Association between secure patient-clinician email and clinical services utilisation in a US integrated health system: a retrospective cohort study

Associations Between Patient-Provider Secure Message Content and Patients' Health Care Visits

Background: Between-visit communications can play a vital role in improving intermediate patient outcomes such as access to care and satisfaction. Secure messaging is a growing modality for these communications, but research is limited about the influence of message content on those intermediate outcomes. We examined associations between secure message content and patients' number of health care visits. Methods: Our study included 2,111 adult patients with hypertension and/or diabetes and 18,309 patient- and staff-generated messages. We estimated incident rate ratios (IRRs) for associations between taxonomic codes assigned to message content, and the number of office, emergency department, and inpatient visits. Results: Patients who initiated message threads in 2017 had higher numbers of outpatient visits (p < 0.001) compared with patients who did not initiate threads. Among patients who initiated threads, we identified an inverse relationship between outpatient visits and preventive care scheduling requests (IRR = 0.92; 95% confidence interval [CI]: 0.86-0.98) and requests for appointments for new conditions (IRR = 0.95; 95% CI: 0.92-0.99). Patients with higher proportions of request denials or more follow-up appointment requests had more emergency department visits compared with patients who received or sent other content (IRR = 1.18; 95% CI: 1.03-1.34 and IRR = 1.14; 95% CI: 1.07-1.23, respectively). We identified a positive association between outpatient visits and the proportion of threads that lacked a clinic response (IRR = 1.02; 95% CI: 1.00-1.03). Discussion: We report on the first analyses to examine associations between message content and health care visits. Conclusions: Our findings are relevant to understanding how to better use secure messaging to support patients and their care.

The Causal Relationship Between Portal Usage and Self-Efficacious Health Information-Seeking Behaviors: Secondary Analysis of the Health Information National Trends Survey Data

Background

Patient portals have drawn much attention, as they are considered an important tool for health providers in facilitating patient engagement. However, little is known about whether the intensive use of patient portals contributes to improved management of patients’ health in terms of their confidence in acquiring health information and exercising self-care. There is a lack of randomized trials with these outcomes measured both pre- and postadoption of patient portals.

Objective

The aim of this study was to examine the causal relationship between the usage of patient portals and patients’ self-efficacy toward obtaining health information and performing self-care.

Methods

This study was a secondary data analysis that used data from a US national survey, the National Cancer Institute’s Health Information National Trends Survey 5 Cycle 1. Patient portal usage frequency was used to define the treatment. Survey items measuring self-efficacy on a Likert-type scale were selected as the main outcomes, including patients’ confidence in obtaining health information and performing self-care. To establish causality using survey data, we adopted the instrumental variables method. To determine the direction of the causal relationship in the presence of high-dimensional confounders, we further proposed a novel testing framework that employs conditional independence tests in a directed acyclic graph. The average causal effect was measured using the two-stage least squares regression method.

Results

We showed that frequently using patient portals improves patients’ confidence in obtaining health information. The estimand of the weighted average causal effect was 0.14 (95% CI 0.06-0.23; P<.001). This means that when increasing the portal usage intensity, for instance, from 1-2 times to 3-5 times per year, the expected average increase in confidence level measured on a Likert-type scale would be 0.14. However, we could not conclusively determine the causal effect between patient portal usage and patients’ confidence in exercising self-care.

Conclusions

The results support the use of patient portals and encourage better support and education to patients. The proposed statistical method can be used to exploit the potential of national survey data for causal inference studies.

Characteristics of Patients Using Different Patient Portal Functions and the Impact on Primary Care Service Utilization and Appointment Adherence: Retrospective Observational Study

Background

Patient portals are now widely available and increasingly adopted by patients and providers. Despite the growing research interest in patient portal adoption, there is a lack of follow-up studies describing the following: whether patients use portals actively; how frequently they use distinct portal functions; and, consequently, what the effects of using them are, the understanding of which is paramount to maximizing the potential of patient portals to enhance care delivery.

Objective

To investigate the characteristics of primary care patients using different patient portal functions and the impact of various portal usage behaviors on patients’ primary care service utilization and appointment adherence.

