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Physicians planning to incorporate electronic communication with their patients must be prepared to manage unsolicited e-mail, maintain patient confidentiality, and adopt practices that

Enhance Physician-Patient Communication

Abstract

The rise in Internet use by patients with musculoskeletal problems has put orthopaedic surgeons under increased pressure to provide Web-based resources Patients are researching musculoskeletal conditions online, and many want to communicate electronically with their physicians Online medical information may be a useful adjunct to traditional physician-patient interaction because it is readily available, is wide in scope, and can provide the patient with basic knowledge on a given topic A clinical encounter may then be efficiently spent refining information and answering specific questions Orthopaedic surgeons should be aware of the advantages

of using Internet resources as part of their practice as well as the potential legal and confidentiality pitfalls in electronic

communication Some patient concerns may be easily satisfied and communication enhanced through the use of e-mail Physicians planning to incorporate electronic communication with their patients must be prepared to manage unsolicited e-mail, maintain patient confidentiality, and adopt practices that maximize the use

of online resources to enhance patient education

Use of the Internet has increased exponentially, from 18 million adult users in the United States in

1996 to 140 million in April 2002.1

As of December 2003, 69% of Amer-ican adults were regularly online.2

The Internet is commonly used to obtain health or medical informa-tion,3but users searching for health information may not have the same needs or interests as actual patients

“Health information” encompasses exercise, diet, and home remedies as well as the usual sphere of medical knowledge

Physician-Patient E-mail Public Demand

There is great public demand for physician-patient e-mail

communi-cation A recent Harris poll of adult Internet users indicated that a sub-stantial number would actually choose their physician based on his

or her ability to use e-mail with pa-tients.4There are methodologic con-cerns with the results, however, be-cause the population of patients is likely not demographically the same

as adults who use the Internet There

is considerable selection bias among adults who are online to begin with,

as well as with those willing to take the time to answer an online poll Kleiner et al5evaluated a popula-tion of pediatric clinics, polling the physicians and parents about their interest in electronic physician-patient communication Sixty-two percent of the parents had regular online access, and 74% of those

ex-J Sybil Biermann, MD

Gregory J Golladay, MD

Richard N Peterson, JD

Dr Biermann is Associate Professor,

Department of Orthopaedic Surgery,

and Director, Musculoskeletal Oncology,

University of Michigan Medical Center,

Ann Arbor, MI Dr Golladay is Clinical

Associate Professor, Department of

Osteopathic Medicine, Michigan State

University, East Lansing, MI.

Mr Peterson is General Counsel, Office

of General Counsel, American Academy

of Orthopaedic Surgeons, Rosemont, IL.

None of the following authors or the

departments with which they are

affiliated has received anything of value

from or owns stock in a commercial

company or institution related directly or

indirectly to the subject of this article:

Dr Biermann and Mr Peterson Dr.

Golladay or the department with which

he is affiliated has received nonincome

support (such as equipment or

services), commercially derived

honoraria, or other non-research–related

funding (such as paid travel) from Pfizer.

Dr Golladay or the department with

which he is affiliated serves as a

consultant to or is an employee of

Zimmer.

Reprint requests: Dr Biermann,

University of Michigan Medical Center,

7304 CCGC/Box 0946, 1500 E

Medical Center Drive, Ann Arbor, MI

48109.

J Am Acad Orthop Surg

2006;14:136-144

Copyright 2006 by the American

Academy of Orthopaedic Surgeons.

pressed interest in using e-mail to

contact their child’s physician or

of-fice In contrast, of the 87% of

pedi-atricians with e-mail access, 79%

did not want to use e-mail for

physician-patient communication

Baraff et al6similarly noted in a

uni-versity pediatric practice that 65%

of respondents wished to

communi-cate with their child’s doctor’s office

via e-mail

In a similar study of family

prac-tice clinics, 950 patients with

sched-uled appointments were polled

about electronic communication.7

Fifty-four percent reported that they

had e-mail access, and the great

ma-jority of those respondents indicated

interest in electronic

communica-tion with their doctors for

prescrip-tion refills (90%), nonurgent

consul-tations (87%), and test results (84%)

