Integrating the Internet Into Your Clinical Practice
http://www.fpen.org/allina
May 8, 1998

Handout:
E-Mail and Discussion Lists

I. Objectives

• Demonstrate the ways in which e-mail can benefit you in your practice and professional life
• Demonstrate and become familiar with basic e-mail techniques, the use of address books, e-mail filters and attaching files.
• Introduce the concepts of discussion groups
• Become familiar with e-mail etiquette
• Understand the promise and pitfall of using e-mail for physician - patient interaction.
• Understand the basics of e-mail encryption and user verification

II. Brief history of the Internet

• 1960s: The Internet was developed as a response to the Cold War and the need for a reliable, independent communication system in the event of nuclear attack.
• The Internet was designed as a very decentralized system with very few controls.
• Used by researchers and defense contractors to share computational resources and to communicate among themselves.
• E-mail and discussion groups were and still are two of the Internet’s most popular applications.

• Nearly instanteous connections between people throughout the world.
• Messages can be accessed and handled at your convenience, 7 days a week, 24 hours a day.
• Provides a written, editable record of professional exchange. Files of either word-processed documents or other applications (including sound, images, and video) can be attached easily.
• Can be very cost-effective, especially for communication between geographically diverse areas.
• Asynchronous communication
• E-mail messages are easy to transport, to reply to, to search, and to send to multiple recipients.
• Some people feel less inhibited in sharing their thoughts in an e-mail message

IV. Creating an E-mail message

• All e-mail messages need the following two components: an address to which the message is to be sent and the body of the message.
• Well-formatted e-mail messages that follow general e-mail etiquette also have a descriptive subject line and a signature block that includes identification of the sender.

• On occasion you cannot reply to the sender of an e-mail message. It may be necessary to use the address in the signature block to create a new e-mail message, instead of replying automatically to the sender of the message.
• E-mail addresses have a specific anatomy.  Typically it takes the form UserID@machine.subnet.company.domain or it may simply be UserID@company.domain.   It can be helpful to think of the address as: Name@StreetAddress.City.State.Country.  A few examples of e-mail addresses are:

Paul@allina.com
Paul@FPEN.org
Kleeberg@toybox.allina.com
75241.117@CompuServe.com
GradStudent@gold.tc.umn.edu

• When typing an e-mail address, be careful to distinguish between similar-looking characters, such as the letter O and the numeral 0, the letter l and the numeral 1, etc. It is probably best to copy-and-paste addresses from another message, not to retype them, if at all possible.
• A descriptive subject line is important.  This will allow for easier searching through a large number of messages.  It lets your recipient scan incoming messages for ones of interest and allows you to browse archives or folders of old messages to find the one you need.
• Be concise and be gentle in the body of your e-mail message. Be aware of tone, the sensitivity of the topic, and to whom you are sending the message.
• When replying to a message, copy a portion of the message to which you are responding to remind your reader of context.
• Include a personalized signature file, indicating to the reader who you are and what methods they can use to get in touch with you. Be concise.  For example:

Paul Kleeberg, M.D.          O   o         Paul@Allina.Com
Allina Health System        -+---+-    Voice: 612-775-1338
1375 Willow Street           |_o_|       Family Practice &
Minneapolis, MN 55403 USA   / \|/ \   Information Services

• Reread the message text and doublecheck the recipient(s) addresses in both the To: and cc: fields.

• Files can be attached to an e-mail message and sent to the recipient for use within their own application.  These can be word-processed documents, spreadsheets, pictures, movies, sound files or other formatted documents.
• The recipient must possess the application capable of opening the document in order to be able to view it.
• Most e-mail packages allow you to attach a file by selecting the item from a dialog box.   For example, Netscape Mail, select "File" from the menu bar, then "Attach" from the menu then "File..." from the submenu.
• Attached files can be sources of viruses.  Be careful not to view any attachments unless you know the sender.  This would be enough to infect your machine if the file were infected.