Methods

A retrospective, observational study using a large dataset of 46,544 primary care patients from University of Florida Health was conducted. Patient portal users were defined as patients who adopted a portal, and adoption was defined as the status that a portal account was opened and kept activated during the study period. Then, users were further classified into different user subgroups based on their portal usage of messaging, laboratory, appointment, and medication functions. The intervention outcomes were the rates of primary care office visits categorized as arrived, telephone encounters, cancellations, and no-shows per quarter as the measures of primary care service utilization and appointment adherence. Generalized linear models with a panel difference-in-differences study design were then developed to estimate the rate ratios between the users and the matched nonusers of the four measurements with an observational window of up to 10 quarters after portal adoption.

Results

Interestingly, a high propensity to adopt patient portals does not necessarily imply more frequent use of portals. In particular, the number of active health problems one had was significantly negatively associated with portal adoption (odds ratios [ORs] 0.57-0.86, 95% CIs 0.51-0.94, all P<.001) but was positively associated with portal usage (ORs 1.37-1.76, 95% CIs 1.11-2.22, all P≤.01). The same was true for being enrolled in Medicare for portal adoption (OR 0.47, 95% CI 0.41-0.54, P<.001) and message usage (OR 1.44, 95% CI 1.03-2.03, P=.04). On the impact of portal usage, the effects were time-dependent and specific to the user subgroup. The most salient change was the improvement in appointment adherence, and patients who used messaging and laboratory functions more often exhibited a larger reduction in no-shows compared to other user subgroups.

Conclusions

Patients differ in their portal adoption and usage behaviors, and the portal usage effects are heterogeneous and dynamic. However, there exists a lack of match in the patient portal market where patients who benefit the most from patient portals are not active portal adopters. Our findings suggest that health care delivery planners and administrators should remove the barriers of adoption for the portal beneficiaries; in addition, they should incorporate the impact of portal usage into care coordination and workflow design, ultimately aligning patients’ and providers’ needs and functionalities to effectively deliver patient-centric care.

Look Who's Talking: Application of a Theory-Based Taxonomy to Patient-Clinician E-mail Messages

Background: Patient-clinician communication between office visits may improve patient outcomes by increasing patients' information retention and offering opportunities for patient-centered communication. Secure electronic messaging offers one such communication modality, but evidence of associations between its use and patient outcomes is mixed. To date, no study has examined the relationship between message content and patient outcomes. Introduction: Secure message content provides context around patients' requests and whether clinicians responded in ways that improve care and outcomes. This study evaluates the use of a theory-based taxonomy to classify patients' and clinicians' message content and describes characteristics associated with coded content. Methods: We coded message threads initiated in 2017 by 73 randomly selected patients with hypertension and/or diabetes. Multiple codes could be applied to each message. Chi-square analyses identified differences by patients' demographics and health condition. Results: We analyzed 658 message threads composed of 1,751 clinician- and patient-generated messages, to which 2,055 taxonomic codes were assigned. Eighteen percent of patients' threads were unanswered. Most codes assigned to patient-generated messages were task-oriented (46%) or information seeking (26%) requests; 30% of clinician responses left those requests unfulfilled or unaddressed. Clinicians were more likely to recommend a patient be seen in the office based on patients' sex, age, and health condition. Furthermore, white patients were more likely to send, and receive from their clinicians, messages with praise and appreciation content compared with black patients. Conclusion: Further research is needed to better understand how and why these differences exist so that patient-clinician electronic messaging is optimized to improve patient outcomes.

Patients with complex chronic conditions: Health care use and clinical events associated with access to a patient portal

Background

For patients with diabetes, many with multiple complex chronic conditions, using a patient portal can support self-management and coordination of health care services, and may impact the frequency of in-person health care visits.

Objective

To examine the impact of portal access on the number of outpatient visits, emergency visits, and preventable hospitalizations.

Design

Observational study comparing patients’ visit rates with and without portal access, using marginal structural modeling with inverse probability weighting estimates to account for potential bias due to confounding and attrition.

Setting

Large integrated delivery system which implemented a patient portal (2006–2007).

Patients

We examined 165,447 patients with diabetes defined using clinical registries. Our study included both patients with diabetes-only and patients with multiple complex chronic conditions (diabetes plus asthma, congestive artery disease, congestive heart failure, or hypertension).

Measurements

We examined rates of outpatient office visits, emergency room visits, and preventable hospitalizations (for ambulatory care sensitive conditions).

Results

Access to a patient portal was associated with significantly higher rates of outpatient office visits, in both patients with diabetes only and in patients with multiple complex conditions (p<0.05). In patients with multiple complex chronic conditions, portal use was also associated with significantly fewer emergency room visits (3.9 fewer per 1,000 patients per month, p<0.05) and preventable hospital stays (0.8 fewer per 1,000 patients per month, p<0.05). In patients with only diabetes, the results were directionally consistent but not statistically significantly associated with emergency room visits and preventable hospital stays.

