The document discusses Marshall McLuhan's view that new technologies constitute "collective surgery" on society with little regard for consequences, and that while the area of direct impact may be numb, it is the entire social system that changes. It provides context on how email, patient portals, and other digital media are used differently in medicine today, with patients now producing their own medical records, participating in decisions, and researching information. Factors driving this change include government financial incentives for adoption of digital health records.

1. Marshal McLuhan in Understanding Media , 1964 “ The new media and technologies by which we amplify and extend ourselves constitute huge collective surgery carried out on the social body with complete disregard for antiseptics. If the operations are needed, the inevitability of infecting the whole system during the operation has to be considered. For in operating on society with a new technology, it is not the incised area that is most affected. The area of impact and incision is numb. It is the entire system that is changed” (p.4). Copyright Susan M. Wieczorek & The University of Pittsburgh, 2009

2. Today’s Medical Environment Email, MySpace, Face Book, Twitters, Web Pages, Patient Portals, EHRs How are these forms of media used differently in the medical profession? What makes them unique?

3. Patients Are Now… PRODUCERS of their own Medical Charts PARTICIPANTS in medical decision making RESEARCHERS of medical information

4. The Impetus for Change ? American Recovery & Reinvestment Act $787 Billion Total Stimulus Package $19.2 Billion HITECH Act $2 Billion to Department of Health & Human Services (HHS) and the newly created Office of the National Coordinator for Health IT (ONC) $17.2 Billion to healthcare providers who can demonstrate utilization of EHRs—e-Prescribing, connectivity that allows full patient health history visibility to providers, ability to report effective use to HHS.

5. Email & E-Messaging as a Social Instrument of Change In the Physician-Patient Relationship Emails exchanged through secured portals Emails allowing/encouraging patient input Emails becoming a part of the patient medical record.

6. Email: A Media Ecology Perspective “Socio-Informatics” A hybrid of letter writing and the spoken word Maintains the spontaneity of oral expression Done at anytime of day, interruption-free Can capture the emotion while it is happening Free-flowing ideas and thoughts representing mental state Provides the permanence of written word Once the “send button” is pushed, you cannot take it back No email is really ever “deleted” Transcends time and space Message sent despite physical disability, location, or age

7. Email: An American Medical Informatics Association Approach The AMIA has defined patient-provider electronic mail as… “ computer-based communication between clinicians and patients within a contractual relationship in which the health care provider has taken on an explicit measure of responsibility for the client’s care.” This includes medical advice, treatment, and information exchanged professionally between physicians and their patients through electronic interactions.

8. Institute of Medicine IOM, 2001 Patients should receive care whenever they need it and in many forms, not just face-to-face visits . Health care systems must be responsive at all times and access to care should be provided over the Internet, by telephone, and by other means in addition to in-person visits. The key to a trusting, effective relationship involves multiple levels of communication , including but not limited to email.

9. Rationale Exists for Emailing But do your patients want & need this ? Center for Studying Health System Changes “Tracking Report” August 2008 (Tu & Cohen, 2008) Over 122 million people in US in 2007 reported seeking information about their personal health concerns. Of this group 16% in 2001 and 32% in 2007 sought medical information on the Internet (a doubling of online usage by adults). Possible reasons for this increase: An exponential increase in high-speech Internet residential assess (Horrigan and Smith, 2007) An increase in Web-based health sites for consumers (Noonan, 2007).

10. Tu, Ha T, and Genna R. Cohen, Striking Jump in Consumers Seeking Health Care Information , Tracking Report No. 20, Center for Studying Health System Change, Washington, D.C. (August 2008).

11. Tu, Ha T, and Genna R. Cohen, Striking Jump in Consumers Seeking Health Care Information , Tracking Report No. 20, Center for Studying Health System Change, Washington, D.C. (August 2008).