Such studies suggest that patients do

want electronic communications

with their providers The growing

availability of online access to

banks, airlines, and retailers has

con-sumers increasingly looking to the

Internet for a variety of services The

health care sector has not kept pace

with these and other institutions

Certain limited segments of the

health care sector already offer

on-line services, as indicated by a

sur-vey of 99 university and college

health centers; of the 89 health

cen-ters that completed the survey, 64%

use some kind of electronic

commu-nication with patients Sixty-four

percent use e-mail for

administra-tive advice, 27% provide medical

ad-vice of a general nature, and 13%

give out select advice on a

case-by-case basis.8 Fifty-four percent of

these university and college health

centers plan further use of e-mail

with their patients The students

treated at these health centers will

expect electronic communication

with their future physicians after

graduation

Although a few electronic

com-munication systems have been

de-veloped and implemented, most

studies have not addressed patient

satisfaction with them However, Liederman and Morefield9evaluated patient satisfaction with a secure Web-based messaging system and re-ported that 88.8% of patients found

it easy to use (206/232) and that 85.8% were satisfied with the sys-tem (199/232) Satisfaction was closely associated with timely pro-vider response

Patients prefer e-mail communi-cation for many of the same reasons that have made the Internet useful for shopping and making travel ar-rangements E-mail is asynchronous,

so patients can send messages at any time of the day or night without be-ing restricted to normal business hours It avoids phone tag with phy-sicians or staff and satisfies privacy concerns when calls cannot be taken privately at work or home Patients may organize their thoughts and carefully review their physicians’

recommendations with no time con-straints E-mail communication also gives patients a “record” to review

to help them remember critical in-formation

Physicians’ Concerns

Physicians, however, have

sever-al personsever-al and professionsever-al reasons

to be wary of e-mail communication with patients Physicians are con-cerned about their e-mail inboxes becoming flooded with patient in-quiries, potential liability issues, and

an increased workload as a result of providing another conduit for pa-tients to reach them (in addition to being accessible via telephone, fax, standard mail, and drop-in visits).10

Additionally, e-mail messages sent

to physicians directly may contain inquiries that would normally be handled by office staff Finally, stud-ies of physicians’ attitudes have demonstrated that physicians would

be more receptive to such e-mail with a reimbursement system in place to compensate for the in-creased workload.11

In a study at the University of Michigan, Katz et al12assessed the

practicalities of physician-patient e-mail communication using two randomized groups of patients in a primary care practice involving

near-ly 100 physicians In the interven-tion group, patients were encouraged

to send e-mail messages to a special triage-based e-mail system with an address bearing their primary care physician’s name; clinic staff

access-ed the account to receive and re-spond to messages The control group had no change in its commu-nication practices The authors

re-ported a significantly (P < 0.01)

great-er volume of e-mail messages in the intervention group versus the con-trol group; however, there were no differences between groups with re-gard to phone volume and visit no-show rates, suggesting that the e-mail activity was incremental rather than substituting for more conventional means

A critical question is whether the use of e-mail actually can diminish health care costs A recent study conducted in California evaluated the use of a secure, Health Insurance Portability and Accountability Act (HIPAA)–compliant online commu-nication service and its impact on health care costs.13 This study, which involved more than 5,000 pa-tients and 282 physicians (mostly primary care providers),

demonstrat-ed statistically significant cost re-ductions in physician office claims

(P < 0.01) and in total health care claims (P < 0.05), which offset the

cost of reimbursement to physicians for Website visits Most physicians surveyed rated the service as satisfy-ing and easy to use; 56% preferred the Website visit to an in-office

vis-it for handling nonurgent patient health needs Patients who used the system were 45% less likely to visit the doctor and 36% less likely to telephone the doctor’s office Patient satisfaction ratings with electronic communication exceeded 90% when patients received a response by the next business morning In data collected separately from the study

