Electronic Communication in Plastic Surgery: Surgery: in Plastic Communication Electronic Copyright © 2017 American Society of Plastic Surgeons

Home , Communication, Plastic

Official Peer-Reviewed Publication Official Peer-Reviewed from the AMERICAN SOCIETY of PLASTIC SURGEONS. None of the authors has any financial None of the authors has any financial Disclosure: or devices mentioned any of the products in interest in this article, to dis- or any other conflict of interest articleNeither this close. consent nor the example phy- legal advice. Rather, formprovide is intended to attorneystheir consult should sicians specific with communications with electronic questions regarding patients. patients and prospective Supplemental digital content is available for this article. A direct URL citation appears in the text; simply type the URL address into any browser to access this content. A clickable Web link to the material is provided in the HTML website text of this article on the Journal’s (www.PRSJournal.com). - August www.PRSJournal.com With the advancement of technology, electronic communication of technology, With the advancement Background: plastic and recon- mode of communication within has become an important video con- the form of e-mail, text messaging, This can take structive surgery. currently no defined media, among others. There are ferencing, and social professional appropriate for guidelines Surgeons of Plastic Society American use of these technologies. Methods: A search was performed database; on PubMed and the Cochrane “metadata,” “video messaging,” “HIPAA,” terms included “telemedicine,” “text and “In- “Twitter,” “Facebook,” media,” “social sharing,” “photo conferencing,” articles was performed;stagram.” Initial screening of all identified of the level were evaluated and articles were evidence, limitations, and recommendations reviewed. in the level I screening process; Results: A total of 654 articles were identified criteria: social net- 41 articles fit inclusion after more comprehensive review, messaging, 10; metadata, four; video con- working, 12; telemedicine, 11; text Portability and Accountability Act, one. ferencing, three; and Health Insurance these articles and guidelines proposed. General themes were identified from an efficient method of Conclusion: Electronic communication can provide within plastic surgerypurposes professional for exchange information but all professional, legal, and ethical con- should be used thoughtfully and with Surg. 141: 500, 2018.) siderations. (Plast. Reconstr.

Boston, Mass. Committee

Lynn M.D. Damitz, ASPS Health Policy ASPS Health Policy Galen Perdikis, M.D. Kyle R. Eberlin, M.D.

lectronic communication has become anlectronic communication has clini- increasingly common mode of sharing plasticcal images and information within Dan J. Krochmal, M.D. Dan J. Krochmal, Plastic and reconstructive surgeryand reconstructive Plastic is an inher

Steven C. Bonawitz, M.D. Steven C. Bonawitz, Loree K. Kalliainen, M.D. Loree K. Kalliainen, Copyright © 2018 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000004022 From the Division of Plastic and Reconstructive the Surgery,From Massachusetts General Hospital, Harvard Medical School. Received for publication January 12, 2017; accepted 4, 2017. SPECIAL TOPIC SPECIAL ently visual specialty; inspection is a key component of clinical evaluation and contributes highly to diag- nosis and treatment. Visual assessment can take many forms. Electronic communication, including the sharing of pictures and videos, can be useful at many stages of patient care, including the initial surgery. The broad category The broad of electronic commu- surgery. text messaging,nication includes the modalities of applica- e-mail, video conferencing, smartphone tions, and social media, among others. Electronic communication can provide an efficient method of information exchange between health care providers, and between patients and their providers.

500 E of Plastic Surgeons Health Policy Committee Surgeons Health of Plastic Guiding Principles from the American Society Society American from the Principles Guiding Electronic Communication in Plastic Surgery: Surgery: in Plastic Communication Electronic Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. American Society of Plastic Surgeons. Copyright © 2017

