Mary Reed, DrPH

 Continuity of patient information across settings can improve transitions after hospital discharge, but outpatient clinicians often have limited access to complete information from recent hospitalizations. We examined whether providers’ timely access to clinical information through shared inpatient-outpatient electronic health records (EHRs) was associated with follow-up visits, return emergency department (ED) visits, or readmissions after hospital discharge in patients with diabetes.

 As an integrated delivery system staggered implementation of a shared inpatient-outpatient EHR, we studied 241,510 hospital discharges in patients with diabetes (2005-2011), examining rates of outpatient follow-up office visits, telemedicine (phone visits and asynchronous secure messages), laboratory tests, and return ED visits or readmissions (as adverse events). We used multivariate logistic regression adjusting for time trends, patient characteristics, and medical center and accounting for patient clustering to calculate adjusted follow-up rates.

 For patients with diabetes, provider use of a shared inpatient-outpatient EHR was associated with a statistically significant shift toward follow-up delivered through a combination of telemedicine and outpatient laboratory tests, without a traditional in-person visit (from 22.9% with an outpatient-only EHR to 27.0% with a shared inpatient-outpatient EHR; 

 < .05). We found no statistically significant differences in 30-day return ED visits (odds ratio, 1.02; 95% CI, 0.96-1.09) or readmissions (odds ratio, 0.98; 95% CI, 0.91-1.06) with the shared EHR compared with the outpatient-only EHR.

 Real-time clinical information availability during transitions between health care settings, along with robust telemedicine access, may shift the method of care delivery without adversely affecting patient health outcomes. Efforts to expand interoperability and information exchange may support follow-up care efficiency.

Continuity in access to patient information across providers in different settings can improve patient transitions. We examined whether timely access to complete clinical information through a shared inpatient-outpatient electronic health record (EHR) was associated with changes in rates of in-person follow-up visits after hospital discharge in patients with diabetes.

Using the shared inpatient-outpatient EHR was associated with a shift toward 7-day follow-up delivered through a combination of telemedicine (telephone and patient-physician secure messages) and outpatient laboratory tests, without a traditional office visit.

Patient outcomes, as measured by 30-day return emergency department visits or hospital readmission, were comparable when using the shared EHR.

Timely availability of clinical information during health care transitions, in a setting with robust telemedicine access, can shift the method of care delivery without adversely affecting patient health outcomes.

For the growing number of patients with chronic conditions, care transitions, such as those after hospital discharge, require coordination among multiple clinicians practicing in different settings.

 Health information exchange (HIE) that ensures that patient health information follows each patient as they move between care settings is important to providing well-coordinated care.

 Still, developing widespread electronic health record (EHR) interoperability and HIE between settings remains challenging.

 Emerging health care payment models, coordination, and consolidation efforts are likely increasing information sharing among providers at follow-up visits.

 Still, there is limited evidence on the impact of sharing electronic patient information across settings on patient care transitions and outcomes, particularly on follow-up care and adverse events after a hospitalization.

With limited electronic data sharing, deficiencies in information availability and communication among providers after hospital discharge are regularly reported by both clinicians and patients—including inconsistent awareness of the hospitalization itself and limited communication of medications, orders, and laboratory results, leading to medical errors and increases in readmission.

 In the absence of broad clinical guidelines for optimal postdischarge follow-up interval or encounter type, differences in follow-up visit rates have been associated with mixed outcomes.

 Shared seamless access to EHRs can offer clinicians direct access to fully view and document detailed patient clinical information across health care settings without requiring shifts across systems, modalities (like paper), or capabilities (like limited snapshots or fragmented documentation).

 The timely exchange of patient information and communication is defined for this paper as data access to support clinical care at any time it is clinically needed, ideally in real time. Timely and seamless EHR access across providers can support patient transitions from hospital discharge to outpatient follow-up care, such as by facilitating coordination, risk stratification, and flexibility for telemedicine encounter types, with potential implications for clinical care quality and efficiency.

 Early evidence from other settings and patient populations about impacts of HIE is mixed; however, findings of some studies have suggested that electronic health information availability and exchange are associated with reductions in repeat tests or imaging, supporting the feasibility of telemedicine follow-up.

Building on previous findings of improved diabetes care and health outcomes after implementation of an outpatient-only EHR, we studied the subsequent implementation of a shared inpatient EHR that seamlessly integrates patient health information between hospital and outpatient providers.