but involving study clinicians,9most

physicians found it easy to use,

per-ceived it as improving patient

com-munication, and valued the

insur-ance reimbursement capability

In a study of the content of

patient-generated e-mails,

investiga-tors reported that, with appropriate

consent and instruction, most

pa-tients adhered to guidelines on

fo-cusing content, limiting the number

of requests per message, and

avoid-ing usavoid-ing e-mail for urgent requests

or highly sensitive content.14

Based on these results, Blue

Shield of California is broadening its

Web-visit program to other providers

in California.15 Additionally, Blue

Cross and Blue Shield of Tennessee,

Colorado, New York,

Massachu-setts, and Florida are beginning pilot

studies facilitated by RelayHealth

Corporation.16-18 In January 2004,

Providence Health Plan of Oregon

became the first insurer in that state

to begin reimbursing physicians for

e-visits.19

E-mail Communication

Options

Electronic communication with a

patient may take any of several

forms, and practitioners may decide

to use all, some, or none E-mail may

be used for clerical purposes—to

schedule, confirm, cancel, or change

appointments Patients may send

messages to request prescription

re-fills or physical therapy

prescrip-tions, or to ask medical questions

Physicians may send them to

pro-vide answers to queries or to propro-vide

additional medical information

Most studies of e-mail

communi-cation between providers and

pa-tients have been in the primary care

setting These studies show that the

additional work in establishing

in-formed consent, maintaining special

e-mail conduits of information, and

educating office staff may be worth

the effort The physician-patient

re-lationship can extend over years and

encompass a variety of medical

prob-lems, with an increased administra-tive load for the “gatekeeper”

prima-ry care doctor An example is the adult hypertensive diabetic patient who needs routine laboratory tests ordered, is on several medications requiring adjustments and refills, re-ceives occasional referrals to special-ists, or needs coverage for

emergen-cy visits In contrast, because of the nature of the specialty, most ortho-paedic practices have higher patient volume with less comprehensive medical care The time and cost of establishing informed consent, of-fice procedures for managing e-mail messages, and record keeping may not be justified for some orthopaedic practices

Setting Up an Office E-mail System

When setting up electronic physician-patient communication, several prac-tical considerations must be taken into account to ensure that e-mail messages are managed efficiently and are compliant with privacy regula-tions Several groups have written guidelines for practical, legal, and eth-ical physician-patient e-mail inter-action.20-23Table 1 contains an exten-sive list of guidelines Kittler et al24

demonstrated that although medical office staff may have some initial con-cerns regarding confidentiality and workload, there is a high degree of sat-isfaction once the electronic messag-ing system is implemented

Office E-mail Policy

Before implementing electronic communication with patients, an of-fice e-mail policy outlining expecta-tions for both patients and staff should be in place For example, con-sider creating a specific e-mail ad-dress for patient and office use, to be checked by a member of the office staff several times a day Implement policies and procedures designed to inform patients of expected response times to e-mail inquiries, and

clari-fy that any emergency or immediate

issues should be communicated via

a telephone call to the appropriate provider (and provide such number)

An emergency telephone number and instructions for hours and days when the office is closed also should

be available

All e-mail messages, from both physician and patient, must be in-cluded in the medical record The of-fice e-mail policy should specify the format for patient inquiries The in-quiry type (eg, appointment change, prescription) should appear in the subject line, with the patient identi-fication number or name in the first line of the body of the message This will save office staff many hours of work in appropriately directing the messages Additionally, the office e-mail policy should specify that pa-tients must respond to each message sent by the office so that the physi-cian knows that it has been re-ceived This receipt message also must be included in the patient’s record

The most practical way to man-age patient inquiries is to have one staff member triage all incoming e-mail messages to a specific e-mail address that is used only for physician-patient communication

To prevent privacy lapses, all work-stations in the office should have password-protected screen savers The policy should state that office staff should never forward patient e-mail messages except for triage and should never give out patient e-mail addresses

E-mail may be an incremental tool rather than a substitute for more conventional communica-tions The expectation with e-mail communication is improved patient understanding and care, but that re-mains to be proved

Informed Consent

An informed consent policy must

be developed for patients who wish

to communicate with the physi-cian’s office via e-mail As part of this e-mail consent policy, the

pa-tient should acknowledge that

e-mail communication may not be

secure and that, although all efforts

will be made to keep the

informa-tion confidential, the physician

can-not fully guarantee such

confidenti-ality In addition, the consent form

should discuss storage of the e-mail

consultations (eg, whether they will

be summarized or maintained as

full-text additions to the medical

record) Further, the informed

con-sent policy should advise patients to

note whether other persons have

ac-cess to messages at the e-mail

ad-dress and that particularly sensitive

medical information should not be

sent through the office e-mail, even

with encryption Finally, the

in-formed consent should notify

pa-tients that there may be an

incre-mental fee or co-pay for certain

services

Patients’ Privacy

HIPAA, along with several

indi-vidual states, mandates several

safe-guards for protecting patients’

