Patients who utilize online health services make greater use of in-person services

Image: PD

Key study points:

1. Users of an online patient portal utilized more in-person services than non-users in both routine (office visits, calls) and emergent (ER visits, urgent care visits, hospitalizations) categories.
2. Chronically ill patient portal users and non-users showed no difference in utilization of in-person services, except for asthmatic and diabetic users making more scheduled office visits and asthmatic users having more hospitalizations.

Primer: Healthcare information technology (HCIT) has been a key component of government health reform efforts in the last decade (1), such that the Obama administration alone allocated over $36 billion towards the transition to electronic medical records (2). HCIT experts suggest that digitizing systems will increase the safety and efficiency of medical care and that utilizing patient-held records could further improve quality by promoting patient autonomy and education. In 2008, the nonpartisan Congressional Budget Office (CBO) published a report on the costs and benefits of HCIT, saying that while there was significant potential for HCIT to reduce medical spending, these claims of cheaper, better quality care were not uniformly supported in the literature (3).

However, there has been promising recent research on the patient portal, which combines electronic personal health records with secure services provided by a physician, mid-level provider, nurse, or practice employee. Two studies suggest that patients’ use of the online portal could decrease use of in-person services. One study out of California showed decreases of 25 and 22%, respectively, in primary and specialty care visits by patient portal users (4). In the Northwest, in-person outpatient visits decreased 6.7% among patient portal users (5). These results suggest the patient portal may reduce costs and improve care for several sets of patients such as those with chronic diseases, the disabled, and the elderly, who are expected to both adopt patient portals at higher rates and to benefit more than the average user (6).

The present study examined use of in-person clinical services by users and non-users of a patient portal in a Kaiser Permanente practice.

Background reading:

1. Kaiser EDU.org – Health information technology
2. Time article – Are electronic health systems cost effective? Not so much
3. Congressional Budget Office report – Evidence on the costs and benefits of health information technology
4. The Kaiser Permanente Electronic Health Record: transforming and streamlining modalities of care
5. Patient access to an electronic health record with secure messaging: impact on primary care utilization
6. Personal health records: a scoping review

This [retrospective cohort] study: examined use of routine and emergent in-person clinical services from 2005 to 2010 by comparing a matched-control sample of 44,321 patients who did access and 44,321 patients who did not access Kaiser Permanente Colorado’s patient portal.

Users of the patient portal used significantly more in-person services than non-users in all five outcomes measured: office visits and calls (0.7 and 0.3 per member per year, respectively) and after-hour clinic visits, emergency department visits, and inpatient hospitalizations (18.7, 11.2, and 19.9 per 1000 members per year, respectively).

Comparing users to non-users across the four chronic illness categories (asthma, diabetes, coronary artery disease, and congestive heart failure) resulted in outcomes with greater variance. The only relationships achieving significance (p<0.001) occurred in asthmatics and diabetics such that asthmatic users of the online portal had more inpatient hospitalizations (43.6 per 1000 members per year) and made more office visits (0.8 per member per year), while diabetic users made more office visits (0.6 per member per year).

In sum: Overall, patients’ use of online health services (e.g. viewing their medical records or messaging their physicians) was associated with greater use of in-person health services. These findings contradict prior similar research in Kaiser clinics (4-5) and could be used to argue that online services have less cost-cutting potential than previously thought. Furthermore, since Kaiser practices are integrated delivery systems – which received the most optimistic outlook for HCIT savings in the CBO report cited above – these results may actually be amplified in unintegrated health settings. However, these findings may also indicate fewer barriers in access to care and thus represent an increase in quality. This may be the case in patients with chronic diseases, as evidenced by the higher rates of scheduled office visits in asthmatic and diabetic users of the online portal. Yet, the trend of increased emergency room visits is troubling because it suggests more reactive and less preventive care.

One limitation on the generalizability of this study is the lack of long-term evaluation of outcomes for patients with chronic diseases, as it’s possible the five-year study period was not long enough to capture how patients’ usage of online health services might increase patient education and slow disease progression or decrease disease severity. Additionally, outcomes for other patient groups who might benefit most from online services, such as rurally located and elderly patients, were not explicitly evaluated. Future research is needed on several fronts: (1) to optimize access to care and costs of care, (2) to develop communication strategies to explain how online health services may replace certain in-person services, and (3) to examine service usage by patients using other kinds of HCIT besides patient portals.  

Click to read the study in JAMA  

Click to read an accompanying editorial in JAMA

By [CH] and [LH]  

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