 In patients with diabetes, this study examined the association between provider use of the shared inpatient-outpatient EHR and rates and types of outpatient follow-up, including office visits, telemedicine encounters (including asynchronous secure patient-physician messages and real-time telephone visits), and laboratory tests. We also examined the impact on adverse clinical events after hospital discharge, measured by emergency department (ED) visits and hospital readmissions.

This quasi-experimental study examined a historical natural experiment in which an integrated delivery system staggered implementation of an inpatient EHR, integrating it with an existing outpatient EHR, across 17 hospitalist-staffed hospitals (2006-2010). This created a stepped-wedge study design to study the impact of shared inpatient-outpatient EHR use (

). The implementation order was not associated with medical centers’ health care quality or readmission rates.

Prior to the study period, the outpatient EHR used by clinicians had already integrated all outpatient records, including primary and specialty care, laboratories, and pharmacy, but did not include complete clinical information from hospitalizations or ED visits. At baseline, providers also already had the capability to conduct scheduled real-time telephone telemedicine visits with patients and had access to a patient portal website that offered patient-provider asynchronous secure messaging tools. As such, our study examines a shift in provider-to-provider access to patient data across settings after implementation of the shared inpatient-outpatient EHR.

The commercially available complete hospital EHR replaced the inpatient paper medical record and a patchwork of optional health information technology tools, creating a shared inpatient-outpatient EHR. Before implementing the inpatient EHR, HIE between inpatient and outpatient providers was not consistent and was provider dependent. After the inpatient EHR was implemented, both inpatient and outpatient EHRs were seamlessly integrated. The hospital EHR automatically integrates patient history and clinical information (eg, clinical notes, procedures, imaging, laboratory tests, medications) with the outpatient EHR used by primary care providers and specialists, including order-entry capability for outpatient follow-up, medication reconciliation before discharge, secure messaging between providers and with patients, and notifications to outpatient providers that their patient had been hospitalized.

Between 2005 and 2011, we identified all hospitalizations among patients with diabetes (using the clinical diabetes registry) in medical centers where the outpatient EHR was already in use. We examined patients with diabetes as an example of the impact of shared EHR use in a common chronic condition that has associated complications. We excluded from our study analytic data set patients who were not health plan members in the year prior to the hospitalization and for 30 days after discharge in order to ensure complete capture of comorbidities and follow-up outcomes. We also excluded hospitalizations of patients who were not discharged home in order to ensure eligibility for outpatient follow-up.

Our data captured all outpatient office visits, telephone visits, secure electronic messages, and laboratory tests after hospital discharge. In the absence of broad evidence-based guidelines for any optimal postdischarge follow-up timing, we examined the encounters within 7 and 30 days after hospital discharge.

 We also examined any 30-day clinical events as a measure of adverse health events or outcomes, including ED visits or readmissions, based on the 30-day Medicare readmission measures.

Among hospitalizations with follow-up, we examined the rates of follow-up through a combination of only telemedicine and laboratory tests.

We used multivariate logistic regression models for each type of follow-up encounter outcome with EHR status as the main predictor and adjustment for patient characteristics (age, gender, neighborhood socioeconomic status [SES], race/ethnicity, co-payment, comorbidity score), seasonality (calendar month, categorical variable), time trend (year 1 for 2005, year 2 for 2006, and so on, as a continuous variable), quadratic term of the time trend, comorbidity score (centered), interaction term of comorbidity score and time trend, medical center, and medical center–specific time trend (interaction term of medical center with time trend and quadratic term of time trend), with standard errors corrected for patient clustering (using Stata SE 10.1 [StataCorp LP]). We defined a patient as having a low SES neighborhood using 2000 US census block groups with 20% of residents having household incomes below the federal poverty level or 25% of residents 25 years or older having less than a high school education.

 To adjust for comorbidity, we used the prospective diagnostic cost group score, which has been adopted by CMS for Medicare risk adjustment.

We reported adjusted odds ratios from these multivariate models. For easier interpretation, we also calculated the adjusted rates of each outcome by applying the coefficients from the logistic regression to the entire cohort as if everyone were in pre–inpatient EHR and post–inpatient EHR periods, respectively, so that patients in pre–inpatient EHR and post–inpatient EHR periods shared the exact same characteristics (margins command in Stata).