“pro-tected health information.” These

safeguards apply to electronic

infor-mation as well as to written medical

records Because of the notorious

in-security of routine e-mail,

encryp-tion is necessary to meet HIPAA and

state privacy guidelines Encryption

may be implemented either by using

a commercial physician service or

with an encryption program that can

be purchased conventionally or

downloaded from the Internet

Pa-tients must also acquire the

soft-ware Unencrypted e-mail does not

meet HIPAA standards, and

physi-cians using it, even to respond to

un-encrypted patient inquiries,

poten-tially may be held liable for failure to

protect the privacy of the patient

MEDEM, a consortium of several

medical societies and the American

Medical Association, provides an

en-crypted e-mail service (www.medem

com) This service also features the

ability to charge for online e-mail

cor-respondence and consultations (with

existing patients only, not new

pa-tients); however, few physicians use

this service MDhub (www.mdhub.

com) is another site featuring secure physician-patient electronic commu-nication Both physicians and patients

must sign in to MDhub These two

sites meet HIPAA requirements be-cause the messages never actually leave the server They are maintained

on the site and thus are at signifi-cantly less risk from hackers

Legal Issues

Physician-patient electronic com-munication remains one of the most rapidly evolving areas of legal atten-tion Medical offices that elect to use electronic communications with their patients must continually up-date their knowledge of the related legal requirements and decisions To date, there have been no legal ac-tions against physicians regarding

Table 1 Guidelines for Physician-Patient Electronic Communication (E-mail)

E-mail allowed only with established patients Establish e-mail policies and distribute to patients in writing Establish format of e-mail communication

Type of inquiry should appear in the subject line Patient name and birth date or identification number in the body of the message

Address privacy concerns Encryption essential Header of e-mail should include a banner that conveys that the information contained in the e-mail is confidential and meant only for viewing by the recipient

No sensitive matters allowed in e-mail format Disclose who will view and respond to e-mail Use password-protected screen savers and timeout feature for desktop PCs

No e-mail address or information disclosed in e-mail will be disclosed to third parties without prior written authorization

Any group mailings should be done using the blind carbon copy feature

to avoid inadvertent transmission of patient e-mail addresses E-mail is saved in permanent record electronically with backup and also copied to paper chart if paperless office is not in effect

Require signed informed consent from patient agreeing to e-mail policies Establish time frames for responses

No urgent or emergent matters should be sent via e-mail Automatic reply should state time frame for response and direction to contact the office via telephone when an urgent reply or additional information is needed

Encourage use of autoreply to confirm patient has received and viewed response e-mail

Establish triage personnel to regularly check incoming e-mail and distribute

to appropriate physician or other health care provider Note whether there will be incremental fees or co-pay as a result

physician-patient e-mail

communi-cations

Commercial Physician

Consultations

Several existing commercial

Web-sites offer patients direct access to

physicians nationwide Depending

on the site, patients may receive an

e-mail response or post a question

that is answered on the site in a day

or two Because doctors are legally

prohibited from diagnosing patients

over the Internet, the services are

something less than a second

opin-ion, but they are far more

personal-ized and interactive than most of the

health information available on the

Internet Sometimes the

informa-tion is free; other sites charge a fee

for medical advice that is sent

direct-ly to the patient via e-mail

Insur-ance generally does not pay for these

consultations As with other

health-oriented sites, a concern is whether

the information actually comes

from a credible licensed physician

Unsolicited E-mail

Orthopaedic surgeons who do not

wish to receive electronic

communi-cation from patients should

consid-er taking appropriate precautions

The physician’s e-mail address

should not be on business cards

giv-en to patigiv-ents This may require

sep-arate business cards that include the

physician’s e-mail address for

profes-sional colleagues and other business

associates The e-mail address

should not be on the office or

hospi-tal Website If the hospihospi-tal or group

practice insists on including an

of-fice e-mail address, it should be that

of an administrator for the group or

unit rather than a personal address

Despite these precautions,

physi-cians may receive unsolicited

clini-cal inquiries Physicians responding

with any specifics may jeopardize

themselves for several reasons From

a legal perspective, depending on

where the patient and surgeon each

reside, giving tailored medical advice may be considered practicing medi-cine without a license Additionally, e-mail does not give full information about a patient encounter; relevant information may be erroneous, mis-leading, or absent; and there is sig-nificant risk of the physician’s giving incomplete or erroneous advice

