Tuesday, November 20, 2012

The Electronic Health Record (EHR) On-Line Portal Increases Hospitalization Rates

"Hi doc! I used my on-line
portal to make an appointment!"
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).


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.


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.

Image from Wikipedia

1 comment:

Jason Burke said...

Thanks for a very relevant article. While I agree with your proposition that EHRs do not represent a panacea of savings, your post title and final statement suggest a conclusion that I don't believe is warranted. Wikipedia offers a reasonable distinction between correlation vs causation. In this study, for example, behavioral and personality factors may completely explain the observed patterns -- they just weren't measured.

Thanks again for a thought-provoking piece.