Web Secret #11 - e-mail?!

In a recent article in the New York Times, psychiatrist Richard A. Friedman, M.D. examines, (rather glibly, I thought), the opportunities and perils of e-mail for mental health professionals. He writes:

"The minute I started giving out my address to my patients, I fantasized about how much time I would save on routine phone calls." In the beginning all goes well. "Could I change a Monday appointment for Wednesday? Of course. Would I phone in a renewal of Prozac? With pleasure."

Then things become complicated. “Dear Dr. Friedman,” one patient e-mailed at 3 a.m. “I am having dark thoughts and wonder if I should increase my antidepressant. Can you let me know what you think?”
It was 8:30 that morning when I opened my e-mail and read her message with alarm. What exactly were “dark thoughts”? I wasn’t sure, but I had to assume the worst — suicidal feelings or thoughts — and called her immediately. She came in later that afternoon and explained that she felt bleak and hopeless and thought she and her family might be better off with her dead.
“Why didn’t you call me right away?” I asked, as I recall the conversation.
“It was the middle of the night and I didn’t want to disturb you,” she replied.
Getting disturbed is what I do for a living, and in this case e-mail seemed like a potential obstacle to her care. Considering the sheer volume of messages, and how many of them are spam, it was lucky I did not miss it.
I was beginning to worry about what I had gotten myself into.

He decides:

"For all the convenience and clarity of e-mail, it can be perilous for a clinician; as part of the written record of patients’ treatment, it can be subpoenaed just like chart notes in the unfortunately common event of legal action. Not just that, but e-mail must comply with the Health Insurance Portability and Accountability Act (HIPAA), which has complex rules to safeguard patient privacy and confidentiality. Your psychiatrist could not, for example, send you a reassuring message about your recent lithium blood level — unless you e-mailed first and specifically asked for it.
Still, being an impatient person, I love the speed of e-mail. But being a psychiatrist, I am leery about the quality of information it conveys. How can I tell whether my patient is being humorous, sarcastic or ironic? Smiley faces are no substitute for the real thing."

At the end of the article, he concludes:

"So here is what e-mail with my patients has taught me: if you need to reschedule an appointment or need a routine medication refill, please push “send”; if you have something on your mind you want to talk about, please call me — the old-fashioned way. I’m almost wistful for the sound of a ringing phone."

I know some clinicians who have made the decision not to list an e-mail on their websites for fear that patients will use it for emergency purposes when a phone call would be more appropriate. At one employee assistance program (EAP), the website lists an e-mail address, but then uses an oversized, red font, to warn: "This e-mail address should be used ONLY for general inquiries. Existing clients should contact us at the phone number listed above." Despite this caveat, the EAP reports that a number of clients have e-mailed very personal information, rather than calling.

So what do you think?

e-mail, or no e-mail?

Do you list your e-mail with a warning?