The best way to manage unsolic-ited e-mails from patients is never to provide patient-specific information

If the volume of unsolicited e-mails

is high, consider creating a form let-ter to paste into the e-mail, indicat-ing that the patient should seek ad-vice from his or her own physician

If relevant, include an office number

in case the patient chooses to make

an appointment Another alternative

is to refer the patient to a hospital or other community resource

Office Website

Little has been published on the ef-ficacy and cost savings of an office Website, likely because those param-eters are more difficult to measure

Nevertheless, even a simple site that eliminates a few telephone calls to the organization to obtain driving di-rections may cut down on staff time

Focusing on patients, their fami-lies, and physicians can be revenue-enhancing for health care organiza-tions Physician and hospital Websites likely have an edge as in-formation brokers in helping pa-tients and consumers identify good, relevant information.25The primary utility in the office or hospital Web-site probably lies in assisting with marketing and practice promotion, the effects of which are difficult to measure A Website that assists po-tential patients in selecting caregiv-ers by providing information about provider interests and background may potentially enhance the new patient’s experience and likelihood

of satisfaction Patients who make informed choices regarding their providers are more likely to remain

with them and over time be happy with their providers.26

Brand awareness of a health sys-tem or group is best created through consumer marketing campaigns rather than through the organiza-tion’s Website However, the Web-site should function as a tool to build on that awareness and to en-able the patient to schedule an ap-pointment or choose a specific pro-vider A Website that facilitates this type of research before a patient se-lects a provider may be an excellent investment for a health care organi-zation.27

One study demonstrated a 39% increase in traffic to one hospital’s Website during a radio campaign promoting the hospital Tracking pa-tients who came into the hospital system by an initial Web-based

“push-to-talk” call-me-now system

or other initial Web entry showed to-tal revenue to the hospito-tal of more than $555,000 from 292 patients who came in through the Website during a 4-month period.28

The office Website has the poten-tial to save many hours of staff time spent providing general information

to patients and referring physicians Appropriate content for the office Website includes logistical informa-tion, such as the number and names

of the physicians in the practice as well as the practice address, hours, and directions to its location Prac-tice philosophy and parameters may

be included Patient education mate-rials may be produced by the prac-tice or, more commonly and at con-siderably less expense, linked to or provided by commercially or profes-sionally available sites, such as that

of the American Academy of Ortho-paedic Surgeons (AAOS) (http:// orthoinfo.aaos.org/) (Figure 1) The office Website may be devel-oped commercially, typically with creation and hosting expenses of sev-eral thousand dollars Alternatively, many national professional societ-ies, including the AAOS and the American Medical Association,

pro-vide members with free Web

host-ing, with design options as well as a

menu of options for including

differ-ent types of material (eg, physician

and staff educational background,

maps)

Once established, the office

Web-site should be kept current The

phy-sician should designate a staff

mem-ber to periodically review the office

Website to ensure that it is up to date

The site also should include the date

of most recent review or updating

For larger sites, page view

counters may be used for focusing

future Website development efforts

on those areas that receive the most

attention.29 Additionally, online

coupons for free gifts or free parking

help track which patients are

com-ing in because of the Website.30The

Website also may be used to collect

information regarding patients and

prospective patients in order to build

a relationship marketing database

Such a database is one component of

customer relationship management,

a planning and marketing strategy

that is growing in the health care

in-dustry.31

Although nearly everyone agrees

that a high-level interactive Website

is optimal for health care

organiza-tions, they can be expensive to build

and maintain for smaller

organiza-tions.32The most successful

interac-tive systems have been in large

hos-pital systems, such as Kaiser

Permanente (www.kponline.org),

which offers physician and nurse

messaging, patient information,

dis-cussion groups, appointment

sched-uling, and other interactive features

This type of site is well beyond the

scope of most small group physician

practices

Online Patient

Education Resources

Patients with musculoskeletal

prob-lems are increasingly relying on the

Internet for self-education A recent

study of visitors to one orthopaedic

education Website noted that

infor-mation about conditions and treat-ment were the two most common reasons that information was sought.33Depending on the diagno-sis, as many as 55% of patients with musculoskeletal conditions will have sought information related to their diagnosis before the office visit.34-36

