Online access to medical records and clinicians prompted the patients in a large health maintenance organization to increase rather than decrease their in-person and telephone contacts for clinical services, according to a report in the Nov. 21 issue of JAMA.
Of particular concern was the finding that those who used electronic patient portals also showed increased utilization of hospitals and emergency services, not just office contacts, according to Dr. Ted E. Palen of the Institute for Health Research, Kaiser Permanente Colorado, and his associates.
Dr. Ted Palen
Proponents of online patient access have argued that if patients could "look up ... their test results, request prescription refills, schedule appointments, and send secure emails to clinicians, then their use of clinical in-person and telephone calls [would] decrease." But the results of this retrospective study of more than 88,000 adult patients argue the opposite, the investigators reported.
Dr. Palen and his colleagues assessed the use of clinical services among 44,321 patients who signed up for online access and a matched control group of 44,321 patients who did not during a 5-year period before and after the introduction of the patient portals.
Contrary to the researchers’ expectations, portal users had significantly more in-person and telephone contacts with their clinicians in the year after the patient portal program was introduced than they had in the preceding year. The rate of office visits rose by 3.2 per HMO member per year, and the rate of telephone contacts rose by 4.2 per member per year.
Patients who used online access also had significantly more in-person and telephone contacts with their clinicians than did those in the control group, the researchers said (JAMA 2012;308:2012-9).
Even more surprising, the rates of after-hours clinic visits, emergency department visits, and hospitalizations also increased significantly for portal users compared with nonusers. Rates of after-hours visits were higher by 18.7/1,000 HMO members per year, rates of ED visits were higher by 11.2/1,000, and hospitalizations were higher by 19.9/1,000.
This pattern of health care utilization persisted when the data were analyzed according to patient age, with both younger patients (under age 50) and older patients (over age 50) increasing their rate of in-person and telephone contact with clinicians after beginning online access.
Patient portals are thought to be especially beneficial for patients with chronic illnesses; the assumption has been that such patients could monitor their condition and communicate with clinicians electronically, reducing their need for in-person visits.
However, in this study, patients with asthma, diabetes, and congestive heart failure who used the patient portal all increased their in-person and telephone contacts with their clinicians, compared with nonusers who had these chronic illnesses.
Dr. Palen and his associates noted that any large study can identify differences between groups that are statistically but not clinically significant. "However, the magnitude of differences in utilization that we identified appears to be clinically significant.
"For example, in a health system with 100,000 adult members with online access, if the rate of office visits increases by 0.5 visits per member per year, concomitant with an increase in telephone encounters by 0.3 per member per year, over the course of a year clinicians . . . would need to provide 50,000 more clinic visits and respond to 30,000 more telephone calls.
"If this also holds true for the small group practice, a primary care physician with 1,000 adult patients who has online access would need to provide for almost 10 more clinic visits per week and over 5.5 more telephone calls per week," they noted.
This study was not designed to examine why patients might change their patterns of contact with clinicians, but the investigators proposed a possible explanation. Perhaps patients who are already more likely to use health care 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," they said.
This study was supported by the Kaiser Permanente Colorado Regional Initiative Committee Fund. No financial conflicts of interest were reported.
