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Electronic communication can extend and complement direct patient encounters, improve adherence and access to care, and increase patients' involvement in their care. E-mail is well-suited for communicating administrative information, medication instructions, patient education, routine laboratory results, and appointment reminders. It can augment home monitoring of treatment plans, such as diabetes care or smoking cessation. Clinicians can make announcements to an entire patient population about vacation coverage, influenza vaccination, changes in referral procedures, withdrawal of medications from the market, and other topics (Table e3–1).

Table e3–1.Some suggested uses of patient–clinician e-mail.

However, using e-mail clinically creates legal, ethical, and practical concerns. E-mail is more permanent than oral communication but can seem more informal than paper correspondence. It is by its nature self-documenting. An e-mail can be duplicated or forwarded with a few keystrokes and inadequate thought, and copies may linger on intermediate or back-up systems long after the sender and receiver have deleted the originals. The casual nature of e-mail in the absence of nonverbal social cues commonly leads to misunderstandings. E-mail can be easily altered by the sender, the recipient, or a third party, retrospectively and without attribution. It is very difficult to positively identify the sender or recipient on either end of an e-mail exchange, and with modest technical expertise, it is easy to fabricate an e-mail from most addresses.

Clinicians are sometimes concerned that once their e-mail address becomes widely available, they will be deluged by messages from individuals with whom they have no preexisting therapeutic relationship. Studies have not found the volume of e-mail from unfamiliar patients to be burdensome in practice. However, there is currently no consensus on the clinician's duty in this situation. Additionally, there may be legal consequences to providing advice to patients who are out of state or abroad and thus beyond the scope of the clinician's license. At minimum, clinicians should post electronic communication policies addressing unsolicited communication wherever their e-mail address can be found.

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