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consultation, formulation of an ongoing treatment An initial search was performed of each afore- plan, and postprocedural monitoring and follow- mentioned term, and potentially relevant cita- up. Recent studies have shown that an increasing tions were identified (level I screening). A title number of physicians directly communicate elec- and abstract search was then carried out and the tronically with their patients1–4 and that there is a sig- full text of each article was reviewed for appropri- nificant interest among patients for communication ateness. For each topic, a list of articles meeting with their providers by means of e-mail and social the inclusion criteria was created (level II screen- media.5 The value of telemedicine, as an overall tool ing). The level of evidence for each study was within the domain of plastic and reconstructive sur- noted and a summary of the evidence, challenges, gery, has been previously reported in the literature.6,7 and limitations was created. This process was per- As technology has evolved, patients have formed separately for each search term. become increasingly facile with the use of smartphones and digital technology. However, a num- RESULTS ber of ethical and medicolegal considerations germane to these modes of communication have A total of 654 citations were identified in the arisen and are of paramount importance to the initial (level I) screening process. There were 245 practicing plastic surgeon. These include com- citations identified for text messaging, 178 for pliance with the Health Insurance Portability video conferencing, 115 for social networking, 60 and Accountability Act related to transmission of for telemedicine, 32 for metadata, 18 for Health secure medical information, concerns related to Insurance Portability and Accountability Act, and establishment of the doctor-patient relationship six for photographs. Critical appraisal of these through virtual means, privacy with storage of citations and their appropriateness for this topic electronic files, and concerns about provision of pared down the list. interstate medical care without appropriate licen- After complete application of inclusion and sure. Given the relative novelty of many of these exclusion criteria (level II screening), 41 articles technologies, there is significant practice variabil- were identified: social networking, 12; telemedicine, ity and no consensus exists among practitioners. 11; text messaging, 10; metadata, four; video confer- This study sought to investigate the evidence encing, three; and Health Insurance Portability and and previously described guidelines for plastic sur- Accountability Act, one. General themes were iden- geons to safely and effectively use electronic com- tified from articles related to each search term. munication, and to better define the associated With the identified articles for social net- ethical and medicolegal considerations. General working, the majority were composed of patient guidelines regarding the communication between and physician surveys. General themes included medical professionals, and between the medical a developing familiarity and comfort with these professional and patient, are then offered. technologies among surgeons, and the perceived importance of having an online presence for one’s practice. Most social networking interac- MATERIALS AND METHODS tions appear to be initiated by patients, and many A literature search was performed on PubMed physicians either decline to interact or admit to and the Cochrane database relevant to several interacting with patients on a case-by-case basis. topics in electronic communication in January One identified concern is the potential for mis- of 2015. Specific search terms were collectively representation of credentials through social net- chosen by members of the Electronic Guiding working and the implications for care delivery. Principles subcommittee of the American Soci- Within the search term telemedicine, arti- ety of Plastic Surgeons Health Policy Committee. cles indicated that this technology might be ben- Search terms included “telemedicine,” “text mes- eficial for patients in rural areas, particularly for saging,” “HIPAA,” “metadata,” “video conferenc- wound care and management of burns. There ing,” “photo sharing,” “social media,” “Facebook,” was a noticeable concern about the veracity of the “Twitter,” and “Instagram.” transmitted information through telemedicine, Inclusion criteria were articles published in and worry about missed diagnoses (such as digital the English literature from 2004 to 2014; narrative nerve injury in the setting of a finger laceration) reviews, case reports, patient experience surveys, requiring additional or more urgent medical care. and physician surveys were also included. Meet- Challenges noted by the authors of these studies ing abstracts and articles published in a language included medicolegal issues related to provision other than English were excluded. of medical care between states, potential Health

