Hey there Accountable Care Organization executive.

You’re probably willing to continue to commit millions of dollars toward an electronic health record (EHR) coupled to an online patient portal.  That’s because you’ve been told by your leadership team that electronic consumer empowerment, patient-provider communication and the substitution of efficient two-way messaging for costly face-to-face visits will increase quality, reduce expenses, generate shared savings and guarantee that your life-sized portrait will be prominently displayed in your flagship hospital’s lobby.

Well, after you’ve read a just-published JAMA research study by Ted Palen, Colleen Ross, David Powers and Stanley Xu, you may want to tell your administrative assistant to cancel that appointment with the portrait artist.

The article’s title is Association of Online Patient Access to Clinicians and Medical Records With Use of Clinical Services.

How the study was done:

Kaiser Permanente Colorado added “MyHealthManager” (MHM) to their EHR in May 2006. MHM allows patients to view tests, records, problem lists as well as care plans, schedule appointments, request refills and message their doctors. By June of 2009, over 375,000 Kaiser patients had signed up for MHM. Of those, about 45% had used the system at least once.  Of this number, Kaiser researchers pulled the records of 44,321 persons who had been continuously enrolled in the Kaiser system for at least two years.

This group was retrospectively matched to a control group of Kaiser patients who had not signed up for MHM.  The authors did this through “propensity matching.” This found a similar number of patients, based on age, gender, race, number of chronic illnesses and baseline office visits who, using logistic regression analytics, appeared to be the type of patient who would otherwise sign up for MHM.

The results:

Compared to non-MHM patients, the MHM experienced an increase in hospitalization rates (20 per thousand patients) and emergency room visits (11 per thousand).  In other words, for every hundred patients, the on-line portal seemed to lead to 2 extra hospitalizations and 1 extra ER visit. Both differences were statistically significant.

There were also increases in the number of office visits (.7 per patient per year), telephone calls (.3 per patient per year) and after-hour clinic visits (18.7 per thousand patients per year).

Caveats:

The authors correctly point out that this study is not perfect.  Retrospective propensity matching is not as good as a randomized clinical trial; it’s possible that the patients who self-selected for MHM were already realtively more interested in or likely to increase their use of health care services.  Results at Kaiser may not apply elsewhere.

Implications:

Despite the limitations, this study should be a wake-up call for those who believe EHR portals is a savings panacea.  By increasing access to on-line services, physicians and patients may paradoxically use the system to address concerns that otherwise wouldn’t come to medical attention.  In other words, the EHR portal exacerbates the classic health care economics problem of supplier-induced demand.

Jaan Sidorov, MD, is a primary care internist and former Medical Director at Geisinger Health Plan with over 20 years experience in primary care, disease management and population-based care coordination. He shares his knowledge and insights at Disease Management Care Blog, where this post first appeared.

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38 Responses for “Study Says, Something Other Than What We Were Expecting. EHR Portals Increase Hospitalization Rates”

  1. BobbyG says:

    WAY less here than nominally meets the eye. Just trying to stir up trouble. I’m not aware of anyone in HIT who I work with who claims that HIT will be a “savings panacea.”

  2. Matthew Holt says:

    hmm….this seems to completely contradict the Hawaii study published in Health Affairs a while back and everythingI’ve heard from Kaiser….I’m very puzzeld

  3. southern doc says:

    Come on, did anyone honestly expect the results to be different?

    If a patient is allowed to write messages that go into their permanent record, and they just mention any vague “chest pain,” SOB,” “headache,” etc., OF COURSE the doc is going to send them straight to the ER. No one is going to create a chain of e-mails dealing with those loaded topics.

    Get real.

    • rbaer says:

      Need to read the JAMA article but I think southern doc is right. I think that the heavily involved patient struggling to understand medical decision making ends up having more requests (that usually will be fulfilled) due to the anxiety produced by reading what his/her symptoms (or test abnormalities) could mean, even though (by statistical chance) they are from the giant pool of the “worried well”. There are for sure A. patients who pick up oversights or a wrong/missed diagnosis, but noone ever writes home about B. the much, much more frequent inverse case (i.e. patient worried about something minor, prompting further medical action). It would be nice to promote A. without enhancing B., but I do not know how this would be possible.

  4. It’s not the technology. It’s what you do with it.
    Online access is usually accompanied by “reminders” to have this or that test, have this or that vaccine, come in if your last A1c was too long ago or too high, and all sorts of other things “per guidelines”. Meaningful Use is requiring that reminders be sent out indiscriminately now.

    So why are we surprised when people respond as designed?
    I’m sure they get “better care”, which will lead to “better health for populations” and eventually to “lower costs”….. Or am I missing something? :-)

    • BobbyG says:

      “Meaningful Use is requiring that reminders be sent out indiscriminately now.”

