Study Says, Something Other Than What We Were Expecting. EHR Portals Increase...

Study Says, Something Other Than What We Were Expecting. EHR Portals Increase Hospitalization Rates

38
SHARE

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.

Leave a Reply

38 Comments on "Study Says, Something Other Than What We Were Expecting. EHR Portals Increase Hospitalization Rates"


Guest
Lillipad
Dec 4, 2012

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?

Guest
legacyflyer
Nov 26, 2012

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.

Guest
legacyflyer
Nov 26, 2012

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.

Guest
southern doc
Nov 26, 2012

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!

Guest
Nov 26, 2012

Meant “sub-clinical marker.”

Guest
Nov 26, 2012

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.

Guest
Nov 26, 2012

Ding, Ding, Ding, we have a winner.

JD rocks.

Guest
Janie Williams, RN
Nov 25, 2012

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?

Guest
Patient Donni
Nov 24, 2012

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.

Guest
Curly Harrison, MD
Nov 24, 2012

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.

Guest
Nov 24, 2012

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.

Guest
southern doc
Nov 25, 2012

“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.

Guest
rbaer
Nov 24, 2012

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.

Guest
Nov 24, 2012

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.

Guest
rbaer
Nov 24, 2012

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.

Guest
Rajesh
Nov 22, 2012

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

Guest
jhayner
Nov 22, 2012

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

Guest
Rocket Scientist
Nov 22, 2012

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.

Guest
see_d_see
Nov 22, 2012

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.

Guest
Nov 22, 2012

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

Guest
Legacy Flyer
Nov 21, 2012

Them too