A few years ago, doctors had only two types of contact with patients -- in person, and occasionally on the phone.

Today, more and more current and potential patients are using e-mail to ask questions, get advice, clarify billing problems, and even make appointments. Although the convenience of e-mail makes it a popular means of communication, it presents a number of risk management issues that doctors must be aware of.

"Confidentiality, security ... authenticity and archiving are four that come immediately to mind," says Catherine Keyes, J.D., an attorney and Loss Prevention Specialist at Risk Management Foundation. ("Patient E-mail Strategy," Resource, a publication of the Risk Management Foundation, June 1999.)

If a patient calls and says:

"I due for my regular appointment in two weeks, but I've been having those same pains in my side that I had a few months ago. Nothing really terrible, but kind of uncomfortable. Should I come in sooner or just wait for my regular visit?"

If you're familiar with the patient's frequent problem with muscle strain due to his job, you might be tempted to shoot back an e-mail response saying:

"I'm sure it'll be okay to wait. If the pain gets worse, we can get you in to check for subluxations before your regular appointment."

Innocent enough, right? Yet, by giving "medical advice" via e-mail, you may leave yourself open to a charge of malpractice if the pain turns out to be something requiring immediate attention. The patient can conceivably accuse you of having made a "diagnosis" via e-mail causing a delay in getting care. Far fetched? Not at all! Many million dollar lawsuits have been filed with less cause than that.

To avoid even the perception of wrongdoing, e-mail must never be used to perform diagnoses. Instead, information should be general, and in keeping with your normal practice purpose. In the above case, for instance, it would have been best to respond:

"It's impossible for me to tell whether you have any subluxations without examining you. If you'd like to come in right away, I'm sure we can set up an appointment. Don't forget, though, the purpose of my care isn't to "cure" your pain -- it's to correct your subluxations. You know from past experience how that has helped you. Why not call my office and set up an extra visit?"

With this message, you've done three things. You've reinforced the fact that you don't provide "medical" treatment, reminded the person of his past positive experience with chiropractic, and shown interest in his or her well-being.

E-mail also raises privacy issues, particularly in light of recent privacy regulations instituted by the U.S. Department of Health and Human Services. E-mail messages are not secure and should never be used for communicating private information.

Although the problems faced by doctors of chiropractic will differ -- and are usually less severe -- than those faced by medical physicians, the Guidelines developed by the American Medical Informatics Association ("Guidelines for the Clinical Use of Electronic Mail with Patients," Journal of the American Medical Informatics Association, Volume 5, Number 1, Jan/Feb 1998) can help identify many of the precautions that D.C.s should take.

The most relevant points of the AMIA Guidelines are:

*** Be sure to tell patients NOT to use e-mail for urgent matters.

*** Let patients know who else might read your e-mail messages (your C.A., billing clerk, practice colleagues, et. al.) and that a written printout of their messages will be placed in their records.

*** Establish what type of transactions (appointment scheduling, general information, billing questions, etc.) will be permitted over e-mail.

*** Ask patients to put the category of message in the subject line of their message: "appointment," "billing question."

*** Have patients put their full name in the body of all messages.

*** Set up an automatic reply to acknowledge receipt of messages.

*** Print all messages, with replies and confirmation of receipt, and place in patient's paper record file.

*** Maintain an e-mail list of patients, but do not send group mailings where recipient names and addresses are visible to each other.

*** Avoid anger, sarcasm, harsh criticism, and libelous references to third parties in messages.

*** Be sure the person you are e-mailing is your patient. Verify e-mail address changes with the patient before using them.