Patient education via Internet re-sources offers the advantage of pro-viding detailed information and ad-vice using minimal staff time

Patients may review the material at their own pace By proactively di-recting patients to Websites, ortho-paedic surgeons can help not only ensure that patients are getting good material but also reduce wasted of-fice time reviewing material gleaned from less reputable sites Many sites, including that of the AAOS, offer downloadable materials that may be

printed without cost, in contrast to the relatively expensive printed pa-tient education materials that sur-geons can purchase

For most orthopaedic practices, there is little need to create new on-line material for patient education because of the abundance of material

on the Internet (Table 2) The AAOS (Figure 1) and most orthopaedic spe-cialty societies have expansive pa-tient education sites, with informa-tion that can be either accessed online or downloaded for later use Surgeons electing to host their own free site with the AAOS may place specific information from the AAOS directly onto their site AAOS mem-bers may log onto www.aaos.org us-ing their member identification number, then click Member Services

to access the site- creation templates

Figure 1

Patient education site of the American Academy of Orthopaedic Surgeons

Table 2

Selected Patient Education Websites

Your Orthopaedic Connection

(AAOS)

http://orthoinfo.aaos.org Wide selection of patient-friendly

information on anatomy as well as surgical and nonsurgical treatment options organized by body region The American Association of Hand

Surgery

http://www.handsurgery.org/

pubedu.html

PDF files of frequently asked questions on 12 common hand conditions

Arthritis Foundation http://www.arthritis.org/conditions/

default.asp

Frequently asked questions Topical index

Informational pamphlets Videos on arthritis and associated conditions

American Society for Surgery of

the Hand

http://www.assh.org/ Find a surgeon; hot topics; public

education content Centers for Disease Control and

Prevention

http://www.cdc.gov/ Listings by topic and alphabetically

Eaton Hand Surgery http://www.e-hand.com Conditions and treatment options

organized by presenting symptoms Good drawings

healthfinder http://www.healthfinder.gov/ Government Website linking to

patient education sites

HealthWeb http://www.healthweb.org/ Well-organized link page

Mayo Clinic http://www.mayoclinic.com/

index.cfm

Highly touted; multiple links, including orthopaedic surgery MedlinePlus http://www.nlm.nih.gov/

medlineplus/healthtopics.html

Health topics listed alphabetically Encyclopedic Interactive tutorials Health news Physician locator National Institute of Arthritis and

Musculoskeletal and Skin Diseases

(NIAMS)

http://www.niams.nih.gov/hi/

index.htm

Alphabetical compilation of handbooks on a variety of musculoskeletal diseases and conditions, with

question-and-answer format OrthopaedicWebLinks (OWL) http://www.orthopaedic

weblinks.com

Extensive links to additional resources

Links graded by reputability of information available National Osteoporosis Foundation http://www.nof.org/ Detailed patient information on

