Palen TE. Association of Online Patient Access to Clinicians and Medical Records With Use of Clinical Services. JAMA: The Journal of the American Medical Association. 2012;308(19):2012.[Accessed November 21, 2012].
Therefore, the findings reported by Palen et al in this issue of JAMA will be sobering for patient portal enthusiasts.
Not really, because I wasn’t under the influence.
About a month ago I was walking with Christine Sinsky, MD, who is a passionate advocate for usability in Electronic Health Records (see her testimony in 2011 here). I told her “5-7 years ago, your work would have made me anxious, because it might prompt people who are pessimistic about the future to not allow our profession (and mostly, our patients) to see the benefits of health information technology while they were just being envisioned.”
Before I discuss the data, I want to celebrate two statements that David Bates and Susan Wells make in their editorial:
The (linked personal health record) appears to be dominating the scene and offers many advantages because it can include specific information from the medical record that is difficult and time consuming for patients to access otherwise.
Personal health records are here to stay, and the tethered (linked) architecture appears to offer the most benefits.
Hooray – David (who is truly an expert in the field and who I had the honor of shadowing in 2007) puts to rest the ongoing myths that (a) PHRs can’t be adopted successfully by large numbers of patients and (b) PHRs that are linked to actual physicians are somehow not really PHRs. Kaiser Permanente’s adoption numbers are near 4.1 million at time of this writing, and represent 63% of the eligible population of users.
Now the data – using a retrospective cohort design, colleagues at Kaiser Permanente Colorado found that rates of office visits, telephone encounters, after hours clinic visits, emergency room visits, and hospitalizations were higher for people who used Kaiser Permanente’s My Health Manager compared to similar patients who did not access or use My Health Manager from 2005-2010. They started the clock on the day the patient signed up for My Health Manager for the MHM User groups. They started the clock on the median date of patient enrollment for the Non-MHM users. I have a question into the study authors about this, since signing up for My Health Manager is usually tied to a visit, which could be tied to increased health care usage in general (response from the study author is in the comments below – added 12/6/2012). The same is not true of the date chosen as the start date to measure for the control group. The study team did a thorough job adjusting for age, gender, ethnicity, number of chronic conditions, and office visits.
So the answer to the question in the title of the post, for this group of patients, is yes. Ironically, this may actually quell the fears of the fee for service health care system and encourage it to adopt PHRs more rapidly. Previously, the concern was that PHRs would reduce reimbursement for visit-based care. So they’ll go faster, integrated care is already there, all the patients will win in the end.
There is NOT an answer to the question, “Do PHRs cause people to use health care more?” There is also NOT an answer to the question, “Do PHRs cause people to be more unhealthy?” In fact, previous studies at Kaiser Permanente show that there’s an association with greater health among users of the same PHR (See: Data Graphic: Patient-Physician E-mail improves care | Ted Eytan, MD). Another significant study shows that there’s an association with more care continuity, because people who use PHRs are more likely to stay with their current health care, especially in their first year of health system membership (see: Now Reading: Access to a PHR constitutes highly meaningful use – published data on member retention from Kaiser Permanente | Ted Eytan, MD).
It’s not clear exactly what’s going on, which means that the next best step is probably to dig into the patient stories to find out answers to the many questions posed by the study authors – are these patients more activated to begin with? Are they more unstable medically which is why they sought PHR use in the first place? Are they more or less healthy (able to achieve their life goals) because of the use of the PHR and associated health services? And a question from me – would their utilization be even higher without a PHR? The way to dig in, of course, is using the biggest innovation that PHRs have brought to health care – going beyond the data and listening.
This brings me back to my walk with Christine. I agree with David and Susan when they say in their editorial that it’s unlikely that studies where patients are randomly given (or denied) accesss to their health information online will be conducted. Happy to be told we are beyond that. People who worked to create PHRs created them to improve the use of health care, so that it would be safer, listen better than it does, be more health focused instead of health care focused. We’ll study that as we give patients what they want. I used to hear the term “turning visits into clicks,” which is really a healthcare centric view of what we’re here for. Interestingly, before I read this study I had the opportunity to visit with Anna Lisa-Silvestre, Vice President of Online Services for Kaiser Permanente (@ALSilvestre), in Washington, DC, and here’s what I tweeted:
I believe this is possible, I am happy that we’ve reached critical mass in being able to study and listen better to our patients, and I’m optimistic about the future. The video below, released with the study, touches on some of these themes below. Thanks for the excellent work, Institute for Health Research.