Potential
There is great interest in the general population to seek out medical information online (8).  This trend can only be expected to increase, and rather than perceiving this as a threat, it can be dealt with as an opportunity.  Web sites offer technology to allow patients to become educated, reduce the number of phone calls and office visits by providing answers to simple questions, and to search online for the medical solution and provider which best suit their needs. Patients can be referred to online educational brochures rather than having the practice purchase or print brochures. Guided tours of the hand may be provided in waiting room or examination room on line kiosks that the patient can browse unattended.

The larger potential involves integrating patient interactions into a customer relationship management system as described above, through which an automated system could allow new patients to provide their initial medical history and insurance information, and existing patients could double check their appointments, be reminded of appointments by e-mail, submit requests for information, and deal with their account information. Eventually, online video interactions may provide additional flexibility for patient consultation.

Current Reality
Automated on-line interaction: The number of patients seeking medical information online greatly exceeds the number of physicians providing it (8). Unfortunately, the ease with which materials may be published online allow information of dubious value from unknown sources to be retrieved as well as legitimate medical information. Patients cannot be expected to critically evaluate the validity of materials they read online. Some physicians are intimidated or irritated by patients who have done on-line research and present it during an office visit for review.  However, the most practical response is to accept this, help patients recognize medical quackery, direct patients to sites which are felt to be reliable, and when possible, contribute high quality patient information on hand surgery online. A large body of resources are available, some of which are detailed in Table 8. Some practices have found it helpful to provide online video brochures regarding hand surgery (62, 48) or apply an infommercial approach to specific procedures such as carpal tunnel release (18). My personal experience is that on line patient information is gratefully welcomed by patients. They are a practical approach for a hand surgery practice, less cumbersome than stocking a large number of different brochures, and can be expanded or updated without limit.

Manual on-line interaction: e-mail or other correspondence type communication between patient and physician represents an entirely different situation with a number of issues to consider.

1. E-mail communication without any security measures may be accessed by third parties, and confidentiality concerns may outweigh the potential benefit of e-mail communication.  Some practices which initially had an open e-mail policy have discontinued patient e-mail for this reason.  The safest method is to use some form of e-mail encryption, or make arrangements with the Web site server to provide secure form based communications. The next best approach is simply to warn patients that e-mail does not have guaranteed privacy and that such communications are at their own risk.
2. E-mails between physician and patient should be considered legal chart documents, and printouts of all patient e-mails in and out of the office should be kept as part of the patient's permanent record.
3. Medical malpractice carriers are developing policies to deal with potential liability of medical e-mail (43)
4. The practice must have a clear policy not only on maintenance of patient e-mail records, but a system to deal with them.  Physicians quite comfortable dealing with personal e-mail may quickly find themselves overwhelmed with e-mail from their practice. Before instituting patient e-mail, the practice should have a clear policy of who will read the e-mail, who will answer it, when it will be checked, when it will be answered, how different requests will be triaged, and how each of these steps will be documented.  This policy should have the same degree of organization, documentation and backup as the practice's telephone and mail policies.
5. The practice must have a clear policy for management of emails arriving from unknown sources, such as solicitation of medical advice by people who are not patients. Requests for medical information can be stimulating and flattering at first, but can also easily overwhelm the physician's ability to respond. If your practice site is visible on search engines and you post an email address, requests for free medical advice from persons unknown will arrive, even if your site boldly states that requests for information will not be answered, or that such requests should be directed to a local physician or to your practice telephone, etc. How will these be handled? Should they be ignored? Should they all be answered with a standard reply of "please contact a local physician"? Should you review each one and decide how to respond? The obvious solution is to handle these the same way that you handle telephone requests for free medical advice - it is up to you, but the issue should be considered and a policy outlined before listing an email address to the general public.
6. The practice web site e-Mail address should be different than the physician's personal email address, even in a single physician web site.

Email efforts are unpaid - currently. However, given the increasing recognition of the demand and value of physician on line consultation (42), there is hope that a system for physician reimbursement for on line consultation can be developed.