Last week I wrote an editorial about the potential benefits of patient access to clinical information titled, “Consumer Oriented Care — So Near, Yet So Far”. The premise behind much of the work that has been done to enable consumer (patient or caregiver) access to online information through patient portals and personal health records has been the potential to improve patient satisfaction while at the same time reduce unnecessary clinic or hospital visits with a corresponding reduction in the cost of care. Initial studies conducted by Kaiser Permanente were able to demonstrate a reduction in caregiver visits; however, a recent article raises some important questions and suggests that our initial assumptions may be incorrect. What if the exact opposite is true? With all the best intentions, there may be unintended consequences that we do not fully understand. By providing access to online health information, we may be increasing the overall costs of care.
A Nov 21, 2012, article in JAMA, “Association of Online Patient Access to Clinicians and Medical Records With Use of Clinical Services” by Palen et al, describes a retrospective cohort study for the period March 2005 through June 2010 at Kaiser Permanente Colorado. The study was designed to assess utilization of the health system by both users and nonusers of online access to health records before and after initiation of a patient patient portal. Researchers studied 44,321 members who signed up for the the online access system (MyHealthManager) and remained active users of the system for at least one year. MyHealthManager provides the ability for members to access their medical records, communicate with their physicians via email, and request appointments and prescription renewals online.
The authors found that contrary to the findings of this study (amongst others), which demonstrated a reduction in total office visits, “patients with online access to their medical records, including secure e-mail communication with clinicians, had a subsequent increase in use of most in-person and telephone clinical services”. The authors could not explain these findings and suggested that influences such as the decision to sign up for online access to their electronic records, may pre-select individuals who have a higher propensity to seek face-to-face care with a provider. By extrapolating their results to a small group practice, the authors suggest that “a primary care physician with 1,000 adult patients who have online access would need to provide for almost 10 more clinic visits per week and over 5.5 more telephone calls per week”.
This is clearly not the type of result that we are seeking by making electronic health records available to patients and their caregivers through portals or integrated personal health records; however, as these tools become more integrated with the care delivery process, we should continuously measure their impact to ensure that we are managing resources responsibly.
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