Insurance Portability and Accountability Act viola- will monitor the telemedicine arena and incorpo- tions with transmission of digital photographs, and rate necessary updates to this document on a bien- issues related to billing for telemedicine visits. nial basis. A sample consent form for electronic Articles about text messaging presented few communication with patients is included in the scientific data but focused more on the potential article’s supplemental digital content. (See Fig- uses of smartphones in health care. Thematically, ure, Supplemental Digital Content 1, which shows this included the use of smartphones for postoper- a sample patient consent for electronic communi- ative monitoring and its effect on flap salvage rates cation, http://links.lww.com/PRS/C607.) and the use of smartphones for tracking patient Although electronic communication is perva- progress. The main unresolved issues identified by sive, there is a paucity of literature describing appro- the articles were the stated concerns about confi- priate legal and ethical guidelines. Most reports in dentiality and data security. Another unanswered the plastic surgery literature have examined the question is the role for use of hospital-provided use of electronic communication for patient triage, smartphones versus personal smartphones. particularly between providers in the emergency Metadata consist of information associated setting. In 2004, Hsieh et al. used electronic pho- with location, call logs, and Web searches and are tography to assist with triage of patients with finger tracked and stored by smartphones and comput- injuries. Using three independent reviewers, they ers. Although there are anonymization models found that in 12 cases (15 percent) there was dis- available, they are not used extensively, which agreement between the teleconsultation and the places physicians and their patients at risk for actual treatment by the attending surgeon.8 Jones unwanted (and perhaps unintended) privacy vio- et al. also used digital photography to evaluate 150 lations. Newer techniques such as medical image trauma referrals to the plastic surgery service, and watermarking have been proposed as a means they found a high concordance between injury of safely storing and protecting electronic data. severity and operative priority.6 In 2008, Diver and However, none of the proposed solutions, to date, colleagues performed a pilot study of 20 patients has been validated or widely implemented within and found that five patients might have been man- the plastic surgery community. aged differently through the use of effective elec- Video conferencing, with appropriate high- tronic communication.9 A study in 2014 by Hoppe et quality imagery, may be useful in emergency al. demonstrated that digital photography was a use- medical communication and between teams of ful adjunct to patient presentation in the emergency providers, particularly in cases of patient trans- room.10 In total, these articles underscore the utility fer. There are some instances, as in cases of pro- of electronic communication between physicians to cedural consent, that video conferencing may be streamline and optimize patient care, although they inadequate. Issues related to Health Insurance did not formally establish guidelines for use. Portability and Accountability Act compliance are In addition to use between physicians, there also pertinent to video conferencing. are many ways in which electronic medical communication can occur between patients and providers. Social media sites such as Facebook and DISCUSSION Instagram have been increasingly used for this Electronic communication has become an purpose. Electronic interactions between patients increasingly effective and ubiquitous modality for and their providers are fundamentally different transmitting health care information. With the than communication between physicians and have advent of smartphones that are capable of taking medicolegal implications that have not yet been and sending high-quality photographs and videos, clearly defined. Some medical organizations, such electronic medical communication has changed as the Federation of State Medical Boards, dis- dramatically over the past 10 years. This technol- courage physicians from interacting with patients ogy, as it relates to health care and specifically to on “personal sites such as Facebook.”11 There is plastic surgery, will continue to evolve and will little scientific literature on the topic, and many likely be an important component of medical care of the recommendations are derived from state- delivery in the future. When used properly, it can ments from the American Telemedicine Associa- benefit both patients and providers. As new mod- tion. Additional applications, such as Snapchat, els for delivery of care and patient-physician inter- are intended to provide a temporary method of actions emerge, the use of telemedicine and the electronic communication. The same principles manner in which it is provided will continue to and guidelines apply to plastic surgeons with use evolve. The American Society of Plastic Surgeons of this “transient” social media.

Despite the lack of robust data and estab- 12 important considerations for plastic surgeons lished legal consensus, it is clear that physicians regarding the use of electronic communication: must follow strict rules when communicating with patients. Physicians must maintain compli- 1. Surgeons and their staff should have policies ance with the Health Insurance Portability and and procedures in place to ensure the security Accountability Act during all modes of communi- of telehealth equipment and the electronic cation, and must exercise care in providing medi- security of data, particularly as related to elec- cal advice and recommendations, particularly tronic modes of communication.14 across state lines. There are at least 10 state medi- 2. Health Insurance Portability and Accountabil- cal boards that issue a special practice license or ity Act compliance must be maintained at all certificate to allow for telemedicine across state times during electronic communication.15 lines, and the majority of states require an in-state 3. Physicians must understand and adhere to state license to render a medical opinion or consulta- and federal regulations related to electronic tion. Plastic surgery, as a specialty, is particularly communication, scope of practice, and inter- vulnerable to medicolegal issues, given the visual state medical licensing. In certain situations, this nature of the field. As described by Dauwe et al., means that medical advice and/or recommen- there is a significant amount of potential liabil- dations cannot be provided electronically.15,16 ity in such encounters, including malpractice, 4. Physician practices should document and patient abandonment, and interstate medical maintain a log of all patient encounters, licensing issues.12 including all technical issues, in a Health E-mail and text messaging are inherently Insurance Portability and Accountability Act– insecure modes of communication. Many hos- compliant manner with secure storage.14,16 pitals and enterprise servers offer the option of 5. Physicians should have an emergency or sending secure e-mail, which should be used at contingency plan for electronic communica- all times when communicating with patients and tion that is communicated to the patient in health care providers. Text messaging from per- advance of the encounter. That is, if aberra- sonal cellular telephones, without the use of spe- tions occur, there should be a streamlined cific encryption software or applications, should process by which to address them.16 be avoided, when possible. If text messaging is 6. Providers should be cognizant of establishing conducted, refrain from using specific diagnoses a provider-patient relationship in the context and identifying information (including protected of a telemedicine encounter. The acceptability health information), and direct the patient or of this may vary by state and may depend on or provider to more secure communication channels necessitate previous face-to-face interactions.16 to further discuss care. If communication involves 7. Physicians and patients should obtain verbal the patient, documentation in the medical record or written consent before any recording of the should be performed by including a summary, encounter, and this should be clarified before copy, or screenshots of the conversation. Such beginning the interaction.16 For purposes of information should be deleted from a personal compliance with the Telephone Consumer smartphone or computer once it has been trans- Protection Act, physicians should (1) maintain ferred to the medical record. records of consent from current and prospec- Given the absence of rigorous, universally tive patients for physicians and practices to accepted guidelines for electronic medical com- send text messages and/or faxes of any kind munication, plastic surgeons should use good eth- (including advertisements), and (2) create opt- ical and clinical judgment for the appropriateness out practices and records with respect to the of such communication.13 As new technologies transmission of such text and/or fax messages. improve and evolve, physicians’ ethical responsi- 8. Physicians and their designees should abide by bilities do not change. Most plastic surgeons are the same local and regional credentialing poli- unaware of the specific medicolegal implications cies as required for a traditional in-person visit of such communication and use professional ratio- as mandated by state and federal law. That is, the nale to guide practice. The billing implications for plastic surgeon is responsible for the visit, and electronic communication are not well defined; all credentialing policies must be followed.16 there are some hospital systems and third-party 9. Practices should implement means for veri- payers that provide reimbursement for these vis- fication of provider/patient identity, using its, but this is not standard. From our review of established means of identification similar to the aforementioned studies, we have identified those for in-person visits.17

