Guided Health Mail Project Design Overview

 

The concept of guided health mail (GHM) was originally proposed by Wilson and Lankton (2003) as a means to improve upon standard email as a medium for communication between patients and clinical staff, including physicians. They outlined a framework for guided health messaging that incorporates the main elements of GHM and overcomes major limitations of email. These limitations include observations that email authorship cannot be positively verified and is therefore not compliant with HIPAA regulations, email message contents are unstructured, open-ended, and difficult for clinicians to interpret, there is uncertainty as to whether email messages are actually received, and email is not sufficiently integrated into clinical operations to enable automatic routing and documentation within the medical record (Katz & Moyer, 2004).

The design of GHM overcomes each of these problems while providing levels of ease of use and usefulness that are comparable to email. GHM uses a web browser interface in conjunction with standard email to support the following features:

• Password authentication is required to enter or read messages and replies. GHM security procedures will meet HIPAA standards.
• Message entry is forms-based, using templates that are customized toward the specific message topic and clinical specialty. Templates guide patients to produce messages that are relevant, concise, and complete, which may act to mitigate resistance that physicians have shown to receiving length, rambling email from patients, as documented by Grant et al. (2006).
• Confirmation of message receipt is sent to patients via email. The confirmation includes a clickable link through which patients can open a monitoring web page.
• Status and transit of messages and replies are monitored in real time. Monitoring reduces patients' uncertainty that their concerns are being addressed in a timely manner.
• Physicians are assisted in replying to messages with customized templates directed toward common message topics, e.g., common medical conditions and routine questions. These templates contain links to related online resources as well as supporting a personal reply by the physician.
• Notifications to the patient are sent via email and include a clickable link through which patients can open and read the reply. GHM does not require patients to use specialized technologies beyond standard email and a web browser in order to send messages, receive notifications and read replies.
• GHM is designed to be built as a service-oriented architecture that can function as a standalone research and development application or can be integrated within clinical systems.
• GHM is designed to be readily extended with additional features, such as augmenting email notifications with automated telephony or incorporating information from the patient's electronic medical record (EMR), as suggested by Wilson and Lankton (2003).

Patient Guidance in GHM

GHM implements guidance in two stages. In the guided triage stage, patients self-select the general message topic as part of the authentication process on their web browser. A generic login form is shown in Figure 1. Message topics are used by GHM to select the form template that is appropriate for the issue and to subsequently route the completed message. In the example shown in Figure 1, appointment requests may be routed to receptionist staff, prescription refills to nursing staff, billing questions to accounts receivable, and office visit follow-up questions to the primary-care physician. Although some message categories may be common among healthcare providers, it is intended that the list of message topics presented in the triage stage will be customized to meet needs that are specific to the clinical partner by incorporating message categories that are key to the clinical specialization.

 

Figure 1. Example login form, implementing guided triage.

The guided elicitation stage begins once the patient's access is authorized. The patient's web browser then displays the template form that elicits information relevant to the chosen message topic. Figure 2 illustrates an example screen generated in response to the message topic, "Ask a question relating to a recent office visit". The patient is initially guided to designate which office visit the question relates to and select the topic of the question. A text area is provided for entering the question, and the patient is then guided to indicate the urgency of the question and how he/she wishes to be notified. Information that is known about the patient from his/her login account, such as patient's e-mail address and phone numbers, is automatically entered on this screen. Additional guidance is provided in dialogs that verify the patient has completed all items prior to sending the message and make suggestions in response to the patient's input, such as providing the provider's emergency contact number as an alternative when the user denotes that a question is urgent.

 

Figure 2. Example message entry form, implementing guided elicitation.

GHM Assisted Physician Replies

GHM will support custom reply templates that physicians can use to reply to common topics. These templates will contain physician-selectable hyperlinks to additional online resources. Templates will be developed cooperatively with a clinical partner to meet needs of the specific clinical specialty.

GHM Routing, Monitoring, and Notification Processes

GHM is designed to support routing, monitoring, and notification processes as shown in Figure 3. Once the patient has completed guided elicitation, the following steps occur (steps are shown as numbered bullets in Figure 3).

• Step 1: The message is routed to the appropriate provider personnel.
• Step 2: Confirmation of message receipt is then sent to the patient's e-mail account.
• Step 3: The confirmation message contains a link to a monitoring facility on the web server, which lets patients check the status of the message using a web browser.
• Step 4: Once a reply has been prepared, patients are notified via e-mail.
• Step 5: Patients follow a link to retrieve the reply from the web server, which is displayed on a web browser.
• Step 6: The web server also provides a facility for the provider to monitor replies (step 6), allowing alternative measures, such as a phone call from the provider, to be taken in case a reply is not retrieved within the appropriate time period.

Alternative Applications

Several alternative OPPC services have been developed, but none of these provides similar research and development capabilities to the proposed GHM application. Several applications offer open-ended communication as a part of a patient web portal, e.g., Liederman and Morefield (2003), Lin et al. (2005), and Wilson and Lankton (2004). These research designs have no mechanism for studying specific feature sets or for learning how it may be possible to improve the application by extending its capabilities. Other applications are limited to very specific clinical domains. For example, Wu et al. (2005) describe a message system in which patients monitor heart failure by entering symptoms, weight, blood pressure, and heart rate parameters on a daily basis. It would be difficult to refocus applications such as this to be usable for other clinical contexts.

 

Figure 3. Guided Health Mail swim lane flowchart.

References

CNSS (2006) National information assurance (IA) glossary. Committee on National Security Systems Report. http://www.cnss.gov/Assets/pdf/cnssi_4009.pdf

Fox, S., & Fallows, D. (2003) Internet health resources: Health searches and email have become more commonplace, but there is room for improvement in searches and overall Internet access. Pew Internet & American Life Report. Retrieved March 10, 2009 from http://www.pewinternet.org/pdfs/PIP_Health_Report_July_2003.pdf

Grant, R. W., Campbell, E. G., Gruen, R. L., Ferris, T. G. & Blumenthal, D. (2006) Prevalence of basic information technology use by U.S. physicians. Journal of General Internal Medicine, 21, 1150-1155.

Katz, S. J., & Moyer, C. A. (2004) The emerging role of online communication between patients and their providers. Journal of General Internal Medicine, 19, 978-983.

Liederman, E. M, & Morefield, C. S. (2003) Web messaging: A new tool for patient-physician communication. Journal of the American Medical Informatics Association,10, 260-270.

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Wu, R. C., Delgado, D., Costigan, J., MacIver, J., & Ross, H. (2006) Pilot study of an Internet patient-physician communication tool for heart failure disease management. World Hospitals and Health Services, 42(3), 32-38.