Using the Internet to 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. U se 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, 3 but 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. 4 There 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 al 5 evaluated 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. 136 Journal of 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 al 6 similarly 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 Morefield 9 evaluated 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 personal and professional 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 al 12 assessed 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 J. Sybil Biermann, MD, et al Volume 14, Number 3, March 2006 137 but involving study clinicians, 9 most 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 using e-mail for urgent requests or highly sensitive content. 14 Based on these results, Blue Shield of California is broadening its W eb-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 provide 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. 20-23 Table 1 contains an exten- sive list of guidelines. Kittler et al 24 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- Using the Internet to Enhance Physician-Patient Communication 138 Journal of the American Academy of Orthopaedic Surgeons 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 J. Sybil Biermann, MD, et al Volume 14, Number 3, March 2006 139 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 patients. 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 hospital 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 W ebsite, 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. 25 The 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 hospital 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- Using the Internet to Enhance Physician-Patient Communication 140 Journal of the American Academy of Orthopaedic Surgeons 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 W ebsite 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. 30 The 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. 32 The 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. 33 Depending 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. J. Sybil Biermann, MD, et al Volume 14, Number 3, March 2006 141 Table 2 Selected Patient Education Websites Website URL Comments 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 Using the Internet to Enhance Physician-Patient Communication 142 Journal of the American Academy of Orthopaedic Surgeons 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 Pract 2001;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. JAm Med Inform Assoc 2003;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 Inform 2003;70:1-9. 12. 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