In sensitivity analyses, we examined the subset of hospitalizations categorized as nonelective and findings were comparable (see 

Among all 241,510 hospitalizations in 104,126 patients with diabetes from 2005 to 2011, 91,331 occurred before the shared inpatient EHR was implemented and 150,179 occurred after. 

After multivariate adjustment, the rate of any type of ambulatory follow-up encounter within 7 days of hospital discharge decreased from 72.8% to 69.2% after use of the shared EHR (

) and more modestly within 30 days after discharge, from 94.8% to 94.1% after use of the shared EHR (

 < .05). These patterns in care changes associated with shared EHR use were consistent when examining within the 30-day period after hospital discharge (eAppendix).

The type of follow-up care also changed after the shared EHR implementation. The proportion of 7-day follow-up delivered by a combination of telemedicine and laboratory tests and without an in-person office visit increased from 22.9% before use of the shared EHR to 27.0% after (

). Specifically, follow-up with an in-person office visit within 7 days dropped from 55.9% to 50.5% (

 < .05), and use of any laboratory testing within 7 days after discharge dropped from 32.0% to 30.7% (

 < .05). No statistically significant changes occurred in the rates of telephone visits or secure messages (

As a measure of adverse health events or outcomes, there were no statistically significant differences in the rates of ED visits or readmission in the 30 days after hospital discharge associated with use of the integrated hospital EHR. After the integrated EHR was in use, 16.7% of hospital discharges were followed by an ED visit (vs 16.4% before; 

 > .05) and 9.4% were followed by another hospitalization within 30 days (vs 9.5% before; 

In this natural experiment involving the staggered implementation of a commercially available inpatient-outpatient shared EHR that shares patient data across providers in inpatient and ambulatory settings, we found that after hospital discharge, patients with diabetes had a higher likelihood of receiving follow-up care delivered only by a combination of telemedicine (telephone visits and asynchronous secure messages) and laboratory monitoring without a traditional in-person visit. We found slightly lower overall rates of follow-up office visits and outpatient laboratory tests. As a measure of clinical events, we found no statistically significant association between inpatient-outpatient EHR use and rates of return ED visits or hospital readmissions. Together, these findings suggest that the timely availability of complete clinical information from using a shared inpatient-outpatient EHR after a hospital discharge in a setting with strong telemedicine access could shift the method of delivering follow-up care without adversely affecting patient health outcomes as measured by repeat ED visits or readmissions.

Although EHR interoperability and HIE functionality have been consistently promoted as policy priorities for improving the quality and efficiency of the American health care system, there is still limited research evidence to inform policy makers about the effects of continuity in provider access to patient information.

 Our study builds this evidence as one of the largest rigorously designed studies to examine the impact of shared health information access across providers during patient transitions between health care settings. Our findings from patients with diabetes also complement findings of previous studies in the same integrated delivery system, in patients with diabetes and in general patient populations, in which both providers and patients reported that EHR use facilitated care coordination both by providing informational continuity among providers and by supporting direct communication between clinicians and medical staff through electronic messaging tools.

 In a general patient population, primary care providers reported enhanced access to timely and complete patient information and better agreement on treatment goals and roles and responsibilities after the inpatient EHR was in use.

The optimal amount and timing of outpatient follow-up care after hospital discharge are not clear.

 Although some studies have found that follow-up visits or telephone calls after hospital discharge were associated with better patient outcomes, others have found no effect or worse outcomes associated with more follow-up care, and the evidence continues to be mixed.

 In the absence of broad evidence-based clinical guidelines for the optimal type or level of after-discharge follow-up, our study aimed to examine whether use of a shared inpatient-outpatient EHR was associated with shifts in the type of follow-up care delivered after hospital discharge. Because we found that follow-up care was more likely to be delivered through only telemedicine and laboratory tests, without any evidence of adverse changes in downstream health events as measured by ED visits and rehospitalizations, these changes in follow-up care represent potential improvements in the efficiency of health care delivery without adversely affecting quality. Similarly, because the rate of outpatient laboratory tests in this study was lower after using the shared inpatient-outpatient EHR without measurable impact on ED visits or hospitalizations, it appears that EHR-enabled information availability may have decreased unnecessary testing. Our findings are consistent with early evidence from other settings and across patient populations, which have found that electronic health information availability and exchange are associated with reductions in repeat tests and imaging and improve the feasibility of telemedicine follow-up.

