Patients Use More Services When They Have Online Access to Physicians, Records

A surprising conclusion was reached by researchers involved in a study published in the Nov. 21 issue of The Journal of the American Medical Association titled "Association of Online Patient Access to Clinicians and Medical Records With Use of Clinical Services." Researchers found that patients who had online access to their physicians and other health care professionals -- access that included secure e-mail communication -- increased their use of in-person and telephone clinical services.

The authors noted that their findings were contrary to their expectations and differed from the results of some previous studies.

"The presumption is if patients could look up health information such as their test results, request prescription refills, schedule appointments, and send secure e-mail to clinicians, then their use of clinical in-person and telephone calls may decrease," wrote the authors.

Rather than interpreting the results as an unexpected consequence of getting patients actively involved in their health care, corresponding author Ted Palen, Ph.D., M.D., M.S.P.H., told AAFP News Now that the study findings actually could indicate that patients were more engaged in their care than generally was assumed.

Although he and his coauthors were not certain why the results were different than anticipated, Palen, the physician manager for clinical reporting at the Institute for Health Research at the Colorado Permanente Medical Group in Denver, said the team already had developed several hypotheses for further investigation.

"One is that perhaps patients with online access may be more engaged in their health care and therefore use more clinical services initially. We want to see if that leads to better health outcomes for these patients down the road," said Palen. Eventually, that scenario could mean a diminishing need for in-person clinical services by some patients.

The authors also considered that perhaps online users had more severe illnesses and therefore required more clinical care. Lastly, "Another hypothesis that deserves investigation is that perhaps those who signed up for the patient portal did so because they anticipated the need for more clinical care," said Palen.

The study was conducted at Kaiser Permanente Colorado, a health care delivery system in the Denver-Boulder-Longmont area that provides services to more than 500,000 people. The health system has used a fully integrated electronic health record (EHR) system since 2004, and in May 2006, it added an online feature called MyHealthManager that allows patients secure online access to their health records through a type of patient portal.

Patients also can go to their portal to schedule and cancel nonurgent appointments, request medication refills, and send and receive messages to and from physicians and other health care professionals.

The study stretched from March 2005 through June 2010. Patient participants had to be at least 18 years old and enrolled continuously in the Kaiser plan for at least 24 months. Portal users must have maintained an active status in the patient portal system for least 12 months and used at least one system feature.

Researchers collected information on patient age, sex, visit frequencies and race/ethnicity. They also watched for diagnosis codes for asthma, diabetes mellitus, coronary artery disease and congestive heart failure. Researchers collected statistics on the number of office visits, telephone encounters, after-hours clinic visits, emergency department visits and hospitalizations.

Study authors identified 87,206 members with online access and 71,663 without access; they found that Kaiser member use of online access increased from about 25 percent at the close of 2007 to nearly 54 percent by June 2009.

When comparing the use of clinical services between portal users and nonusers within a specific time period, researchers saw a significant increase in per-member rates of office visits (0.7 per member per year) and telephone encounters (0.3 per member per year).

Researchers also noted a significant increase in per-1000-member rates (per year) of

The utilization pattern held true for patients regardless of age.

With regard to specific disease conditions, researchers found that, among other things, patients diagnosed with asthma who used the patient portal had significantly increased rates of office visits and hospitalizations; portal-using patients with diabetes showed an increase in the number of office visits and after-hours visits; and portal users with congestive heart failure had an increased rate of telephone encounters. Patients who didn't use online access did not show similar high levels of increased usage.

Patients with coronary artery disease showed no difference in utilization of services regardless of use or nonuse of a patient portal.

Researchers said their findings "suggest that the relationship between online access and utilization is more complex than the simple substitution of online for in-person care suggested by earlier studies."

They noted that health care delivery planners and administrators may need to plan for a reallocation of resources to cover for an increased use of clinical services as online applications become more widespread.

Palen said physicians can use the data to their advantage as they bolster their use of enhanced physician/patient communication.

"The takeaway for physicians is not to be afraid of patient portals. Patients like them," said Palen. "Both patients and clinicians need to learn to use them to improve health care delivery. Physicians may need to anticipate an initial increased need for clinical services, but perhaps this will improve the health for patients in the long run.

"We have much more to learn before we know the answers," he added.