Could Electronic Communication Between Providers and Patients Have Unintended and Negative Consequences?

Jan. 5, 2018
A five-year data sample from a large U.S. health system shows that e-visits could have unintended consequences for MDs.

Using technology to strengthen the patient-provider relationship has been a goal of most physicians, hospitals and health systems over the past several years, but new research points to issues that could arise for physicians who adopt electronic visits (e-visits).

As researchers from the Wisconsin School of Business at the University of Wisconsin–Madison stated in their paper, “The Impact of E-Visits on Visit Frequencies and Patient Health: Evidence from Primary Care,” there are plenty of frequently suggested benefits of e-visits and of electronic communication between providers and patients, such as enabling providers to give patients a low-cost alternative to visiting the doctor’s office. “Creating an online channel for care delivery offered the promise of reducing healthcare costs, while increasing the capacity of primary care physicians to see more patients by allowing them to handle routine questions or concerns through e-visits. At the same time, e-visits were seen as an innovation that could improve patient health by allowing patients to receive more attention and increased monitoring,” the paper’s authors wrote.

However, the researchers analyzed data from a large healthcare system in the U.S between 2018 and 2013, and were able to make several conclusions that support the idea that e-visits could have unintended consequences as well. These include: providers adopting e-visits experienced a 6-percent increase in office visits; the additional visits resulted in an additional 45 minutes per month of additional time doctors spent on those visits; to make up for that additional time spent on office visits, there was a 15-percent reduction in the number of new patients seen each month by those providers; and there was no observable improvement in patient health between those utilizing e-visits and those who did not.

The unnamed U.S. health system that was analyzed is involved with both research and clinical care, and operates multiple hospitals (with over 2,000 beds in total) and medical centers, along with several primary and specialty care practices in its region. In all, this totals some 2.5 million primary care encounters in those five years for more than 143,000 patients, and since the data are structured at the patient level, these encounters can be with physicians or non-physician providers such as nurses and residents.

Researchers Hessam Bavafa, Ph.D., Wisconsin School of Business assistant professor of operations and information management, along with Lorin M. Hitt, Ph.D., and Christian Terwiesch, Ph.D., of the University of Pennsylvania, say the findings suggest providers may need to structure and target their e-visits systems differently in order to improve outcomes.

Perhaps the most telling quote from the study’s authors was this one from Bavafa: “Offering e-visits seems like a great way to save time and money by reducing the need for office visits because routine questions or updates could be done via email. The problem is that healthcare is much more complicated—patients may overreact to minor symptoms or not be clear enough in describing their situation and that leads to doctors feeling obligated to schedule an office visit.”

To better grasp what implications these findings might have, I took a deep dive into the report’s specifics. It’s important to point out that while some may correlate “e-visits” with the broader term “telemedicine,” there seemed to be no video or remote monitoring interactions in this study. Rather, the examination was limited to electronic commutation between patients and providers, mostly in the form of secure messaging via patient portals.

One core finding from the paper was that providers who adopted e-visits experienced a 6 percent increase in office visits—or about one extra office visit every 100 months for the patient. But importantly, as the authors noted, “While this is not very large for an individual patient, for an average physician  in  our  data  with  a  panel  size  of  1,611  patients  and  13.4-percent  e-visit  adoption  rate,  this amounts to 2.16 additional visits each month.” And, given this number, coupled with the average appointment time of 20 minutes, this equates to about 43 minutes of additional time doctors spend on these extra visits per month.

Related to this finding, Bavafa also noted that e-visits may result in doctors getting ambiguous or insufficient information that makes it difficult for them to offer a diagnosis, and that those additional communications with doctors create more potential opportunities for doctors to feel obligated to see the patient in the office.

Digging deeper, the authors wrote that there are  four main possibilities to consider about where the additional visits come from: (1) the  physician  reduces the  amount  of  time  with  non-e-visit-adopter  patients (“e-visit  adopters” is a term used for patients who have communicated with any primary care provider via the secure messaging service of the patient portal at least once); (2)  the physician admits fewer new patients; (3) the physician works more hours to provide the additional appointments; (4) the physician conducts shorter duration appointments. Put all together, the data gathered showed that 74 percent of the new office visits generated by e-visit adopters occurred at the expense of new patient visits, and the remaining 26 percent occurred at the expense of non-adopters.

The paper also had a noteworthy finding related to patients’ health outcomes, which of course is a primary goal of most health IT efforts. Said Bavafa, “Despite more patient contact and interaction through e-visits, there were no obvious improvements in patient health tied to that channel. In fact, the additional office visits appear to crowd out some care to those not using e-visits.”

For the study, the two key measures of health were LDL (low-density lipoprotein) and HbA1c (hemoglobin A1c) levels. Higher levels of these measures are generally correlated with worse patient health, and the medical community has established important cutoff values for each of these measurements that map to whether patient health is “under control” or unhealthy. The authors concluded, “Perhaps not surprisingly in the context of our results on office visits, we find that adopters experience no change in the levels of LDL testing, and increases in the levels of HbA1c testing among patients with at least one test. These findings suggest that e-visit adoption increases care consumption not only through increased office and phone visits with providers, but also through the utilization of other system resources such as the testing facilities,” they said.

What’s also incredibly revealing from this research is how e-visits align with healthcare’s shift to value-based reimbursement. As the authors wrote in their conclusion section, “The overall impact of e-visits on a health system will depend on the extent to which a system is (a) at capacity, and (b) compensated on a fee-for-service basis. In particular, the bottom line will improve for health systems which are not at capacity and in which physician compensation is primarily on a fee-for-service basis since e-visits can increase physician utilization. Systems  that  are  already  at  capacity  or  paid  on  a  capitation  basis  may  not  see  the  benefits  of e-visits that they expect, since the additional visits by existing patients may reduce capacity for new patients without necessarily generating incremental revenue.”

For me, it’s this last statement from the researchers that points to a much broader and more impactful issue at hand than simply analyzing a sample of e-communications between patients and providers. If these types of visits are actually increasing in-person visits from existing patients across health systems nationwide, physicians could be put in a tough spot as they continue to be pushed towards a system that rewards the quality of care over the quality of services provided. Indeed, if we have a system that pays for value over volume, could it be possible that these doctors might prefer to decline methods of e-communication if they lead to an increase in office visits as well as an uptick in time spent during these visits, and a reduction in the number of new patients seen?

This brings me back to a similar debate that existed when the OpenNotes initiative first began. Skeptics said at the time that if patients had access to their providers’ notes, it would result in a greater workload on clinicians who have to deal with more questions from patients now that they are reading their notes actively. In essence, would the initiative actually prove to be counterproductive? But in the years following the OpenNotes pilot, there has been plenty of research that has debunked this notion. In fact, the overwhelming majority of physicians who participate in the program have no complaints at all.

Could the same be true for electronic communication between patients and providers? For the sake of healthcare’s future, let’s hope that this study serves as motivation for both sides to improve the quality of “e-visits” throughout U.S. patient care organizations. 

Have any thoughts or questions? Feel free to tweet at @RajivLeventhal or comment in the section below.

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