answer patient e-mails", to "she's better off getting correct answers from you than incorrect answers online" - and everything in between.

Clearly this is a controversial issue, and it will only get more controversial in the future; so I decided to look at what has been published on the subject.

In 1998, Eysenbach and Diepgen1 questioned this subject and designed a study to address it. Posing as a patient, they sent e-mails to random dermatologists describing an acute dermatologicalproblem, tallied the responses they received, and followed up with a questionnaire.

As with my informal survey, the authors found what they termed "a striking lack of consensus" in their responses: 50% of the physicians queried responded to the fictitiouspatient's e-mail; of those, 31% refused to give advicewithout seeing the patient and 59% offered a diagnosis, with a third of the latter group providingspecific advice about therapy (Figure 1). In response to the questionnaire, which was sent to responders and non-responders alike,28% said that they tended not to answerany patient e-mails, 24% said they usually replied with a standardmessage, and 24% said they answer each request individually. The authors concluded that "standards for physician responseto unsolicited patient e-mail are needed."


Patient Emails

Figure 1. Physician responses to fictitious patient e-mails, as demonstrated by Eysenbach and Diepgen (1998)1


My own decidedly non-scientific survey suggests that, almost two decades later, there is still nothing resembling a consensus on this issue. While several groups, including the American Medical Informatics Association (AMIA)2 and the American Medical Association (AMA)3 have proposed guidelines, none seem to have been generally accepted. Until that happens, it would be wise for each individual practitioner to take time to adopt their own guidelines. For ideas, take a look at the AMIA and AMA proposals, plus any others you can find. When you are done, consider running your guidelines past your attorney to make sure you have not forgotten anything, and that there are no particular requirements in your state.

Your guidelines may be very simple (if you decide never to answer any queries) or very complex, depending on your situation and personal philosophy. However, all guidelines should cover issues such as authentication of correspondents' identities, informed consent, licensing jurisdiction (if you receive e-mails from states in which you are not licensed), and above all, confidentiality.

Contrary to popular belief, the Health Insurance Portability and Accountability Act (HIPAA) does not prohibit such communication, nor require that it be encrypted. The HIPAA website (see specifically says "patients may initiate communications with a provider using e-mail. If this situation occurs, the healthcare provider can assume (unless the patient has explicitly stated otherwise) that e-mail communications are acceptable to the individual."

Still, if the lack of encryption and other privacy safeguards makes you uncomfortable, encryption software can be added to your practice's e-mail system. Enli (, Sigaba (, Tumbleweed (, Zix (, and many other vendors sell encryption packages. (I have no financial interest in any product or enterprise mentioned.)

But rather than simply encrypting your e-mail, consider adopting web-based messaging, where patients enter your website and send a message using an electronic template that you design. You (or a designated staffer) will be notified by regular e-mail when messages are received, and you can post a reply on a page that can only be accessed by the patient. Besides enhancing privacy and security, you can state your guidelines clearly to preclude any misunderstanding of what you will and will not address online.

Web-based messaging services can be freestanding or incorporated into existing secure web sites. Medfusion (, RelayHealth (, and other companies offer secure messaging services.

As for the e-mail query which triggered all this; I responded, but I told the patient I could not provide specific answers to such personal questions over the Internet, particularly when they were asked anonymously; but I would be happy to address her concerns in person, in my office.

Meanwhile, I'm working on my own guidelines.



  1. Eysenbach G and Diepgen TL. Responses to Unsolicited Patient E-mail Requests for Medical Advice on the World Wide Web. JAMA 1998;280:1333-5.
  2. Kane B and Sands DZ. Guidelines for the Clinical Use of Electronic Mail with Patients. J Am Med Inform Assoc 1998;105:104-11.
  3. American Medical Association. Guidelines for Patient-Physician Electronic Mail. Available at: Accessed 12 January 2016.