Dr. Steven Adkins was in Target on a Saturday night when his cell phone rang. One of his patients had finally broken out in the rash that Adkins was expecting. The patient sent a photo of the rash to Adkins, he diagnosed her with shingles and called in a prescription for her.
For Adkins, a family medicine provider at Holston Medical Group’s Weber City, Va., office, electronic communication like this can be an appropriate way to deal with established patients.
Adkins doesn’t routinely give his cell phone number and e-mail address to his patients, but a second patient did use a cell phone to forward a photo of a foot wound.
"These are people you have an established relationship with and are dealing with an evolving or ongoing problem," he said. "The ability to have that photo graph of that wound in real time is adjunct care. It’s not a substitute for care. It’s just a tool and a tool has good and bad things about it. It’s how we use that tool that’s important. None of that should be substituted for hands-on, face-to-face when necessary."
Gone are the days when the only way to reach your doctor was by telephone. Both HMG and Wellmont Health System have patient portals — secure, private websites — that allow patients to access their personal health information and the ability to interact with their health-care provider. Some physicians are willing to communicate with their patients through email or texting. And, Adkins said, telemedicine — medical information exchanged from one site to another via electronic communications — is evolving.
It’s new and ever-changing territory for health-care providers. With it comes concern about using communication that could violate HIPAA (the federal Health Insurance Portability and Accountability Act) designed to protect the privacy of health information.
Wellmont Health System does have a policy concerning how its doctors communicate with their patients, said Dr. Landon Combs, a pediatrician with Gray Station Primary Care in Gray and a member of the Wellmont Medical Associates’ board of directors.
"Currently it’s by phone, in person or for physicians who are part of [Wellmont Medical Associates’] Patient-Centered Medical Home project ... [patients] can ask a nurse a question, receive records or schedule an appointment. Because it’s a secure email communication, they’re not really sharing personal health information across the Internet. We have to follow the standards set forth by our legal council and HIPAA."
Using the patient portal and a secure login, Wellmont Medical Associates patients can request an appointment, ask a nurse questions, request a prescription refill, and request immunization records.
"There’s not anyone I know who texts," Combs said. "The policy should address all. It covers telephone, person-to-person, who information can be shared with, and it covers the portals and email communication."
Combs said he doesn’t text or email with patients because there’s no way to guarantee the security of it.
"The nice thing about the patient portal, when a message is sent or received, the patient’s email account is attached. ... You’re not emailing them directly. Your doctor has sent a message through the portal. You need to log in and see the message. You log into your account and it’s very secure."
Messages sent through the patient portal are handled much like a phone call directly to the physician’s office. There’s a 24- to 48-hour respond time, and patients shouldn’t use the portal in the event of an emergency.
"The majority of patients still pick up the phone and call, but many have signed up for it and the use increases daily," Combs said.
In December, Wellmont Medical Associates will launch an even more robust patient portal that will give patients more access to medical information and further enhance communication. It will also help those physicians better coordinate patient care by enhancing communication between Wellmont Medical Associates’ primary care doctors and physician specialists through more complete sharing of patient medical information.
HMG has thousands of patients actively utilizing the myHMG/mySeasons patient portal. It also has physicians, like Adkins, who will occasionally communicate by text with patients under what they call "special patients; special circumstances."
Adkins said he’s not aware of a formal policy for HMG providers regarding texting and emailing, and believes some guidelines will need to be established.
"Our general approach is to try to drive that through our patient portal as much as we can, but we recognize those technologies are out there and are going to be used," he said. "There are certain statutes out there already like HIPAA regulations regarding patient privacy and that’s a big concern. Most standard email systems are not HIPAA compliant. It’s something we’re wrestling with right now."
Adkins said he informally questioned fellow HMG physicians and wasn’t surprised to learn that a handful of them will text with certain patients.
"We’re all over the map when it comes to these technologies used by patients and for medical communication. The genie is out of the bottle, and we’re not going to get the genie back in," he said. "A majority of responses were along the lines of, ‘Yes, I do it, but only certain times — ‘special patients, special circumstances.’ It’s email and text. Every provider has a cell phone, and the majority are smart phones. Most get email on their phone; they do texting. You really have the same concerns regardless of the method — privacy and security, medical liability and documentation," he said.
"One of things that is a problem is how to capture that information and pull it into the EMR [electronic medical record]. How do we move that information from that conversation on the mobile device into the EMR?" he said.
Adkins said the majority of providers who responded affirmatively are primary care physicians who believe that by answering a text or email they can help their patient and save him or her a trip to the emergency room or urgent care facility.
One HMG physician told Adkins that he will provide his post-surgical patients with his cell phone number, if he is going to be out of town or otherwise unavailable to those patients. That way he can deal personally with issues that might come up after surgery.
Adkins said he’s had several instances lately where he’s communicated with patients through cell phone or texting, including the patient with shingles.
"I think to not use these tools when they’re at our disposal does the patient a disservice, but we have to use them properly," he said. "It’s useful technology, but it’s still evolving.
"The direction we want this to go ... is to drive all of this to mobile versions of our electronic health record and our patient portal so in the next three, four months we’re anticipating a major upgrade to the HMG patient portal," he said.
Patients will have access to an app on their smartphone that will enable them to access lab results, make appointments and change appointments, request medication refills and their child’s immunization records.
"That’s the optimum. That’s the way to do it, and as we get these different technologies better integrated, their smartphone becomes their primary way they want to communicate with us," he said.
Combs agrees that health-care needs to keep pace with changes in communication.
"Because of technology available and with the younger generation, this is what they’re used to doing. That’s how a lot of these technologies are advancing and that’s why we’re doing it," Combs said. "We want to contact them the way they want to be contacted."