Issue 46 / 26 November 2012

A NEW US study showing online access to medical records and doctors led to an increase in GP and emergency department visits is no cause for concern, according to Australian medical leaders.

AMA president Dr Steve Hambleton said a spike in the use of clinical and hospital services that was identified by the study was not a result of patients with online access developing additional health concerns but, rather, because the people who participated in online access were more worried and motivated about their health.

“It wasn’t because of access, it was because of self-selection bias”, Dr Hambleton said.

The study, published last week in JAMA, found that patients who took up access to online medical records and online communication with doctors had an increase in visits to GPs (0.7 more visits per patient per year), telephone encounters (0.3 more), emergency department visits (11.2 more visits per 1000 patients per year) and hospitalisations (19.9 more per 1000). There was also a significant rise in after hours clinic visits (up 18.7 per 1000). (1)

The retrospective cohort study compared the use of health services by 44 321 patients using a secure online access system with 44 321 non-users who were all enrolled at a group model, integrated health care delivery system in Colorado. The online feature, introduced in 2006, allowed member patients to obtain secure access to their health records, including test results, immunisation records, active medications and care plans.

The researchers wrote that the patients with online access to their medical records, including secure e-mail communication with clinicians and appointment booking, had a subsequent increase in the use of most in-person and telephone clinical services during the 5-year study period. They said the result was “contrary to our expectations and the results of some prior studies”.

Dr Hambleton said the researchers should have randomly allocated people after they opted in to the online access system as opposed to splitting the cohort between self-selected users and non-users.

The authors acknowledged a limitation of the study was that members who signed up for online access might have greater health concerns that influenced health care contact rates.

However, they wrote that the magnitude of differences in utilisation was 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 and the health system would need to provide 50 000 more clinic visits and respond to 30 000 more telephone calls”, they said.

Dr Mukesh Haikerwal, national clinical lead of NEHTA (National E-Health Transition Authority), the organisation overseeing Australia’s new personally controlled electronic health record (PCEHR), said that in the short term he expected costs to go up after the introduction of online access for patients, but they would eventually go down as chronic illnesses became better managed.

He was unconvinced the findings foreshadowed negative consequences for the rollout of the PCEHR and rejected the notion that the use of electronic health records would be solely responsible for driving up costs.

“These assertions do not take into account the environment we are dealing with now. Health costs are increasing anyway”, he said.

An accompanying JAMA editorial warned that the results would be “sobering for patient portal enthusiasts”. (2)

Dr Hambleton said he “disagreed entirely”. He said the results were encouraging because they showed people were enthusiastically taking up access to a tethered portal.

“It shows there is a business case in Australia for allowing lots of people to look at [online records]”, he said. “And it shows there is opportunity for innovative Australian practitioners.”

Another US study, published in the Archives of Internal Medicine last week, found doctors were more likely to prescribe during e-visits compared to GP visits for two conditions — sinusitis and urinary tract infection. (3)

The research letter examined all e-visits and office visits for the two conditions at four primary care practices over a 16-month period.

Dr Hambleton said it would be concerning if antimocrobial prescription rates went up, particularly given the global incidence of antibiotic resistance.

Dr Haikerwal said e-visits should be used as an adjunct to face-to-face visits, not as a substitute. “[The study] shows the dangers of using e-visits as a substitute”, he said. “But it can be good if you need to get to someone in a hurry.”

– Amanda Saunders

1. JAMA 2012; 308: 2012-2019
2. JAMA 2012; 308: 2034-2036
3. Arch Intern Med 2012; Online 19 November

Posted 26 November 2012

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