• Address books can be set up to save e-mail addresses for individuals. Groups, representing collections of addresses, can be set up to send e-mail messages to committee members or other special populations.
• Mail filters can be set up to sort incoming mail according to defined parameters, such as the sender’s address or the type of message (i.e., Error messages). This can help with e-mail message maintenance, especially if you subscribe to numerous groups.

VII. Discussion groups

• Discussion groups or listserv lists can be thought of as e-mail distribution lists.   One must subscribe to a list and then messages from individual postings are delivered directly to a subscriber’s e-mail box.
• They consist of "threads" or postings discussing particular topics, but they arrive chronologically as they are individually sent. Because individuals usually have to subscribe in order to be able to post a message, they create a "living room atmosphere" for communication.
• Some groups are moderated by a list manager who screens postings to make sure they are appropriate for the designated topic before forwarding to the entire list.  Many groups are screened. Subscribing to moderated lists can greatly enhance the relevance of the list and cut down on e-mail "noise".
• Some groups have restricted subscriptions to only a select group, such as users of a particular product or members of a particular medical specialty; most groups are not restricted.
• Messages from lists can be delivered one at a time to the subscribers e-mail, as soon as they are posted, or they can be delivered in digest format (collected in one large message) once a day.
• Like the use of the Internet in general, discussion groups have grown in number over time.  As of 9/93 there were over 2,300 topical lists; in 8/94 the number was closer to 5,300; 12,850 by 11/95; and over 89,000 as of 5/98.
• There are web sites that provide databases of discussion groups

• The Medical Matrix mega-site (http://www.medmatrix.org) also provides links to forums on nearly every medical specialty.
• Discussion groups are typically subscribed to by sending an e-mail with the following message "Subscribe <name of list> <your name>" to the discussion group’s administration address
• The two types of addresses associated with discussion groups are important to keep straight. They are as follows:

Administration address (used for subscribing, unsubscribing, other automated requests to the computer on which the discussion list resides):

• DO NOT send requests to sign off from a list to the discussion group members address. Doing so is like having your request to stop receiving the New York Times appear on their editorial page - many will read it but not the person who can change your subscription.
• Some discussion groups are VERY active and you can receive a high volume of messages each day, so be prudent when subscribing to them.

• Beware of strong emotions.
• Always include a signature so that people can contact you.
• Copy the essence of a message when replying, not the entire message.
• Send a gentle reminder or resend the message if you have not heard back. E-mails can get lost on the Internet or on a busy person's e-desk.
• Keep your posting to a discussion group relevant to the topic of the list.
• Be careful when using all caps in a message; it is considered to be the equivalent of shouting.
• If you are asked to talk about a commercial interest of yours, be sure to remove all advertising hype and testimonials, and be concise.  Clearly state in your message that you have a financial interest in the product.
• And most important of all, check to whom you have addressed your e-mail message before sending it. We’ve all been embarrassed by sending a message to someone we didn’t mean to include.
• For a copy of Allina's discussion list etiquette, please see http://www.allina.com/lists/etiquette.html

IX. Security issues

• Always back-up important files on your computer.  Crashes occur and are unpredictable.  Would you drive an uninsured automobile?
• Caution should be used when opening files from someone else. Any file from another computer no matter how trusted, may contain a virus. This can also be true with attachments to e-mail. The best practice is to only use files when you know the source and be sure your system is backed up.
• The decentralized nature of the Internet itself, and the circuitous route that a typical e-mail message will follow, means that most e-mails should be considered a public communication. System administrators have access to incoming and outgoing messages. You also must be aware that e-mails can be easily forwarded by recipients.  For this reason, communicating with patients about their health problems is a risky business.
• Secure e-mail is possible using encryption technology where the sender and the receiver have encryption keys.  This will also allow you to verify that the sender is who he says he is and that only the intended recipient will be able to read the message.
• For a more thorough discussion of the clinical use of electronic mail with patients, see http://www.amia.org/positio2.htm.