An Ethical Approach to Email and Text in Patient Care

This is the third in a series of articles in this column designed to facilitate adaptation to modern digital media by helping psychiatrists maintain professionalism and boundaries while employing new technology. Specifically, this article addresses ethical concerns when using email and text messaging to communicate with patients.

Although some institutions, such as the Armed Forces and Massachusetts Institute of Technology, have had access to electronic message sharing systems since the 1960s, email became accessible to the masses in the 1990s. Psychiatrists who are mid-career or older probably began using email for work at medical schools, hospitals, or clinics and only later created a personal email account. For many physicians, email is cognitively congruent with professional work, so it may feel natural to use email to communicate with patients.

Nokia was the first mobile phone capable of sending a text message, in 1993, but text messaging didn’t take off until the start of the 21st century. In the United States, texting surpassed calling on phones in 2007. Especially for those under 40, many people prefer the speed and convenience of text instead of voice messaging. Indeed, many corporations are eliminating voice mail in favor of text and other instant messaging applications.

Howe, Neil, “Why Millenials Are Texting More and Talking Less,” Forbes, July 2015

Both email and text have the advantage of convenience, and many patients would prefer to use these modalities to communicate with their health care professionals, especially for less sensitive information like scheduling an appointment. The ethical psychiatrist must weigh the advantages of convenience and patient preference against concerns about confidentiality and boundaries.

Because of its association with workplace communication, it may feel very natural to email with colleagues and patients about clinical matters. This communication can be printed for inclusion in a paper chart or digitally saved into an electronic medical record (EMR). For physicians in some health care settings, email communication with patients via a password-protected website is an explicit expectation. Those providers don’t need to worry as much about confidentiality, but they should notify the patient that those communications may be read by anyone with access to the EMR, so while the communication is considered confidential, it is not entirely private.

Email communication outside of a password-protected patient portal is more vulnerable to being hacked. Additional hazards to confidentiality are the possibility of inadvertent forwarding of an email chain containing information not intended to be shared with a third party. For example, a patient might email a psychiatrist about two problems, a fight with a family member and a potential medication interaction. The psychiatrist might forward the email to the patient’s primary care provider (PCP) to confer about the medication interaction, inadvertently disclosing the family fight. Emails are also susceptible to being read by patients’ family members without permission and by employers if the patient is using their work email account.

Text messaging is even more convenient than email and is especially efficient for scheduling appointments, receiving notice from patients that they are running five minutes late to their appointment, or other nonclinical tasks. It may be a more reliable way to communicate with adolescents and young adults who don’t listen to their voice messages. Most people read and respond to text messages much faster than they do to emails or voicemails.

What’s the downside of all this convenience?

Text messaging suffers from similar confidentiality concerns as email. Cell phones can be hacked, and the text history read. Incoming text messages can be briefly displayed on a phone’s screen for anyone to see. Unlike email, one can’t easily print a record of a text conversation, so it cannot be included in the medical record, as all communication between doctor and patient should be. Furthermore, text messaging is too brief of a format for clinical communication, yet that temptation will arise. A patient could send a text asking to change the dose of a medication, for example, and the psychiatrist might reflexively respond by text rather than calling the patient to inquire about symptoms, side effects, and context, all of which are required to make an appropriate medical decision.

The confidentiality and clinical concerns surrounding text and email can be mitigated by setting clear limits with patients about whether and how you communicate within these media, and then being consistent in upholding these standards. Patient reports that contain identifying information should not be sent by standard email but can safely be sent within password-protected systems, such as an EMR portal or secure platforms like ShareFile. Even if a patient indicates willingness to forgo confidentiality by transmitting sensitive clinical information by email or text, it is the psychiatrist’s duty to uphold the usual standards of privacy expected of us.