JAMA: Association of Online Patient Access to Clinicians and Medical Records With Use of Clinical Services

Published in the Journal of the American Medical Association this paper by Ted E. Palen, MD, PhD, MSPH; Colleen Ross, MS, MPH; J. David Powers, MS; Stanley Xu, PhD “Association of Online Patient Access to Clinicians and Medical Records With Use of Clinical Services” has provided fuel for some scary headlines for any healthcare providers considering offering online services to patients:

Kaiser Health News:


Huffington Post:

The Clinical Advisor:

US News:

Clinical Endocrinology News:


It’s been out only a few days and I can only imagine how many ways it will be misinterpreted by those who need a good headline or still think the world is flat (and we can ignore the opportunity to communicate with patients using technologies that THEY want to use and find convenient and effective) and now think they’ve been handed evidence to support their out of date point of views. I thought it might be helpful to share my thoughts:

More data sharing leadership from Kaiser Permanente

Obviously KP’s my favorite major US healthcare brand but when you learn that all the funding and support for this extensive study was provided by the Kaiser Permanente Colorado Regional Initiative Committee Fund and that their role as sponsor involved no role “in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript” I think you realise this is an organisation that is head and shoulders ahead of it’s competition in understanding the opportunity there is to open up data to public scrutiny and make every responsible for innovation.

Imagine if the NHS could take a systematic approach like this – instead of the situation we have today where NHS Trusts are wasting as much as £500M per year because they are even competing with one another

The MyHealthManager service hasn’t built on best practice on how to conduct online consultations – it’s completely ignored it

Dr John Bachman, Prof of Primary Care, Mayo Clinic has published an incredible body of work on the way to effectively conduct online consultations with patientshere’s a brilliant seminar I would recommend you watch. Unfortunately it’s clear from the explanation of how this service works (a basic messaging portal with email reminders that you’ve got mail) that MyHealthManager hasn’t built on this best practice.

It should be abundantly clear that making a statement like “Online medical records may not improve efficiency” is as naive as someone in the 80’s telling you “computers may not improve typing efficiency” because my secretary is an ace on the QWERTY and hasn’t a clue how to use a computer.

Whenever I happen to meet people who suffer from the effects of Group Think like this I thoroughly encourage them to read “No Straight Lines: Making sense of our non-linear world”.

Is the whole context wrong?

Context: Prior studies suggest that providing patients with online access to health records and e-mail communication with physicians may substitute for traditional health care services

I don’t think there’s any strong evidence suggesting this. I think there’s plenty of evidence that poor communication and undocumented consultations are proving problematic (they are the biggest cause of medicolegal litigation) and the rejection by clinicians of info that patients are bringing to the office is a classic sign that “traditional health care services” need a redesign.

Could “patient online access systems” be too one dimensional for health needs?

Members can send secure e-mails to clinicians through the MHM system. When MHM messages are sent by clinicians, members receive notifications in their personal e-mail accounts prompting them to log in to MHM to retrieve their messages in a secure manner

This design appears to me to present the classic way to use IT to waste clinician and patient time by tying them up in tag interactions that are difficult for both sides, go nowhere quick, waste time and energy.

I wonder if the fact that the service is designed to offer patients online access to Doctors is too heavily focused on providing exactly that eg. what other outcome would you expect after marketing a service like this to patients?

KP’s MyHealthManager is an old product (in internet terms eg. it started out even before Facebook!) so perhaps it’s moved on a bit but I think the idea of a static 1-2-1 communication portal is very dated. Perhaps a patient community that enabled the sharing and group discussions around rich video content would lessen the load on professionals and help patients use the portal to become more actively involved in self care?

The staple for effective replacement of face-to-face consults with remote consults is information sharing

Some reports estimate that 25% to 70% of all visits to physicians do not require face-to-face appointments.11- 13 Therefore, online consultations may substitute for traditional health care visits

I think this statement highlights the fact that the big challenge is one of filtering – unless we’re letting patients share their history with a Doctor for review before they meet we don’t know which 30-75% of consults are the ones that can effectively and safely be managed with a remote consultation or video recording/information.

A portal is not enough – online Health Records need to be complemented by content

Previously, studies within Kaiser Permanente demonstrated that patients with access to online messaging had fewer annual office visits than patients without online access, but this lower rate of visits was more than offset by an increased rate of telephone contacts

I think this highlights the opportunity to do more than just teelephpne calls eg. pushed links to rich video content that shows patients what they need to know:

Doesn’t the opt in nature of the service explain the increased use?

