Patient Access to an Electronic Health Record With Secure Messaging: Impact on Primary Care Utilization | Page 2

Published Online: July 01, 2007
Yi Yvonne Zhou, PhD; Terhilda Garrido, MPH; Homer L. Chin, MD; Andrew M. Wiesenthal, MD; and Louise L. Liang, MD
Baseline primary care office visit rates for cohort and matched-control subjects were slightly higher than the baseline rates for the entire region, consistent with the increased prevalence of chronic conditions. The baseline visit rate of the control group in the matched-control study was between the regional baseline rate and the subjects' rate.

Cohort Study. Annual adult primary care office visit rates decreased by 9.7%, a statistically significant decline from 2.47 to 2.24 office visits per member per year (P < .001).

Matched-control Study. For the subjects in the matched-control study, the annual adult primary care office visit rate decreased by 10.3%, or 0.25 visits per member per year (P < .001). The corresponding decrease for controls was 3.7%, or 0.08 visits (P < .003). The difference between changes in primary care office visit rates for the 2 groups, 6.7%, was also statistically significant (P < .003). Table 3 summarizes office visit utilization results for both studies.

Primary Care Telephone Contact Rates

KPNW implemented new documentation procedures for telephone contacts during the study period; as a result, documented primary care telephone contact rates for the entire region increased by 24%. Documented primary care telephone rates for the cohort subjects increased by 15.6%. To evaluate the impact of access to KP HealthConnect™ Online in the context of this broad trend, we relied on the matched-control study.

Matched-control Study. The annual primary care telephone contact rate for subjects increased by 16.2%, or 0.32 documented telephone contacts per member per year, over the study period (P < .001). The corresponding increase for controls was 29.9%, or 0.52 documented telephone contacts per member per year (P < .001). The difference between these increases (13.7%) was also statistically significant (P < .01), as displayed in Table 4.


We evaluated the impact on office visit and telephone contact rates of patient access to an integrated multifunction electronic personal health record that included secure patient–physician electronic messaging. Annual adult primary care outpatient visit rates decreased by 6.7% to 9.7% for members using KP HealthConnect™ Online, and these members had a smaller increase in documented telephone contacts (16.2%) than the control group (29.9%).

Conducting a randomized controlled trial would have required fundamental changes to the KP HealthConnect™ system so that only patients randomized to the intervention were allowed to access online features. However, inconsistent member access to system features would have resulted in a prohibitive work-flow burden for physicians and healthcare teams. Additionally, random implementation of secure messaging would have confounded its true operational impact on office visit utilization. Nevertheless, our study controlled for individual patient factors, physician work styles, and regional trends as alternative explanations for reduced utilization.

Access to parts of the personal health record or other KP HealthConnect™ Online features may have influenced primary care office visit and documented telephone contact rates. However, an early evaluation of KP HealthConnect™

Online use among 1000 registered users found that more than 70% of sessions resulted in patient–physician messaging, indicating the importance and influence of this feature.

Although our sample size didn't support evaluating the impact of individual features, registered users most frequently cited telephone calls and office visits as alternatives to secure messaging. A random sample of 2700 KP HealthConnect™ Online users who e-mailed their physicians during a 3-month period yielded more than 1700 completed questionnaires. A quarter of the respondents indicated they would have scheduled an appointment in lieu of electronic messaging (Figure) and were satisfied with and appreciated the alternative mode of care.

A limitation of our study is that the subjects and controls in the matched-control study were not paired by baseline office visit or telephone contact rates. Subjects had higher preregistration utilization rates than did controls because high utilizers were more likely to register. Further research would assess whether different baseline utilization rates affect the impact of access to secure messaging on utilization rates.

Our study suggests several additional areas for further study. Annual primary care office visit rates held steady for the region as a whole. However, visit rates were lower, to a statistically significant degree, in the post-period for both groups in the matched-control study. We hypothesize that, because subjects and controls were matched by primary care physician (among other characteristics), these physicians may have become more attuned to care efficiencies during the study period. Further research would validate this hypothesis.

