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Clinicians and Patients Online Relationships Increase Office Visits

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….

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.

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

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. Dr. Palen mentioned that online access 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.

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?

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JAMA Nov. 21, 2012