Online Relationship Linked to More Office Visits

November 20, 2012

Healthcare futurists have viewed online communication between clinicians and patients as a welcome substitute for low-level office visits and telephone calls, lightening a clinician's load. In addition, some studies have found that virtual visits make a waiting room a little less crowded.

However, a study published in the November 21 issue of JAMA showed that letting patients email their clinician and access their records online was associated with more, not fewer, telephone calls, office visits, and clinical services in general. In this case, the substitution theory did not hold.

Lead author Ted Palen, MD, PhD, MSPH, and coauthors studied the effect of an online Web portal for patients that was deployed by Kaiser Permanente (KP) Colorado, a group model, integrated healthcare delivery system. The portal, called My Health Manager (MHM), connects to KP's electronic health record system. MHM lets patients access test results, request medicine refills, schedule nonurgent appointments, and exchange messages with their clinician on nonurgent health issues.

The authors measured the use of healthcare services by 44,321 users of MHM before and after they adopted the system compared with healthcare use by an equal number of nonusers. All patients in the study were continuously enrolled in KP Colorado for at least 2 years from March 2005 through June 2010.

"We went in with the hypothesis that we would see a lower need for in-office services (with MHM users)," said Dr. Palen, a practicing internist who also conducts research for KP Colorado. "Our results surprised us."

Dr. Palen and colleagues found that the number of office visits by MHM users increased by 0.7 per member per year compared with nonusers. Telephone encounters rose at a smaller rate of 0.3 per member per year. The rates of after-hours clinic visits, emergency department encounters, and hospitalizations per 1000 members per year rose significantly, by 18.7, 11.2, and 19.9, respectively. These patterns held true whether the patients were younger or older than 50 years.

In contrast, a 2007 KP study of this issue in the organization's Northwest region reported that office visits decreased between 7% and 10% for patients using the patient portal. At that time, however, only 6% of KP Northwest patients were signed up for it. Today, roughly 50% of all KP patients, and about 60% of those in Colorado, are logging on. The need to reexamine online communications between clinicians and patients at a more mature stage warranted a follow-up study like his, said Dr. Palen.

However, Dr. Palen and colleagues do not consider their research the final word on the matter, especially because it remains unclear why online access was linked to a higher rate of clinical services.

Online access, Dr. Palen told Medscape Medical News, might have helped patients take more responsibility for their healthcare, which led them to use more services. Or perhaps patients who signed up for MHM were already likely to use more services because of clinical characteristics that the study failed to control for (simply put, they were sicker). Future research will try to tease out cause and effect, he said.

Could Patient Portals Increase the Demand for Clinicians?

Dr. Palen said he also wants to explore other nuances of patient portal use.

Is an increase in use for logged-on patients linked to the type of online interaction or the kind of clinician seen? And does it make a difference what kind of health plan the patient has? After all, a patient might have an economic incentive to substitute an online consultation for an office visit if the former is free — which often is the case — and the latter involves a copayment, coinsurance, and deductible.

The latest KP study did not control for the type of health plan. KP Colorado offers a wide gamut of plans, including traditional health maintenance organization (HMOs), high-deductible HMOs with health savings accounts, and preferred provider organization plans.

An even more important question to answer, said Dr. Palen, is the effect of the online clinician–patient relationship on clinical outcomes. If virtual visits lead to more face-to-face visits, does a patient's health necessarily improve as a result?

Dr. Palen said that if future research continues to find a link between patient portal use and a higher uptake of clinical services, medical organizations will need to staff accordingly. The authors estimate that if office visits for a solo practitioner with 1000 adult patients increase by just 0.5 visits per patient per year, the physician will need to book 10 more appointments each week.

"It would be prudent to be prepared," he said.

Dr. Palen is employed by the Colorado Permanente Medical Group. The other authors are employees of Kaiser Permanente Health Plan of Colorado. The authors have disclosed no other relevant financial relationships.

JAMA. 2012;308:2012-2019. Abstract