Members with diabetes were disproportionately represented among KP HealthConnect™ Online users. This fact raises important questions about electronic communications in chronic illness care. Other models of electronic communications, such as Internet-based glucose self-monitoring programs, have proved effective in increasing glucose control over the short term,18 and physicians view electronic communication as enhancing care for patients with chronic conditions.19

Anecdotal evidence from KP physicians indicates that secure messaging may actually increase the number of patient "touches." In addition to messaging itself, in 19.4% of 93 randomly sampled patient–physician secure message threads, the physician recommended an additional contact: a laboratory test, phone call, office visit, procedure, or health education class. It is important to note that some key elements of diabetes clinical treatment guidelines (ie, glycated hemoglobin [HbA1C], lipid, and microalbuminuria monitoring) do not require a face-to-face physician office visit with the availability of an electronic medical record.

To confirm that secure messaging is used for nonurgent issues, a review of the level of service of 50 secure messaging threads revealed that two thirds were coded as either "brief" or lower.

KPNW collects data for the Health Employer Data and Information Set (HEDIS®) as part of routine quality surveillance. The HEDIS reports for HbA1c testing did not vary to a statistically significant degree during the years under observation.

Secure messaging reduces overall physician workload if it requires less time than the replaced visits and telephone contacts. Although we did not examine overall efficiency, patients perceive electronic messaging as preferable to telephone consultations in many situations.20 Physicians and staff state that electronic messaging requires less time than telephone calls and that lengthy messages can be completed at intervals throughout the day.21

The extra capacity that secure messaging creates through increased efficiency can be used at the discretion of the care provider or organization. In noncapitated systems, an overall reduction in office visit rates may not be financially advantageous, and providers may choose to fill the resulting extra capacity with additional patient visits with a higher level of service to recover lost revenue. In a system with different incentives, more preventive care could take place at each visit or the time freed up by reduced office visit rates could be used for panel management.

KP is a largely prepaid, integrated healthcare delivery system. Patients and physicians generally used electronic messaging free of the reimbursement concerns that presently challenge the US healthcare system. The results from this large-scale study of secure messaging indicate that, as these issues resolve, it may provide a win-win-win solution to pervasive efficiency and access issues from the perspectives of patient, healthcare provider, and payer.

Take-Away Points

This is the largest study to date of the impact of access to secure patient–physician messaging on provider workload. The results demonstrated that:

  • Annual adult primary care outpatient visits decreased by 6.7% to 9.7% among patients using electronic messaging.
  • Members using electronic messaging had a smaller increase in documented telephone contacts (16.2%) than the control group (29.9%).
  • Electronic messaging may provide a solution to pervasive efficiency and access issues for both patients and providers.


The authors would like to acknowledge many physicians, operation lead ers, and analysts in the Kaiser Permanente Northwest region and Program Offices for their work. In particular, we thank Susan Moy, MS, Carl Serrato, PhD, Sharon Fox, MS, Rene Walton, MS, Michael Kositch, MD, Robert Peterson, MD, David Shenson, MD, Anna-Lise Silvestre, MPH, and Kate Christensen, MD, for their leadership and many contributions, and Jenni Green, MS, for advice and help in writing this article.

Author Affiliations: Kaiser Foundation Health Plan—program offices (YYZ, TG, LLL); Northwest Permanente (HLC); The Permanente Federation (AMW).

Address Correspondence to: Yi Yvonne Zhou, PhD, Kaiser Permanente, 2850 NW Nicolai St, Portland, OR 97210. E-mail: yvonne.y.zhou@kp.org.

Author Disclosure: The authors (YYZ, TG, HLC, AMW, LLL) report relationship or financial interest with any entity that would pose a conflict interest with the subject matter discussed in this manuscript.

Authorship Information: Concept and design (YYZ, TG, HLC, AMW, LLL); acquisition of data (YYZ); analysis and interpretation of data (YYZ, TG, HLC); drafting of the manuscript (YYZ, TG); and critical revision of the man uscript for important intellectual content (YYZ, TG, HLC, AMW, LLL); statis tical analysis (YYZ); obtaining funding (TG, LLL); administrative, technical, logical support (TG, HLC); and supervision (YYZ, TG, HLC, AMW).

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Issue: July 2007
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