Patients with online access to clinicians, medical records have increased use of clinical services

Patients with online access to their medical records and secure e-mail communication with clinicians had increased use of clinical services, including office visits and telephone encounters, compared to patients who did not have online access, according to a study appearing in the November 21 issue of JAMA.

"Using health information technology to foster efficient health care delivery is an important component of health care reform," according to background information in the article. "Prior studies suggest that providing patients with online access to health records and e-mail communication with physicians may substitute for traditional health care services." The presumption is if patients could look up health information online such as their test results, request prescription refills, schedule appointments, or send secure e-mail to clinicians, their use of clinical in-person and telephone calls may decrease. "Many previous studies involved small numbers of patients and were conducted early in the implementation of patient online access."

Ted E. Palen, M.D., Ph.D., M.S.P.H., of the Institute for Health Research, Kaiser Permanente Colorado, Denver, and colleagues investigated the association between patient online access and use of clinical services. The study examined the use of health care services by group members (18 years of age or older) who were continuously enrolled for at least 24 months during the study period March 2005 through June 2010 in Kaiser Permanente Colorado, a group model, integrated health care delivery system. Utilization rates were calculated for both users and nonusers of My Health Manager (MHM), a patient online access system. Member use of online access steadily increased from about 25 percent at the end of 2007 to 54 percent by June 2009 (n = 375,620). More than 45 percent of members with MHM access used at least 1 MHM function. The refined groups each contained 44,321 matched members.

The researchers found that when they compared the use of clinical services before and after the index date between MHM users and nonusers, they saw a significant increase in the per-member rates of office visits (0.7 per member per year) and telephone encounters (0.3 per member per year). "There was also a significant increase in per-1,000-member rates of after-hours clinic visits (18.7 per 1,000 members per year), emergency department encounters (11.2 per 1,000 members per year), and hospitalizations (19.9 per 1,000 members per year) for MHM users compared with nonusers. This utilization pattern was seen for members both younger and older than 50 years." More variability was found in rates of utilization by MHM users with chronic illnesses.

The authors suggest several possible explanations for these findings. "Online access to care may have led to an increase in use of in-person services because of additional health concerns identified through online access. Members might have activated their online access in anticipation of health needs. Members who are already more likely to use services may selectively sign up for online access and then use this technology to gain even more frequent access rather than view it as a substitute for contact with the health care system."

"If these findings are evident in other systems, health care delivery planners and administrators will need to consider how to allocate resources to deal with increased use of clinical services. As online applications become more widespread, health care delivery systems will need to develop methodologies that effectively integrate health information technologies with in-person care."

David W. Bates, M.D., M.Sc., and Susan Wells, M.B. Ch.B., of Brigham and Women's Hospital, Boston, write in an accompanying editorial that these findings may be disappointing for patient portal enthusiasts, but should not discourage organizations from increasing the use of electronic health portals by patients.

"Personal health records (PHR) are here to stay, and the tethered architecture appears to offer the most benefits. The data on utilization are uncertain and PHRs may not decrease health care utilization. However, electronic access to PHRs represents an extremely powerful tool from a variety of perspectives and can help empower and engage patients. More data on how to use them and on what specific modules and applications will be beneficial are clearly needed."