Limitations

Observational study in an integrated delivery system.

Conclusion

Access to a patient portal can increase engagement in outpatient visits, potentially addressing unmet clinical needs, and reduce downstream health events that lead to emergency and hospital care, particularly among patients with multiple complex conditions.

Communication Preferences and Satisfaction of Secure Messaging Among Patients and Providers in the Military Healthcare System

Introduction

Use of electronic secure messaging (SM) is rapidly growing in various healthcare settings. However, there is a large number of patients that choose not use SM or use it minimally. Thus, understanding preferences for patient-provider communication modalities is critically important, particularly among military healthcare beneficiaries. The purpose of this study was to assess preferences for patient-provider communication modalities (in person, telephone, SM, or mail) among a sample of patients, providers, and staff located at five Air Force military treatment facilities across the USA.

Methods

We recruited patients, providers, and staff, from five family health clinics to complete a short survey. We measured participants' preferences for communication modality for various healthcare concerns, such as responses to non-urgent medical questions, test results, and medication renewal information. We also measured satisfaction with MiCare, the Air Force's SM system. We conducted chi-square analyses and Fisher's exact tests to assess differences in communication preferences by patients, providers, and staff and we computed frequencies in satisfaction responses.

Results

We found that while providers and staff (N = 70) prefer to communicate with patients about various healthcare concerns online through MiCare, patients (N = 1,260) prefer to communicate in-person or through the telephone. Patients were generally satisfied with MiCare; however, there was a large proportion of patients who were undecided about MiCare's impact on the quality of care they received (40.3%). Additionally, although the majority of providers and staff believed MiCare improved their efficiency (58.0%) and communication with patients (72.3%), 65.7% of providers and staff believed MiCare had increased their workload.

Conclusion

MiCare is a promising tool to improve patient-provider communication. However, future studies are needed to better understand why patients within the military healthcare system prefer communication modalities other than MiCare and to identify strategies to decrease provider and staff workloads while using MiCare.

On the effect of electronic patient portal on primary care utilization and appointment adherence

BACKGROUND

The objective of this study was to investigate the impact of patient portal adoption on patients' primary care utilization and appointment adherence.

METHODS

We conducted a retrospective observational study using a panel difference-in-differences (DID) framework to investigate the use of primary care services by patients, adjusting for their disease burden and allowing for time-dependent portal effect. A large dataset with 46,544 patients of University of Florida (UF) Health during the study period July 2013 - June 2016 was used. The main outcome measures are disease burden adjusted rates of office visits arrived, no-show, and cancellation to primary care physicians (PCPs) per quarter between patient portal adopters (denoted as users) and non-users.

RESULTS

At the time of adoption, the quarterly PCP office visit rate ratio (RR) of patient portal users to non-users was 1.33 (95% CI, 1.27-1.39; p < 0.001). The RRs were between 0.94 to 0.99 up to four quarters after portal adoption (p = 0.749, 0.100, 0.131, and 0.091, respectively), and were significantly less than one at the seventh (RR =0.82; 95% CI, 0.73-0.91; p < 0.001) and the eighth (RR = 0.80; 95% CI, 0.70-0.90; p < 0.001) quarters post adoption. The quarterly no-show rates of the users were significantly smaller (RRs were between 0.60 and 0.83) except for the seventh, eighth and tenth quarters post adoption. In these three quarters, the no-show rates were not significantly changed (p = 0.645, 0.295, and 0.436, respectively). Quarterly cancellation rates were not significantly affected by portal adoption (p > 0.05 for all cases).

CONCLUSIONS

Patient portal users' disease burden adjusted PCP office visit rate was significantly reduced in one and a half year and thereafter post portal adoption. PCP appointment no-show rate was also significantly reduced and cancellation rate was not affected, implying improved care engagement of patients.

Patient portal adoption and use by hospitalized cancer patients: a retrospective study of its impact on adverse events, utilization, and patient satisfaction

BACKGROUND

Portal use has been studied among outpatients, but its utility and impact on inpatients is unclear. This study describes portal adoption and use among hospitalized cancer patients and investigates associations with selected safety, utilization, and satisfaction measures.