Seamless and timely electronic HIE is still limited across the US health care delivery system. Calls for increases in exchange capabilities at hospital discharge are growing, but few settings have measured the large-scale impact of EHR-based information integration across delivery settings.

 Our study finds that movement toward more seamless health information access, even within an already integrated system, can affect the efficiency of follow-up care after hospital discharge without adversely affecting quality. These shifts may also potentially improve patient convenience through telemedicine follow-up without requiring the transportation and cost of making an in-person visit to health care providers. Although patient convenience and access are typically considered primary benefits of telemedicine, our finding of EHR-supported efficient posthospitalization follow-up through telemedicine may also be relevant as current crisis-based social distancing to protect patients and providers from infectious disease spread is rapidly shifting many medical office visits to telemedicine.

Although our study found modest average decreases in in-person visits, cumulative impacts of this magnitude may be substantial if replicated broadly across large numbers of annual hospitalizations in patient populations with chronic conditions. In addition, our finding of no statistically significant differences in clinical events can be interpreted as reassuring that negative impacts of care shifts were not detected. Further research is needed to explore patient follow-up care preferences and the clinical impacts of variations in follow-up care types in more detail.

There are several limitations to the interpretation and generalizability of our study design and setting. First, the natural experiment of shared inpatient-outpatient EHR implementation in this study is historical and may not fully generalize to current practice, which may vary across settings. Because the sharing of patient data across health care settings is still currently evolving, however, the study findings have potential relevance despite the historical study period. Further, the study relevance is supported by examining a study setting with relatively mature telemedicine and a patient portal in which patients could access a portal website to schedule a telemedicine visit to communicate with physicians and to review visit details and laboratory results. The follow-up care patterns we identified would not be feasible without the ability to follow up with patients readily by phone or through secure messages. In other settings, in-person follow-up office visits may be needed to share paper discharge summaries or to notify providers of a recent hospitalization.

 Also, the rates of follow-up care in our study at baseline were higher than previously reported in other settings, and the hospital readmission rates were somewhat lower; therefore, other settings with more limited follow-up patterns at baseline may experience different shifts with the availability of HIE across settings.

 Our study examined patterns in follow-up care after implementing a systemwide EHR system, and we are not able to characterize the clinical appropriateness of any specific follow-up care regimen. Further study of the clinical significance of changes in follow-up care encounter types is needed. This study examined only patients with diabetes, and we cannot generalize directly to other patient populations. Shared EHRs and HIE are only tools to increase information availability; their impact is dependent on the clinical workflow and delivery system context in which they are used.

Overall, in a setting that implemented a shared EHR with seamless HIE between inpatient and outpatient providers, patient follow-up care after hospital discharge was less likely to include an in-person office visit and instead was managed through exchange of asynchronous secure messages, telephone telemedicine, and outpatient laboratory tests. We found no statistically significant change in the rate of return ED visits or readmissions within 30 days after discharge, and we conclude that increased and timely information availability through the shared inpatient-outpatient EHR changed the pattern of follow-up care after discharge, enabling care delivery through non–office visit encounters without adversely affecting patient short-term outcomes.


 Kaiser Permanente Division of Research (MR, JHu, DB, RN, BF), Oakland, CA; Department of Epidemiology and Biostatistics, University of California at San Francisco (RB), San Francisco, CA; Department of Health Policy and Management, Emory University (IG), Atlanta, GA; Kaiser Permanente San Francisco Medical Center (MGJ), South San Francisco, CA; Kaiser Permanente San Rafael Medical Center (DB), San Rafael, CA; Mongan Institute for Health Policy, Massachusetts General Hospital (JHs), Boston, MA; Department of Health Care Policy, Harvard Medical School (JHs), Boston, MA.

 National Institute of Diabetes and Digestive and Kidney Diseases (R01DK085070). The study sponsor had no role in the design and conduct of the study, including the collection, analysis, and interpretation of data and the writing of the article and the decision to submit it for publication.

 Dr Hsu serves as a consultant for Cambridge Health Alliance, Columbia University, Community Servings, Delta Health Alliance, Robert Wood Johnson Foundation, and University of Southern California. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (MR, JHu, RB, IG, MGJ, BF, JHs); acquisition of data (MR, JHu); analysis and interpretation of data (MR, JHu, RB, IG, MGJ, DB, RN, BF, JHs); drafting of the manuscript (MR, JHu, DB); critical revision of the manuscript for important intellectual content (MR, JHu, RB, IG, MGJ, DB, RN, BF, JHs); statistical analysis (JHu, RB, RN); obtaining funding (MR); administrative, technical, or logistic support (MR); and supervision (MR).