medical management of osteoporosis

Southern California Orthopedic

Institute

http://www.scoi.com Anatomy and frequently asked

questions Regional topics Patient videos University of Washington Shoulder

and Elbow Service

http://www.orthop.washington.edu/

shoulder_elbow

Comprehensive review of shoulder and elbow conditions and treatments

Other national patient education

Websites include that of the

Arthri-tis Foundation, which has excellent

material on surgical and nonsurgical

management of various forms of

ar-thritis Additionally, several

teach-ing hospitals and universities have

created excellent Websites to which

patients may be referred, or to which

orthopaedic surgeons may wish to

link their own sites Patient

advoca-cy groups, such as the Scoliosis

As-sociation, and orthopaedic specialty

societies also have extensive

educa-tion components on their Websites

Summary

The Internet is an ever-expanding

source of medical information for

pa-tients Using electronic media may

assist in patient education, and they

have the potential to aid in

stream-lining office practices Studies

sug-gest that patients would like to

com-municate with their physicians via

e-mail Although some physicians

are successfully using electronic

communication, in general,

ortho-paedic surgeons currently find

patient-specific e-mail

communica-tion logistically, legally, and

techni-cally complicated Given the

de-mand, however, methods of

streamlining the process likely will

arise Websites can be a valuable

source of patient education

material—both medical and

logisti-cal—and may assist the surgeon in

delivering health information to

pa-tients Advances in e-health

technol-ogy likely will drive the next level of

patient self-care.37 Orthopaedic

surgeons who are interested in

im-proving their physician-patient skills

should see the AAOS Website

(http://www5.aaos.org/courses/csmp/

index.htm), which provides

informa-tion on mentoring programs

References

Citation numbers printed in bold

type indicate references published

within the past 5 years

1 Taylor H: Those with Internet access

continue to grow but at a slower

rate The Harris Poll #8, February

2, 2003 Available at: http://

www.harrisinteractive.com / harris_

poll/index.asp?PID=356 Accessed October 15, 2003.

2 Taylor H: Online activity grows as

more people use Internet for

more purposes The Harris Poll

#4, January 21, 2004 Available at: http://www.harrisinteractive.com /harris_poll/index.asp?PID=433 Ac-cessed May 20, 2004.

3 Fox S, Rainie L: Vital decisions: How

Internet users decide what informa-tion to trust when they or & their

loved ones are sick Pew Internet &

American Life Project Available at:

http://www.pewinternet.org/reports/

toc.asp?Report=59 Accessed October

15, 2003.

4 Taylor H, Leitman R (eds): Patient/

Physician online communication:

Many patients want it, would pay for

it, and it would influence their choice

of doctors and health plans Health

Care News 2002;2:1-4 Available at: http://www.harrisinteractive.com /news / newsletters / healthnews / HI_

HealthCareNews2002Vol2_Iss08.pdf.

Accessed May 20, 2004.

5 Kleiner KD, Akers R, Burke BL,

Wern-er EJ: Parent and physician attitudes regarding electronic communication

in pediatric practices. Pediatrics

2002;109:740-744.

6 Baraff LJ, Wall SP, Lee TJ, Guzy J: Use

of the Internet and e-mail for medical advice and information by parents of a university pediatric faculty practice.

Clin Pediatr (Phila)2003;42:557-560.

7 Couchman GR, Forjuoh SN, Rascoe

TG: E-mail communications in

fami-ly practice: What do patients expect?

J Fam Pract2001;50:414-418.

8 Neinstein L: Utilization of electronic communication (E-mail) with patients

at university and college health

cen-ters J Adolesc Health 2000;27:6-11.

9 Liederman EM, Morefield CS: Web

messaging: A new tool for

patient-physician communication J Am

Med Inform Assoc2003;10:260-270.

10 Houston TK, Sands DZ, Nash BR,

Ford DE: Experiences of physicians who frequently use e-mail with

pa-tients Health Commun 2003;15:

515-525.

11 Hobbs J, Wald J, Jagannath YS, et al:

Opportunities to enhance patient and

physician e-mail contact Int J Med

Inform2003;70:1-9.

12 Katz SJ, Moyer CA, Cox DT, Stern

DT: Effect of triage-based E-mail

sys-tem on clinic resource use and patient and physician satisfaction in primary care: A randomized controlled trial.

J Gen Intern Med2003;18:736-744.

13 The RelayHealth webVisit Study:

Final report RelayHealth Available

a t: http: //demo.relayhealth.com/rh/ GENERAL / studyResults / webVisit StudyResults.pdf Accessed May 20, 2004.

14 White CB, Moyer CA, Stern DT, Katz

SJ: A content analysis of e-mail com-munication between patients and their providers: Patients get the

mes-sage J Am Med Inform Assoc 2004;

11:260-267.

15 Solovy A: E-mail minus ‘e-mail:’

Cal-ifornia study shows that online com-munication can benefit patients,

phy-sicians and payers Hosp Health

Netw2002;76:26.