METHODS

A retrospective review of 4594 adult hospitalized cancer patients was conducted between 2012 and 2014 at Mayo Clinic in Jacksonville, Florida, comparing portal adopters, who registered for a portal account prior to hospitalization, with nonadopters. Adopters were classified by their portal activity during hospitalization as active or inactive inpatient users. Univariate and several logistic and linear regression models were used for analysis.

RESULTS

Of total patients, 2352 (51.2%) were portal adopters, and of them, 632 (26.8%) were active inpatient users. Portal adoption was associated with patients who were young, female, married, with higher income, and had more frequent hospitalizations (P < .05). Active inpatient use was associated with patients who were young, married, nonlocals, with higher disease severity, and were hospitalized for medical treatment (P < .05). In univariate analyses, self-management knowledge scores were higher among adopters vs nonadopters (84.3 and 80.0, respectively; P = .01) and among active vs inactive inpatient users (87.0 and 83.3, respectively; P = .04). In regression models adjusted for age and disease severity, the association between portal behaviors and majority of measures were not significant (P > .05).

CONCLUSIONS

Over half of our cancer inpatients adopted a portal prior to hospitalization, with increased adoption associated with predisposing and enabling determinants (eg: age, sex, marital status, income), and increased inpatient use associated with need (eg: nonlocal residence and disease severity). Additional research and greater effort to expand the portal functionality is needed to impact inpatient outcomes.

Do Headache Patients Require More Care in Between Visits Than Other Neurology Outpatients?

BACKGROUND

There is evidence that time spent in patient care in between patient visits is increasing and a contributor to physician burnout. The extent of this work on providers in the field of headache medicine is unknown.

OBJECTIVES

To establish whether headache outpatients require a high level of care in addition to clinic visits, based on the quantity of remote encounters per patient (phone calls and secure email communication to the clinics), in comparison to other neurologic clinics.

METHODS

In an academic referral clinic, a total of 3164 established patients were included in this retrospective analysis, 275 from the headache clinic, the remainder from various other neurology clinics (2 physician providers per clinic except 3 physician providers in the headache clinic). Patients presenting for a follow-up visit between January 2014 and April 2016 were observed for a 12-month period during which the number of a) telephone and b) secure email (MyChart) encounters per patient was recorded, and in addition, the number of entries related to each of these encounters. This analysis did not require IRB approval as per institutional guidelines.

RESULTS

Headache clinic patients required a high frequency of remote encounters (composite of both telephone and email messages) per patient, second only to the MS clinic patients. Use of secure email messaging (MyChart) per patient was much higher in the headache clinic compared to all other clinics.

CONCLUSION

Patients in a headache clinic in an academic tertiary care setting require a high intensity of remote outpatient care, more so than patients in other neurology subspecialty clinics and general neurology clinic, with the exception of the neuroimmunology/MS clinic. This is to a large extent secondary to the very frequent use of secure email linked to the electronic medical record by headache patients.

The potential of alternatives to face-to-face consultation in general practice, and the impact on different patient groups: a mixed-methods case study

Background

There is international interest in the potential role of different forms of communication technology to provide an alternative to face-to-face consultations in health care. There has been considerable rhetoric about the need for general practices to offer consultations by telephone, e-mail or internet video. However, little is understood about how, under what conditions, for which patients and in what ways these approaches may offer benefits to patients and practitioners in general practice.

Objectives

Our objectives were to review existing evidence about alternatives to face-to-face consultation; conduct a scoping exercise to identify the ways in which general practices currently provide these alternatives; recruit eight general practices as case studies for focused ethnographic research, exploring how practice context, patient characteristics, type of technology and the purpose of the consultation interact to determine the impact of these alternatives; and synthesise the findings in order to develop a website resource about the implementation of alternatives to face-to-face consultations and a framework for subsequent evaluation.

Design

Mixed-methods case study.

Setting

General practices in England and Scotland with varied experience of implementing alternatives to face-to-face consultations.

Participants

Patients and practice staff.

Interventions

Alternatives to face-to-face consultations include telephone consultations, e-mail, e-consultations and internet video.

Main outcome measures

How context influenced the implementation and impact of alternatives to the face-to-face consultation; the rationale for practices to introduce alternatives; the use of different forms of consultation by different patient groups; and the intended benefits/outcomes.

Review methods

The conceptual review used an approach informed by realist review, a method for synthesising research evidence regarding complex interventions.