 Mary Reed, DrPH, Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA 94612. Email: Mary.E.Reed@kp.org.

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Articles

Using a seamlessly shared inpatient-outpatient electronic health record was associated with greater rates of postdischarge follow-up delivered through telemedicine or laboratory monitoring and without an in-person office visit.

Inpatient-Outpatient Shared Electronic Health Records: Telemedicine and Laboratory Follow-up After Hospital Discharge

To understand when patients use secure e-mail messaging with healthcare providers across several types of questions or concerns, associations between out-of-pocket costs for in-person visits and use of secure messaging, and to examine patient-reported impacts on care-seeking behavior and overall health.

 Cross-sectional survey of patients in an integrated healthcare delivery system, with access to a patient portal to send secure e-mail messages to providers at no out-of-pocket cost.

 The study included patients with a chronic condition (N = 1041). We described patient-reported preferences for contacting providers and patient-reported impact of e-mail use on phone calls, in-person visits, and overall health. We used multivariate analyses to examine patient characteristics associated with using e-mail as a first contact method, and effects on care-seeking and health.

Overall, 56% of patients sent their provider an e-mail within 1 year, and 46% reported e-mail as their first method of contact for 1 or more types of medical concerns. After adjustment, higher out-of-pocket costs for in-person visits were significantly associated with choosing e-mail as a first method of contact (

 <.05). Among patients who had e-mailed their provider, 42% reported that it reduced their phone contacts, 36% reduced in-person office visits and 32% reported e-mailing improved their overall health.

 Patients reported using e-mail broadly to initiate conversations with their providers, and patients with higher out-of-pocket costs for in-person visits were more likely to choose e-mail as a first contact method. Use of secure e-mails reduced patients’ use of other types of healthcare and resulted in improved overall health.

	In a survey of patients with a chronic condition and with access to send secure e-mail messages to providers, nearly half had used e-mail as their first method of contacting providers for various types of health concerns. 

		Patients with higher out-of-pocket cost-sharing for visits were significantly more likely to report e-mail as their first method of contact with a health concern. 

		More than 1 in 3 patients who sent an e-mail to providers reported that it reduced their phone contacts or office visits. 

		Nearly one-third of patients who sent an e-mail to providers reported that it had improved their overall health.

Secure electronic messages offer patients and physicians an additional channel for communication and may serve as a unique mechanism for healthcare delivery. Although recent estimates show that most physicians in the United States are not yet regularly communicating with their patients electronically, most patients indicate an interest in communicating directly with their healthcare providers online.

 In order to receive the second stage of federal incentive payments for “meaningful use” of electronic health records and to avoid eventual financial penalties, clinicians will need to offer patients access to their health information through Web-based tools and to exchange secure electronic messages.

 However, the effects of these policy-driven shifts toward more electronic information and communication on patient care-seeking decisions and healthcare utilization are unclear.

There is limited information on what types of health concerns patients discuss with their providers using secure messaging, subsequently conflicting with evidence on the ways in which having Web-portal access affects in-person care-seeking behavior. Additionally, there is little attention paid to how patients’ cost-sharing for in-person visits affects their choice to contact their providers by e-mail.

 To understand how patients report their use of secure messaging tools to discuss concerns or questions about their health with their healthcare providers, we surveyed patients in a large health system that offers patient—provider secure electronic messaging tools, focusing specifically on patients with a chronic condition. We examined patient preferences for contacting healthcare providers across a variety of types of questions and concerns, whether cost-sharing for in-person visits was associated with this decision, and the patient-reported impact of secure message use on their in-person visits and overall health. We hypothesized that preferences for first contact method would vary by type of health concern, and that they would be affected by out-of-pocket costs.

Kaiser Permanente Northern California is an integrated delivery system with more than 3 million members. Health system members who register to use the password-protected patient portal website are able to exchange secure electronic messages directly with a provider in their healthcare team. Patients and providers are each notified when they have received a new message. There is no charge to the patient for using the patient portal, which also offers patients the ability to view lab results, request medication refills, and to view portions of their health records and visit summaries. Patients in this health system can also schedule nonemergency office visits through the portal website or by telephone.