10. Physicians should refrain from directly advis- query. Personal details of the procedure and ing patients through social networking sites Health Insurance Portability and Accountability without secure modes of personalized com- Act–related materials should not be disclosed nor munication. Specific recommendations for discussed during the reply. Practices should con- individual patients should not be provided sider having patients sign a consent/waiver form over insecure social networking sites; provid- for use of electronic communication. Patients ing general, impersonal information can be should understand and acknowledge that the use acceptable.12 of electronic communication may not be secure, 11. In general, physicians should encourage particularly if the patient is not using a secure patients to schedule an office visit to discuss communication platform. their medical care and treatment plan.12 12. Practices should have a defined plan to deal A Personal Friend, Who Is Not a Physician with adverse events, including spam, negative or Colleague, Sends You a Photograph of His comments, complaints, and unprofessional Neighbor—by Means of Text Message—Who behavior. Physicians are not permitted to Sustained a Laceration to His Forehead and write their own evaluations on review sites, or Inquires Whether an Emergency Room Visit or to have this done by someone in their practice Suturing Is Recommended unless he or she is an actual patient of the phy- It is not appropriate to provide specific medi- sician and does so voluntarily.18 cal recommendations through electronic means, in this scenario, without direct evaluation of the These guidelines are broadly applicable patient. It is appropriate to respond to this inquiry to many clinical situations within plastic sur- with a general message about these types of inju- gery, both inside and outside of the operating ries, but the message should not be directed at room. Intraoperative photographs, commonly this specific patient without a clinical, in-person obtained by plastic surgeons, must also adhere evaluation. to all Health Insurance Portability and Account- This study has many limitations, primarily ability Act/privacy regulations and should not be because few of the searched studies contain level transmitted without ensuring patient confidenti- I or prospective data. Furthermore, there are no ality. In addition to these overarching principles universally accepted guidelines for these commu- of electronic communication, three hypothetical nications and there are few clearly defined medi- scenarios through which to consider the most colegal regulations. We believe that electronic appropriate use of electronic communication communication will become increasingly com- are listed below. mon over time, particularly with our younger gen- eration of plastic surgeons, and future prospective A Patient, Known to You and on Whom You studies are needed to clarify the legal ramifica- Have Previously Performed Surgery, Finds Your tions of different technologies. Personal Profile on Facebook and “Adds” You as a Friend It is not recommended to “accept” the friend CONCLUSIONS invitation from this patient on one’s personal pro- Electronic communication can provide an file, unless a personal relationship has already efficient method of information exchange for been established. Personal and professional rela- professional purposes within plastic surgery, but tionships should be separated, particularly on should be used thoughtfully and with all legal social media sites. If the surgeon has a professional and professional considerations. Based on cur- profile for his or her practice, independent of a rent medicolegal standards, it can be acceptable personal profile, it may be acceptable to accept to communicate electronically with patients, pro- this invitation. vided that federal statutes and other professional A Patient for Whom You Have Provided an obligations are strictly followed. In-Office Consultation Obtains Your Work e-Mail Kyle R. Eberlin, M.D. Address and Sends You an e-Mail to Ask about Division of Plastic and Reconstructive Surgery Additional Details of Surgery and Expected Massachusetts General Hospital Outcomes Harvard Medical School Wang Ambulatory Care Center 435 If the communication is secure, it is accept- 55 Fruit Street able to respond to the patient from your pro- Boston, Mass. 02114 fessional e-mail address to address the patient’s [email protected]

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