Results

Alternatives to the face-to-face consultation are not in mainstream use in general practice, with low uptake in our case study practices. We identified the underlying rationales for the use of these alternatives and have shown that different stakeholders have different perspectives on what they hope to achieve through the use of alternatives to the face-to-face consultation. Through the observation of real-life use of different forms of alternative, we have a clearer understanding of how, under what circumstances and for which patients alternatives might have a range of intended benefits and potential unintended adverse consequences. We have also developed a framework for future evaluation.

Limitations

The low uptake of alternatives to the face-to-face consultation means that our research participants might be deemed to be early adopters. The case study approach provides an in-depth examination of a small number of sites, each using alternatives in different ways. The findings are therefore hypothesis-generating, rather than hypothesis-testing.

Conclusions

The current low uptake of alternatives, lack of clarity about purpose and limited evidence of benefit may be at odds with current policy, which encourages the use of alternatives. We have highlighted key issues for practices and policy-makers to consider and have made recommendations about priorities for further research to be conducted, before or alongside the future roll-out of alternatives to the face-to-face consultation, such as telephone consulting, e-consultation, e-mail and video consulting.

Future work

We have synthesised our findings to develop a framework and recommendations about future evaluation of the use of alternatives to face-to-face consultations.

Funding details

The National Institute for Health Research Health Services and Delivery Research programme.

Alternatives to the face-to-face consultation in general practice: focused ethnographic case study

BACKGROUND

NHS policy encourages general practices to introduce alternatives to the face-to-face consultation, such as telephone, email, e-consultation systems, or internet video. Most have been slow to adopt these, citing concerns about workload. This project builds on previous research by focusing on the experiences of patients and practitioners who have used one or more of these alternatives.

AIM

To understand how, under what conditions, for which patients, and in what ways, alternatives to face-to-face consultations present benefits and challenges to patients and practitioners in general practice.

DESIGN AND SETTING

Focused ethnographic case studies took place in eight UK general practices between June 2015 and March 2016.

METHOD

Non-participant observation, informal conversations with staff, and semi-structured interviews with staff and patients were conducted. Practice documents and protocols were reviewed. Data were analysed through charting and the 'one sheet of paper' mind-map method to identify the line of argument in each thematic report.

RESULTS

Case study practices had different rationales for offering alternatives to the face-to-face consultation. Beliefs varied about which patients and health issues were suitable. Co-workers were often unaware of each other's practice; for example, practice policies for use of e-consultations systems with patients were not known about or followed. Patients reported benefits including convenience and access. Staff and some patients regarded the face-to-face consultation as the ideal.

CONCLUSION

Experience of implementing alternatives to the face-to-face consultation suggests that changes in patient access and staff workload may be both modest and gradual. Practices planning to implement them should consider carefully their reasons for doing so and involve the whole practice team.

Primary Care Practice Reengineering and Associations With Patient Portal Use, Service Utilization, and Disease Control Among Patients With Hypertension and/or Diabetes

BACKGROUND

We describe the role of primary care reengineering in the Ochsner Health System (OHS) patient portal implementation strategy and compare subsequent trends in service utilization and disease control among portal users vs nonusers within this context.

METHODS

This retrospective cohort study includes 101,019 patients with hypertension or diabetes who saw an OHS primary care provider (PCP) between 2012 and 2014. Inverse probability treatment weighting was used to reduce case-mix differences between study groups. We used generalized estimating equation modeling to compare changes in encounter rates (PCP, telephone, specialty services, emergency department [ED], inpatient hospitalization), blood pressure (BP), and hemoglobin A1c (HbA1c).

RESULTS

Age, sex, race, comorbidities, insurance, preindex utilization, and portal use were associated with changes in utilization, BP, and HbA1C; however, the strength and direction of these differences varied. An adjusted analysis comparing portal users to nonusers showed an increase in PCP (rate ratio per patient per year of 1.18, 95% confidence interval [CI] 1.14-1.22) and telephone encounter rates (1.15, 95% CI 1.08-1.22; both P<0.001) but no significant differences in specialty, ED, or inpatient hospitalization encounters. Among patients with preindex systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg, portal users compared to nonusers had a greater decline in their BP, although the between-group difference was small (mmHg [SE], -1.1 [0.42] and -1.2 [0.34], respectively; both P<0.01). Portal users with diabetes compared to nonusers with diabetes also had greater decreases in HbA1c (all patients, % [SE], -0.13 [0.06]; patients with a preindex HbA1c ≥8, -0.43 [0.13], both P<0.05).

CONCLUSION

Our findings may reflect patient factors and system-level portal implementation strategies that focused heavily on accessibility to care.