The Kaiser Foundation Research Institute Institutional Review Board reviewed and approved the study protocol, waiving the requirement for informed consent.

Our source population for this study included all adult patients (18 years or older) who were in at least 1 of the health plan’s clinical chronic disease registries for asthma, coronary artery disease, congestive heart failure, diabetes, or hypertension during 2010. We studied patients with chronic conditions in order to focus on patients with at least 1 condition to discuss with a provider, but our survey asked generally about patient—provider messages for any type of condition or concern. Because the survey included questions about the impact of patient out-of-pocket costs (eg, co-payments and deductibles) on care-seeking behavior, we limited our sample to patients who were continuously enrolled through an employer-sponsored health insurance plan with no cost-sharing changes in their health plan benefits during 2010.

To ensure a sufficient number of participants who had recently sent a secure message and who had higher out-of-pocket costs for in-person care, we used a stratified random survey sample. Using automated records from the 12-month period before our study began, we randomly selected 25% of our sample from those who had not sent any secure messages and 75% from those that had sent at least 1 secure message. We also stratified the sample to include 25% from patients with a high-deductible health plan and 75% from patients without a high-deductible health plan. The high-deductible plans in our study met the IRS requirements for health savings account eligibility, including a deductible of $1200 or higher for an individual ($2400 for family coverage) that applied to most healthcare services, including nonpreventive office visits.

Beginning in June 2011, we mailed each potential participant a study introduction letter, a reply postcard, and a questionnaire with a postage-paid return envelope. We offered the option of completing the survey questionnaire by mail, by Web-based electronic survey, or by telephone interview in order to include of as many respondents as possible regardless of technology access or preferences, and in order to maximize response rates. Between June and December of 2011, trained interviewers contacted those who had not responded to our initial mailing in order to conduct telephone interviews, attempting to reach potential participants during different times of the day on weekdays and weekends. As needed, interviewers also called respondents who had mailed the written survey to complete and clarify any missing items. At the end of our data collection period, we again mailed a copy of the survey with a prepaid return envelope to all potential participants we had not been able to reach. All study participants received a $5 coffee gift card.

Of the total 1314 potential respondents contacted: 117 could not be reached after 15 phone call attempts, 183 were ineligible for study participation (a language barrier or health problem prevented them from completing an English-language interview or survey or they could not be reached due to incorrect contact information), and 1041 patients completed the study questionnaire (the response rate among eligible participants was 79%). Among all respondents, 51% completed the survey by telephone, 34% returned the survey by mail, and 15% completed the Internet-based survey. Comparing respondents with nonrespondents, women and respondents older than 65 years were more likely to complete the survey (

The survey questionnaire asked respondents how often they use the Internet for any reason and what devices they use to access the Internet. We also asked participants to report if, in the previous 12 months, they had any of 5 types of health concerns: 1) questions about a medical test result, 2) questions about a new health condition, 3) questions about an ongoing or chronic health condition, 4) questions about a medication, or 5) a request for a referral.  For each type of concern reported, we then asked respondents how they first contacted their provider or the healthcare system (ie, telephone call for advice or to schedule a visit, e-mailing their provider, visiting the emergency department, or no contact at all). We grouped phone calls for advice and to schedule a visit together since the patients’ first method of contacting the health system was by phone.

If e-mail was the preferred method of provider contact for a given type of concern, we then asked respondents what other method they would have used to contact their provider if the option to send a secure e-mail message had not been available. Respondents who reported past use of secure messaging also answered questions about which provider they had e-mailed and how long it took to receive a response from the provider. We also asked whether using secure messaging affected the number of times they contacted their provider by phone or the number of in-person office visits, and if using the secure messaging tool to e-mail their provider had an impact on their overall health status.

We asked all respondents to report their health plan’s cost-sharing requirements for doctor’s office visits and several demographic characteristics, including education, annual household income, race/ethnicity, marital status, and self-reported health status. Using health plan administrative data, we identified participants’ age, gender and DxCG comorbidity score (diagnosis-based risk score).

Because our study used a stratified sample, all analyses and results presented were weighted using study sampling proportions to represent the overall source population of patients with chronic conditions. We describe participants’ access to the Internet, with participants who reported never or rarely using the Internet categorized as not accessing the Internet. We also calculated the percentages of respondents who reported the 5 specific types of concerns in the last 12 months, their preferred method of contact for each type of concern, and the percentage who had registered to use the patient portal website. Among those who were Internet users and had registered to use the portal, we calculated the percentage who reported using secure messaging with any healthcare provider in the last 12 months, the type of provider e-mailed, and the average time to provider response. Among those who e-mailed their provider, we calculated the percentages who reported that e-mails with their provider changed the number of calls or visits with providers, or had an impact on their overall health.

