A recent article indicates that increased patient access to online records was associated with increased in-person and telephone contacts (JAMA 2012; 308: 2012-19).
Background (from study introduction): The Institute of Medicine’s report on “Crossing the Quality Chasm” indicated that electronic patient-physician messaging was a promising technology to improve quality and efficiency. Furthermore, previous studies have suggested that 25-70% of all visits to physicians do not require face-to-face appointments.
Design: To explore this topic further, the authors performed a retrospective cohort study on the use of health care services between 2005-2010 at Kaiser Permanente in Colorado. This study examined patients ≥18 years old and looked at health care utilization before and after initiation of MyHealthManager (MHM). Users of MHM were compared with nonusers. And, both groups (users and nonusers) were examined with regard to their health care utilization before and after MHM rollout. The first 30 days before and after activation of MHM were excluded from analysis to minimize the effect of increased utilization at the initiation of MHM.
Results:
- By June 2009, patient use of MHM had increased to 53.8%. In total, 87,206 MHM patients were identified and 71,663 nonusers were identified for study participation.
- MHM users were slightly older and more likely to be female.
- After initiation of MHM, the rate of office visits increased by 0.7 per member per year (p<0.001) and the number of telephone encounters increased by 0.3 per member per year (p<0.001).
- The authors breakdown this data based on age, absence of chronic disease, presence of specific diseases (diabetes, coronary artery disease, congestive heart failure). In all of these scenarios, MHM users had increased visits after initiation of MHM. Nonusers generally had the same or less visits at the same time.
- Figure 2 shows that MHM and nonusers had identical health care utilization beforehand. Afterwards, the MHM users maintained a parallel line of increased usage that was fairly consistent for a year after rollout.
Why did this happen? The authors note that the result was contrary to their expectations. They speculate that individuals may have increased their in-person use after developing additional concerns following their review of information online and that individuals may sign up who are already more likely to use services. Online access, in these individuals, may facilitate access to more frequent visits.
I think this article points to a more pervasive miscalculation of the effect of information technology and health care utilization. While electronic health records (EHRs) can help organize and communicate vast amounts of information, the proposition that they will ultimately reduce health care costs/utilization or improve efficiency is looking dubious. In my opinion, the best we can hope for is that EHRs, when used optimally, will improve the quality of the care. It is equally possible, however, that EHRs could result in more legible but less accurate information due to well-recognized issues like copy-forwarding with inadequate editing.
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