This article, published in Health Affairs today, adds to the body of information we already have about patients and physicians enjoying the benefits of secure e-mail access to each other, with information about impacts on health care quality.
Thanks to the scale of Kaiser Permanente (and even in just one region of Kaiser Permanente), it is possible to look at the use of secure e-mail between patients and the 3,092 primary care physicians (there are 6,000 total in this multi-specialty group) who had used it with at least one patient, by December, 2008.
And…in a comparison between patients with diabetes and/or hypertension who did and did not exchange e-mail with their physicians two months after the service was available, there was a statistically significant (better) improvement of all of the Healthcare Effectiveness Data and Information Set (HEDIS) measures for this population.
Not just one of the measures analyzed, all of them.
In addition, the more messages sent resulted in more improvement for four measures (HbA1c and cholesterol screening, HbA1c control, and nephropathy screening).
The patients with e-mail use were compared to patients similar to them based on baseline measures (where they started disease-wise), age, sex, and primary care provider. In other words, this takes care of differences between doctors who may practice differently in terms of working with patients to improve health.
What this matching does not take care of, as the authors point out, are patients that are more likely to use secure e-mail in the first place, because they have more resources, they are more engaged, etc.
On this note, I have been having conversations of late about the “engaged in their health” person. I know that a lot of people are taught to promote the idea that many patients don’t want to be engaged in their health, but really, this is an idea whose origin is not clear to me. How many people do we know that want to be engaged in being sick? Comment from the patient community?
One thing to notice – look at the rate of blood pressure control across all the patients – 90%. This is unheard of in most of health care, where the average control rate is less than 40%, in a condition (high blood pressure) that accounts for 27% of total CVD events (stroke, heart attack) in women and 37% in men. That by itself is huge, and it actually makes a study like this very difficult, because unlike the rest of health care, in this system there is almost nowhere to go but down.
One note from the authors that I agree is worth considering, an unintended consequence of a system that still thinks “in person” is more important than “accessible”:
Nonfinancial barriers to the use of e-mail should also be addressed. Current quality measures, such as those used by HEDIS and the National Committee for Quality Assurance, rely on face-to-face visits as the standard of care. For example, an office visit is now required to document the ongoing presence of hypertension.
These are impressive findings, and I think ready (and useful) to be replicated in health environments where the quality numbers are not as good to begin with. I do not say this pejoratively, all health systems can be this good for their patients, and every tool helps. If you are a health care provider or patient using an online system to communicate, please post your experiences in your perceived quality of care since you began, even anecdotally, what do you think?
I feel the need to paste in Exhibit 1, showing the p values of improvement for each measure checked. Looks good.