Among patients who reported having any of the 5 specific types of health concerns, we used multivariable logistic regression to examine the association between reporting a preference for using e-mail to contact providers for any type of concern and visit cost-sharing levels, adjusting for patient characteristics, including gender, race-ethnicity, age, marital status, education, self-reported health, income, and comorbidity score. All multivariate analyses account for the survey sampling strategy in the point estimates and variance estimation (Stata version 9.0 [

 LP, College Station, Texas] using the svlogit command). We also used multivariable logistic regression to examine the association between reporting a preference for using e-mail as the first method to contact providers and reported impacts on phone contact and office visit rates, with adjustment for patient characteristics. We categorized respondents as having high visit cost-sharing if they reported having a deductible that applied to office visits or out-of-pocket cost (eg, co-payments or deductibles) of $60 or higher. We then computed the adjusted percentage of respondents who reported using e-mail as a first method of contact by fitting results from the logistic regression model by each patient characteristic and reported cost-sharing levels for office visits.

 shows the characteristics of the 1041 participants in our study after weighting. Among the 71% of participants who access the Internet at least monthly, 79% reported sending at least 1 secure message to their provider in the past year (24% sent 1-2, 29% sent 3-5, and 26% sent >5 e-mails). 

 shows the types of providers they e-mailed and the reported provider response times.

Among patients who reported having each type of health concern, 

 shows the reported first contact method. After multivariate adjustment, patients who were female, who used the Internet more often, or who reported higher out-of-pocket cost for in-person visits (≥$60) were statistically significantly more likely to choose to e-mail their provider as a first method of contact (

). After adjusting for patient characteristics, 85% of patients with higher cost-sharing for in-person visits reported choosing e-mail as their first contact method compared with 63% of patents with lower cost-sharing.

Across the types of health concerns, 85% to 91% of those who reported e-mail as their first method of provider contact indicated that if e-mail was not available, they would instead have contacted their provider by phone for advice or to schedule a visit; 4% to 11% reported that they would have scheduled a visit through the health plan website. Less than 3% reported that they would have avoided contact with their provider altogether if e-mail had not been available, and less than 1% reported that they would have instead sought care at the emergency department.

Among all participants who exchanged a secure message with their provider, 

 shows the reported impact on office visits and phone calls with the health system. Overall, 42% reported that the number of times they contacted the health system by phone decreased because of e-mail exchanges with their provider, 36% reported that their number of office visits decreased because of e-mail exchanges with their provider, and 32% reported that being able to communicate via e-mail improved their overall health. In multivariate analyses adjusting for patient characteristics, participants who reported e-mail as their first method of contact for any type of concern were significantly more likely to report that using e-mail had decreased their number of phone contacts with health system by phone and the number of office visits they had (

 <.001). After adjustment, 50% of those who reported using e-mail as their first method of contact reported that it decreased the number of calls, 42% reported that it decreased the number of office visits, and 35% that it improved their overall health compared with 14%, 11%, and 22%, respectively, of those who did not have any preference for e-mail as a first method of contact.

In a survey of patients with a chronic condition within a healthcare setting that offers patients the ability to send secure electronic messages to their healthcare provider, we found that a large proportion of patients used e-mail as their first method of contacting providers across multiple types of health-related concerns. Patients with higher out-of-pocket cost-sharing for in-person visits were statistically significantly more likely to report e-mail as their first method of contact with a health question. While the majority of patients who e-mailed their provider reported that this did not affect their number of phone contacts or office visits, more than 1 in 3 reported that their phone contacts or office visits decreased because of e-mail exchanges with providers, and nearly one-third reported that exchanging e-mails with their provider had improved their overall health

Secure patient portals have been proposed by the Institute of Medicine as a promising method of decreasing medical errors and increasing healthcare quality.

 Although the majority of US adults value Web-based access to their medical records as important, in 2013, only 28% of Americans were offered access to their online medical record.