      That is simply not true. Reminders are to be targeted, per patient delivery method and for specific f/up needs/conditions ( >20% of pts).

      Moreover, that one is in the “Menu Set” (meaning optional).

  5. Curly Harrison, MD says:

    It is the technology, especially when ill conceived with grandiose expectations; and it is what you do with it, or what you are told to do with it.

    I am shocked, literally shocked, at the results of the study.

    Who would have thunk it, especially with the likes of Regina and the infamous epatient dave, who between the two of them, made the noise of an army to require portals for the lay folk?

    I am even more shocked that the @farzad team did not get it and put forth what is meaningfully useless as useful. Hello?

  6. Whatsen Williams says:

    The entire concept that patients should be their own doctors by having access to the complex language of results is farcical.

    Via this portal fantasy, the ONC and HHS leaders have increased the population of worried well exponentially, and the costs will travel along for the ride.

    This is sort of the kicker for the already expense increasing CPOE and EHR systems that have not improved outcomes while increasing costs via upcoding and other games that they play with numbers and dollars.

  7. Legacy Flyer says:

    So the HealthCare experts with no clinical experience were wrong about cost saving?

    I’m shocked.

    From the movie Casablanca – Captain Renault: “I’m shocked, shocked to find that gambling is going on in here!” [a croupier hands Renault a pile of money]

    • BobbyG says:

      “HealthCare experts with no clinical experience.”
      __

      Like Farzad Mostashari, MD, Paul Tang, MD, Christopher Chute, MD, John Halamka, MD, C. Martin Harris, MD…?

      A very long list. Look it up.

      • southern doc says:

        Mostashari, Tang, and Chute: the Rove, Morris, and Luntz of lousy HIT prognostication.

      • pcb says:

        do they still see patients? Or have they moved on from spending significant time practicing medicine. Plenty of MDs out there who quickly forget what actually dealing with patients is about.

        • BobbyG says:

          You guys got an excuse for everything.

          • southern doc says:

            Expecting EMR advocates to provide evidence to support their claims means I have “an excuse for everything”?

            Seriously, I don’t get your point.

          • BobbyG says:

            The (refuted) assertion was “people with no clinical experience,” that’s all I was responding to. Stay on point.

          • southern doc says:

            So “you guys” referred to an assertion, not the previous posters? OK, I’m back on point.

            The fact that many of the most enthusiastic advocates of EMRs have never used them doesn’t completely invalidate their opinions, but does make them less interesting to me. I don’t put much stock in film reviews by critics who never watch a movie.

  8. Legacy Flyer says:

    Them too

  9. Great post..i think people should go through it. i really like it. Thank you for sharing.

  10. see_d_see says:

    The sham on the patients and taxpayers continues to be proven.

    EHR, CPOE, Pt. Portals, and CDS are emerging diseases that need scrutiny by the CDC.

    Several of the vectors are listed above by Bobby G.

    We are funding an immunization program.

  11. Rocket Scientist says:

    Duh, who knew??

    The ONC has been putting the cart before the horse beginning with D. Brailler, the Bush the Second’s appointee, who was put in there to inititiate the national coercion programme in HIT (because Bush knew that these devices were safe, improve outcomes, and reduced costs).

    He and his team, not unlike Obama’s, were educated by HIMSS, SeeChit, and now, advance with maintenance propaganda from ONC, reinforced by HHS Secretary Sibelius.

    Sickening.

  12. jhayner says:

    large study on patient satisfaction has similar results. The bottom line is the attempt to replace the patient physician relationship is failing

  13. Rajesh says:

    As with the similarly shocking studies that EMRs drive billing and use of imaging services, dropping technology into a dysfunctional healthcare non-system can have unintended consequences that don’t support the administration’s promises of cost savings and/or better quality.

    Expect the ONC response to be direct and vociferous.

    Which begs the question: If ONC is focused on proving that HITECH is a success, who’s actually trying to understand and apply what actually works (and prevent more of what doesn’t)?

    R

  14. SJ Motew, MD says:

    The increase in utilization by those connected through Kaiser’s portal tells us nothing about:

    1. Overall measures of health and wellness/disease states
    2. Total costs associated with this population

    Ideally, the more engaged population uses these resources earlier in their disease process and as preventative treatment/visits. Theoretically, those less connected might not goto their doc, ED or hospital until much later and at greater expense.

    Also, despite propensity matching, those not feeling well are more likely to use the process post hoc the matching criteria.

    • rbaer says:

      Ideally, the more engaged population uses these resources earlier in their disease process and as preventative treatment/visits. Theoretically, those less connected might not goto their doc, ED or hospital until much later and at greater expense.