16 Unique pilot program reimburses for

greater contact with patients

Inter-net Medicine: A Critical Guide2004; 9:1, 3.

17 Kowalczyk L: The doctor will e-you

now: Insurers to pay physicians to

an-swer questions over the Web The

Boston Globe Available at: http://www.boston.com/dailyglobe2/ / 145metro/ The_doctor_wille_you_ now+.shtml Accessed May 25, 2004.

18 Cobbs C: Doctors’ advice may be just

a click away: Blue Cross Blue Shield of Florida plans to try online

consulta-tions for nonurgent problems

Orlan-do SentinelJune 7, 2004:A1.

19 Herzog B: Doctors paid for medical

care via e-mails: The Providence Health Plan reimburses physicians for some online medical consultations.

The OregonianMay 12, 2004 Avail-able at: http://www.oregonlive.com/ business/oregonian/ index.ssf?/ base/ business/108436315859910.xml Ac-cessed May 14, 2004.

20 Bovi AM, Council on Ethical and

Judi-cial Affairs of the American Medical Association: Ethical guidelines for use of electronic mail between

pa-tients and physicians Am J Bioeth

2003;3:W-IF2.

21 Kane B, Sands DZ: Guidelines for the clinical use of electronic mail with pa-tients: The AMIA Internet Working Group, Task Force on Guidelines for the Use of Clinic-Patient Electronic

Mail J Am Med Inform Assoc 1998;

5:104-111.

22 Spielberg AR: On call and online: So-ciohistorical, legal, and ethical impli-cations of e-mail for the

patient-physician relationship JAMA 1998;

280:1353-1359.

23 Luria Spiotta V: Legal concerns

sur-rounding e-mail use in a medical

prac-tice JONAS Healthc Law Ethics

Regul2003;5:53-59.

24 Kittler AF, Wald JS, Volk LA, et al: The

role of primary care non-physician

clinic staff in e-mail communication

with patients Int J Med Inform 2004;

73:333-340.

25 Johnson DE: Web site experimenting

can benefit hospitals Health Care

Strateg Manage2000;18:2-3.

26 Hsu J, Schmittdiel J, Krupat E, et al:

Patient choice: A randomized

con-trolled trial of provider selection.

J Gen Intern Med2003;18:319-325.

27 Malcolm C: Making a healthcare Web

site a sound investment Healthc

Financ Manage 2001;55:74, 76,

78-79.

28 Figuring ROI: How much is your site

worth to your organization? Internet

Healthc Strateg2003;5:9-12.

29 Ong KR, Kingham B, Sotiridy K,

Kauf-man D, Polkowski M, Schofield J:

Web presence of an integrated deliv-ery system at year one: Lessons

learned Int J Med Inform 2003;70:

11-18.

30 Get a free gift on your first visit Swed-ish Medical Center Seattle, WA Avail-able at: http://www.swedish.org/

body.cfm?id=764 Accessed June 1, 2004.

31 Rees T: Illinois hospital using Web to build database for relationship mar-keting. Profiles Healthc Mark

2000;16:1, 4-9, 3.

32 Bell H: Going interactive: Once the laggards of interactivity, hospitals are beginning to build Web sites

consum-ers can use Healthc Inform 2000;17:

85-86, 88, 90-92.

33 Shuyler KS, Knight KM: What are

pa-tients seeking when they turn to the

Internet? Qualitative content analy-sis of questions asked by visitors to an orthopaedics Web site. J Med Internet Res2003;5:e24.

34 Krempec J, Hall J, Biermann JS:

Inter-net use by patients in orthopaedic

sur-gery Iowa Orthop J 2003;23:80-82.

35 Beall MS III, Golladay GJ, Greenfield

ML, Hensinger RN, Biermann JS: Use

of the Internet by pediatric

ortho-paedic outpatients J Pediatr Orthop

2002;22:261-264.

36 Gupte CM, Hassan AN, McDermott

ID, Thomas RD: The Internet–friend

or foe? A questionnaire study of

ortho-paedic out-patients Ann R Coll Surg

Engl2002;84:187-192.

37 Forkner-Dunn J: Internet-based

pa-tient self-care: The next generation of

health care delivery J Med Internet

Res2003;5:e8.