  However, Stage 2 of the Meaningful Use federal programs that offer payment through the Medicare and Medicaid programs for demonstrating “meaningful use” of electronic health records will require clinicians to access and exchange secure e-mails with patients. Still, although our study was conducted in an integrated delivery system, many other reimbursement arrangements may limit the use of patient—physician e-mail, and Medicare does not generally provide separate payment for secure message exchanges.

It is unclear how these broad changes in electronic data and communication access will change patient care-seeking behavior and outcomes. Our study finding of high rates of use of electronic messaging as the first method of contact for a range of health-related questions will likely become increasingly widespread as more patients and clinicians gain access to, and begin using, these tools regularly. Because patients in our study largely reported that they would call the health system for advice or to schedule a visit if e-mail had not been available, this initial contact shift likely has consequences for telephone communication and in-person utilization patterns as well. We found that one-third of those who e-mailed their provider reported that this communication decreased their use of in-person visits.

With the rapid growth of healthcare costs, health plan benefits that include high levels of patient cost-sharing (such as high deductibles), in order to curb demand for services, have been growing in popularity with policy makers and employers. High-deductible health plan enrollment will likely increase further with implementation of health reform in the Affordable Care Act.

 Several studies have demonstrated that cost-sharing, in various forms (eg, co-payments, deductibles), reduces utilization of medical services,

  but may lead to decreases in necessary care, including for chronic conditions.

 In addition to the cost-sharing associated with a doctor’s office visit, patients often face additional barriers and costs to seeking in-person care, such as difficulty getting time off from work or arranging transportation or childcare. The convenience of e-mail may reduce these barriers to accessing care. Also, our finding of higher rates of patients using secure messaging as their first method of contact when facing higher out-of-pocket costs for in-person care may signal changes in patients’ care-seeking patterns that could become increasingly common as patient cost-sharing levels continue to grow and the ability to communicate with providers electronically becomes more widespread.

Existing evidence on the impact of patient use of patient portal websites on healthcare use and health outcomes has been limited and the results are conflicting.

 Previous studies do not capture the patient-reported choice to use electronic tools relative to more traditional in-person types of healthcare services; it is challenging to identify switches between types of services or delays in healthcare service use using administrative data sources. We uniquely captured patients’ own reports of initial methods for contacting their healthcare providers according to type of health concern and patient-reported impacts of e-mail on visits and health. Some patients explained that issues such as lab orders, medication changes, and patient questions could be addressed by e-mail and could reduce the need for an in-person visit. In addition, patients noted that greater information availability and engagement in their own care improved the management of their conditions and overall health. Overall, we found that patients regularly used secure messages to initiate conversations with their providers across a wide range of types of health questions and concerns and many report that these exchanges improved their health.

The direct generalizability of our findings is limited to the populations and delivery system setting of our study; however, since we studied patients’ self-initiated e-mail exchanges with their providers, our findings may reflect more general patient care-seeking behavior. Also, while our study is based on patient-reported survey data, automated clinical data sources are unlikely to capture patients’ initial health concerns and care-seeking decisions that we present. These patient-reported findings do complement previous studies, in the same integrated delivery system, in which providers report that electronic tools and messaging facilitated care coordination, by improving communication and providing informational continuity.

 Additionally, although our study focused only on out-of-pocket charges for healthcare services such as co-payments and deductibles, patients may have also had other unmeasured personal expenses for transportation, lost wages, childcare, etc, associated with any healthcare encounter. Overall, the study data are cross-sectional; thus, these findings are not designed to establish causality. Future studies should continue to examine the impact of patient—provider e-mail use on healthcare-seeking behavior, clinical care delivery work flow, and patient outcomes.

We found that patients with chronic conditions sent secure e-mail messages to their providers as a first method of contacting the healthcare delivery system for a wide variety of health concerns, and that higher out-of-pocket costs for in-person visits were associated with use of e-mail. Nearly one-third of respondents who used this tool reported that e-mailing their healthcare providers had improved their overall health, and more than 1 in 3 reported that e-mailing their provider decreased their phone calls to their providers or their in-person doctor’s office visits. As more patients gain access to patient portal tools associated with an electronic health record, patient-provider e-mails may shift the way that healthcare is delivered and have the potential to impact efficiency, quality, and health outcomes.

Patients with higher out-of-pocket visit costs, such as co-payments and deductibles, initiated provider contact by e-mail more often. Patients report that e-mailing changed their care-seeking behaviors and improved overall health.

Mary Reed, DrPH

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