Members receive information about the system and invitations to register in their membership materials, via notices posted in Kaiser clinics, at clinic check-in, through periodic member mailings, and in quarterly newsletters. Members of KPCO may visit the Kaiser website to register for MHM. Once they are registered, they obtain their own unique user ID and password, which allows secure MHM access via any computer with internet access

Because the serivce is opt in it’s quite clearly going to be self selecting those patients who go to the clinic a lot (they’ll see more of the posters) and want to use it. In light of this is it any surprise these patients use services more than they did in the prior years eg. they may have failing health, they have been avoiding the Doctor before through the inconvenience of office visits, they may feel that they are encouraged to use these services (after all the clinic is advertising them!), etc

The research paper pays a not to the potential of this but I’m confidenet that this is something that the vast majority of reporters (who simply reiterate the headlines) will communicate to readers:

Online access to care may have led to an increase in use of in-person services because of additional health concerns identified through online access. Members might have activated their online access in anticipation of health needs. Members who are already more likely to use services may selectively sign up for online access and then use this technology to gain even more frequent access rather than view it as a substitute for contact with the health care system. Members who made more clinic visits also received more opportunities to hear about and sign up for online access

I also wonder if the research is undermined by the fact that the very effective marketing of the My Health Manager service has influenced patient behaviour eg. many patients may have felt encouraged to use the service because they saw it being advertised in the clinic waiting room eg. “my Doctor obviously wants me to use this, I’m doing her a favour, etc”:

In the year following activation, members with such access had increased rates of office visits, telephone encounters, and acute care services compared with a matched cohort of members without online access. These findings were consistent in both younger and older individuals and for those without chronic health conditions

Why haven’t the researchers pointed to some of the cost and flexible working advantages for care providers?

I’m surprised there’s no mention of the other benefits that KP has gained from taking communications online. Have they not introduced home working opportunities? Have these online consultations helped them get more value from their Doctors (eg. during quiet times they’ve now got location independent patients that they can care for), have patients been using more appropriate use of consultations (eg. as a result of direct referrals to specialists), etc?

When the report suggests:

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. If this also holds true for a small group practice, a primary care physician with 1000 adult patients who have online access would need to provide for almost 10 more clinic visits per week and over 5.5 more telephone calls per week

I think it’s important to remind readers that this is because the designers of the MyHealthManager portal have neglected to imagine the opportunity they have in the online world to respond to a patient enquiry with something other than a telephone call or an office visit.

Smart clinicians of course see this opportunity, instead of having a patient come in for a chat about something these Doctors are pointing these patients and carers in the direction of rich online content that can help inform them in better ways than they could have achieved in the office. To give you an example if you have a patient who’s left the ER after finding they’ve torn their Achilles tendon and they want to talk to you about the issues and complications associated with surgery try sharing a youtube video like this with them (by Orthopedist Howard Luks MD).

The elephant in the room no one’s talking about: Specialisation

Overall, our findings suggest that the relationship between online access and utilization is more complex than the simple substitution of online for in-person care suggested by earlier studies. If these findings are evident in other systems, health care delivery planners and administrators will need to consider how to allocate resources to deal with increased use of clinical services. As online applications become more widespread, health care delivery systems will need to develop methodologies that effectively integrate health information technologies with in-person care

I’m not sure the authors have grasped the opportunity for specialisation that we have today as a result of the ability to share healthcare information online, use patient history taking tools and connect remotely with one another via video (both recorded and live P2P).

Today, largely as a result of mobile data services, we have the opportunity to introduce diverse new working opportunities for Doctors and if we choose to ignore these we’re just making it easy for someone else to disrupt our business model.


Conclusion: Having online access to medical records and clinicians was associated with increased use of clinical services compared with group members who did not have online access

If I was the author of this paper I would’ve communicated this a lot more accurately:

“Conclusion: When you ignore best practice and the opportunity to redesign your service and simply try to provide patients with online access to their medical records and clinicians they will be forced to use them in such a way that they will require additional clinical services”

My Take away

I think the healthcare industry could learn lots from the Wright brothers who accepted that flying was possible but could only be achieved effectively if they solved the problem of controlling the aircraft.

In 2012 just as the Wright brothers knew we could fly, Healthcare leaders need to know that patients deserve accessible healthcare services. They must have the imagination to sense the enormous opportunities that will open up for Patients to present early and for carers to work with them in ways that are more effective, informed and scientifically based.

This report has highlighted for me how the MyHealthManager online patient portal has (like many other failed online health portals before it) been launched without the required ability to control the new environment that is arrived at once it’s being used by patients.

Without redesign it is inevitable that it will be more expensive for care providers to provide online care than it will be to stick with the status quo (where patients are made to make appointments, wait for appointments, take time off to go to appointments, etc). The challenge before us is in how we design and build for these new opportunities so that they don’t consume excessive healthcare resources or leave behind and disadvantage patients who aren’t connected.

Sadly if we fail to leverage the full range of opportunities mobile connectivity offers we’re not supporting online interactions with the infrastructure they need in order to make a sustainable difference and they’ll continue to fail.

What do you think? Is the idea of Patients and Healthcare Professionals communicating effectively online even more impossible than heavier-than-air machines flying?

About David Doherty

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1 Response to JAMA: Association of Online Patient Access to Clinicians and Medical Records With Use of Clinical Services

  1. Pingback: Too Posh to Prescribe? Too Learned to Listen? | NHS Alliance

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