Whether you use e-mail at home or in clinical practice, there are some basic rules to follow when sending your messages through cyberspace. If you’re under the impression that it doesn’t matter how you write your e-mails or that no one else will ever see them, read on.

Pause Before Pressing

Mary Newton Bruder, also known as “The Grammar Lady,” advises that e-mail should adhere to the same rules as any other written communication. Before you press the send key¹ —

• Figure out what you want to say. If you don’t know what you want to say, don’t send it.
• Read it over to be sure it says what you want it to say.
• Be concise, but give enough information so that the recipient knows what you need. People who read a lot of e-mail don’t have time to try to figure out what you mean. The delete key is to the computer what the “circular file” was to past generations.
• Use correct grammar. If you need help in this area, find a good grammar text such as Joanne Feierman’s Action Grammar or visit www.grammarlady.com.
• Be polite. Say “thank you.”

Rites of Passage

Just as there are rules of etiquette when conducting either your personal or professional business in person, there are rules in cyberspace — also called “netiquette” for writing and sending e-mails:^2,3,4

• Don’t say anything in an e-mail that you wouldn’t say to the recipient’s face.
• Don’t send e-mail in all uppercase letters. This is the equivalent of yelling. Don’t “bold” the font unless something is extremely urgent. Keep exclamation points (called “bangs” in computer-speak) to a minimum.
• Follow the Golden Rule. Don’t forward chain letters, jokes in bad taste, or anything else that you wouldn’t want to receive yourself.
• If you must forward an e-mail, remove any arrows (<<<<<) that may precede the message.
• Be careful how you say things. Remember that the written word may not convey the same emotion you might express if you were speaking. Using emoticons (“smiley faces”) can help the tone of your message, but it’s important to use them sparingly.
• Be specific about the content of your e-mail in the subject line.
• Don’t start or continue flame wars. Flaming is a verbal attack in electronic form.
• What you send is not private. Don’t press the send key unless you’re absolutely certain that your e-mail, in the hands of the unintended, would not embarrass you or others.
• Keep your personal and professional e-mail accounts separate from one another.
• Whatever you write might come back to haunt you. Even deleted messages can be retrieved and circulated.
• Don’t expect people to respond to your e-mail immediately. If you need a quick response, pick up the phone.

Serious Business

If you use e-mail on the job, one of the most important areas of concern is that of confidentiality, according to Nancy Brent, RN, MS, JD, legal expert for Nursing Spectrum Online’s Brent’s Law. “The use of e-mail in any business, including healthcare delivery, must always be focused on the issue of confidentiality, both for the patient as well as the employee,”says Brent.

Not intended as specific advice, Brent highlights some general principles about confidentiality and e-mail. For employees, the review or reading of an employee’s e-mail must not violate state and federal statutes that place restrictions on intentionally intercepting electronic communications. “The bottom line for the employee,” says Brent, “is whether or not there is an expectation of privacy when using the facility or company’s e-mail system.” Nurses should check their individual state laws pertaining to accessibility of employee e-mail. For example, some states allow monitoring of e-mail for quality assurance purposes, training, and research.

If e-mail is used to communicate to patients or to other healthcare providers, it is important that information be protected as any oral or conventional sharing of the information would be. Brent suggests that patients give written consent for the use of e-mails containing communications that are confidential and private. It is also a good idea to put a confidentiality disclaimer on all e-mails that contain private and confidential information, according to Brent.

Although it is best to seek specific legal advice about wording and use, such a disclaimer might read, “The information contained in this e-mail is confidential and private. Its dissemination is a violation of state and federal laws. If you are not the authorized recipient, you must not disclose, copy, distribute, or retain this message or any part of it.”

HIPAA and E-Mail

The Health Insurance Portability and Accountability Act was passed in 1996, but will be enforced as of April 2003. The HIPPA regulations require that “electronic transmissions” and the “storage of individually identifiable health information” be protected.5 “Any healthcare provider who does billing and submits claims through e-mail or stores patient information in their databases will need to become very familiar with HIPPA,” says Brent.

Karen Carpenter, RNC, FNP, MS, JD, clinical assistant professor, University of Massachusetts, Amherst, MA, and professor, Quinsigamond Community College, Worcester, MA, says that she does not correspond with patients using e-mail because she has no way of securing the transmissions. She adds that other healthcare providers often make referrals using e-mail and faxes, but are requested not to do so. “Students also journal with faculty about clinical situations, but are instructed not to identify the client in any way and to speak in general terms by listing objectives for care,” says Carpenter.

Using secure websites and encryption technology, there are some software packages that provide secure transmissions between patients and healthcare providers. Examples of two such packages are www.healinx.com and www.mydoconline.com. These packages store confidential patient information in accordance with HIPAA regulations.

Integrating E-Mail with Clinical Practice

As a staff nurse in the medical ICU at Massachusetts General Hospital (MGH), Boston, Eileen Comeau, RN, uses e-mail to receive practice information, such as equipment changes, formulary updates, and policy implementation; and hospital information,including benefits, new services, news, updates on current events, emergency procedures, quality alerts, and professional educational offerings.

Every patient room at MGH has a network connection,so it is not uncommon for patients to catch up on their e-mail using a laptop computer, according to Comeau. The Blum Patient and Family Learning Center provides Web and e-mail access. The first person to use the Center was the father of a 5-year-old child with a brain tumor. He was grateful to be able to e-mail updates to his family and friends. Comeau is also grateful for the availability of e-mail “I think e-mail is a great benefit to nursing at MGH. I receive information relevant to my practice and work life and it makes me feel connected to leadership and my colleagues.”