      My anecdotal wisdom (we – our unversity medical center – are doing exactly was Kaiser is doing): Emailing simply lowers the threshold of contacting the health care provider (keep in mind that providers always could and can be contacted via nurse/answering service). In my experience, that does result in more symptoms reported and more tests performed, mostly for the worried well (keep in mind that Email creates a detailed written record, automatically heightening provider fear of litigation based on later reinterpretation of the Email; the old documentation standard, a summary based on the recollection of the provider is usually perceived less risky). The indolent personalities ( the ones not going to the ER despite a stroke or chest pain) will not use Email/mychart, nor will people with poor habits request lifestyle counselling by Email because they could.

      • SJ Motew, MD says:

        Undoubtedly that seems to be part of many center’s experience, the point is however that most of these assumptions are anecdotal. It would be nice to back this up with analysis that looks at cost and health outcomes rather than number of visits.

        • rbaer says:

          I haven’t read too much about Email/mychart experiences (neither observational research nor anecdotes) … in any case, you seem to call for controlled or at least large well designed studies. But isn’t the onus for that research on the camp favoring introduction of Email/ mychart, because the change needs to prove superiority and not the status quo? You could make the point that there is overwhelming consumer demand, but I do not buy that (some patient/consumer polls I have seen seem to lump the “modestly favor chart access in theory” with the small fraction of dedicated self declared patient advocates … we are a very IT literate city with a very high educational level, and yet mychart sign up appears modest, despite efforts from my institution to enroll every one or at least to formally offer it.

    • southern doc says:

      “Ideally, the more engaged population uses these resources earlier in their disease process and as preventative treatment/visits.”

      Assuming that the ideal will become a reality is not scientific, but is very popular in health care these days.

  15. Curly Harrison, MD says:

    I find it shallow that anyone would think that if patients’ access to medical information is increased, that usage and costs would decrease.

    For self proclaimed health experts to attempt to use derivative endpoints to excuse the obvious defect in logic on outcomes from patient portals is a defense to the flawed cognition.

  16. Patient Donni says:

    Does anyone remember Justin Deal? Why is is this such a big surprise. Just go and Google Kaiser and see what comes up. Funny, you don’t see the blather of Dave Roberts or his Cronies in here. No, because they’re still waiting to get their hands on more money to ram Clinical Decision Support down our throats. BTW: patient reporting belongs as part of the case history- WTF is wrong with you money grubbing up-coders that you think the patients should not have a voice? AH, yes the answer as always is GREED.

  17. Janie Williams, RN says:

    I do not want to see my results. I trust my doctor to provide me the guidance and information. He does not have EMR because based on what he has read in jouransl and blogs, and seen in hospitals, he thinks that they cause too many unexpected errors and deaths

    This movement to patient portals and access to information they do not understand is ludicrous.

    R u listening, all you e-patiensts?

  18. J.D. Kleinke says:

    Two words: “engagement bias.” There is no way to sufficiently case-control patients who go through the bother of signing up for a personal health information portal and those who do not, and then comparing the two groups’ relative health system access patterns, utilization, or costs. The very act itself is probably a sub-clinical market for underlying illness-severity that showed up in the subsequent bump on use and costs.

    But I’m glad the “researchers” got one more chance to snipe at HIT and quantify the terrible price we are all paying for giving patients access to their records. Someday, thanks to important contributions like this, the computerization of medicine and transparency of information will all go away like a bad dream and patients will go back to not wondering and doing only what they are told.

  19. J.D. Kleinke says:

    Meant “sub-clinical marker.”

  20. legacyflyer says:

    Of course this is not an experiment and those that seek to use a portal are a self selected group that may be more ill, but are certainly more concerned about their health.

    Only way to tell is a randomized controlled study, with people assigned to “portal” and “non-portal” groups.

    I do think that this is important information though and brings up the question: “What evidence do you have that giving patients access to their own data through portals improves outcomes/saves money?”. The answer – none.

    I also think that there is a separate ethical/moral issue as to whether people should have access to their own medical information. I think the answer to that is YES, regardless of whether it improves incomes/saves money or not.

    • southern doc says:

      What the study seems to show is that the portal-users, even if self-selected, increased their health care consumption significantly over their own baseline after the index date. Non-users didn’t.

      Docs are just so tired of being lied to about what EMRs will do!

  21. legacyflyer says:

    To my mind portals are something like efforts to stop smoking – they are worth doing for reasons other than saving money.

    The attempt to create the illusion that these things will save money is Marketing/PR from HealthCare IT to persuade gullible buyers to purchase before “evidence based data” exists.

  22. Lillipad says:

    This is possibly an obvious question, but what is the discussion around having an EMR in which patients could view all their information in one place, yet NOT have the capability to email their physician?

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