13. August 2009 http://thomsonreuters.com/content/healthcare/pdf/394449/healthcare_trend_report

16. April 22, 2008 Alicia Chang AP Science Writer It's no LOL: Few US doctors answer e-mails from patients http://www.boston.com/news/health/articles/2008/04/22/its_no_lol_few_us_doctors_answer_e_mails_from_patients/?p1=Well_MostPop_Emailed7

17. Guidelines for the Clinical Use of Electronic Mail with Patients The American Medical Informatics Association responded to patient need and physician concern with their own guidelines: (1) effective interaction between the physician and patient (2) the need for medico- legal prudence

18. AMIA General Guidelines on the Physician-Patient Relationship and Emails Must only be used when improving not complicating the relationship Must rely upon a negotiation between the patient and provider with emphasis on turnaround time, privacy permissible transaction and content discreet and categorical subject headers Must be formally and carefully delivered, received, and recorded. (Patients might be spontaneous but physicians must treat it like a legal document .)

19. AMIA Specific Guidelines on the Physician-Patient Relationship and Emails Use Automatic Replies to incoming messages must be sent indicating who has received the message and when it will be responded to. Place Email on Patient Chart. Email transactions must be archived in full and placed on the patient chart or EMR Have Patients Acknowledge They Received the Message. Acknowledgment of messages from the physician office should be requested from the patients to assure whether or not and at what point they received the information. Use a Footer to Direct Emergencies. This is necessary to help direct patients to escalate communication if an emergency arises. Use Blind Copies for Group Mailings. The address book and group mailings (generally with educational information)should be recorded with care and sent using a blind copy to insure privacy. Avoid Emotional Content to avoid misinterpretation. Omit Emoticons !

20. PHONE EMAIL Urgent Messages Less Urgent Messages “ Phone Tag” Direct Message to Receiver Synchronous Asynchronus Not Automatically Recorded Always Recorded Nonpermanent “proof” Permanent “Proof” Constant Office Interruptions End-of-Day Answers More Time Consuming Less Time Consuming Answering Machine Uncertainty Relayed Only to Consumer AMIA on Medico-Legal Prudence Treat Emails and Telephones Differently

21. AMIA on Medico-Legal Prudence Cont. Be sure email messages are encrypted HIPPA (Health Insurance Portability and Accountability Act) regulations state that email messages should be encrypted to prevent breaches of information or interception of data. Small physician practices can use software such as PGP (Pretty Good Privacy) but the patients’ computer must have the same software which can be downloaded off of the Internet. A secure password shared between the physician and patient enables both to have access to the medical data. Another possibility is a secure server messaging service (such as Healinx) which is a hybrid version of online communication. The patient goes to a third party server that is viewed as a Web page. Remember this is a LEGAL document and provides malpractice evidence of medical error. But no matter what the media, “The confidentiality of medical information and the privacy of email are paramount (Mandl, et al.).

22. AMA Guidelines for Physician-Patient Electronic communication Emails are not to be used to establish a patient-physician relationship They should only supplement other, more personal encounters such as the office visit. AMA recommends that emails be restricted to professional interactions placed in the patient’s EMR/Chart http://www.ama-assn.org/ama/pub/category/print/2386.html

23. Reimbursement Possibilities American College of Physician Executives Stated that over half the physicians surveyed stated that they would be willing to email medical advice to patients if they were reimbursed. Aetna and Cigna ($25 per consultation)

24. The Future From….Apple iPhones 3G and Push Emails Doylestown Hospital, Philadelphia 360 independent physicians in contact 24/7 To….Hawaii Medical Service Association Blue Cross Blue Shield Licensee Began January 15, 2009 An Internet version of the house call American Well (Internet Service) 700,000 members use the service for a $10 fee Nonmembers are charged $45 Each additional minute is $10

25. “ Once a new technology comes into a social milieu it cannot cease to permeate that milieu until every institution is saturated.” (McLuhan, 1964)

26. [email_address]

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