This study investigated the impact of patients having online access to their medical records through Kaiser Permanente's MyHealthManager (MHM) system. The results showed that MHM users had a 18% higher rate of office visits and 9% higher rate of phone visits compared to non-users. Rates of after-hours clinic visits, emergency department visits, and hospitalizations also increased. While increased access seemed to lead to greater use of healthcare services, further research is still needed to understand the reasons and outcomes.

1. HMORN 2012 session C1-04
Online Patient Access to Their Medical
Record and Health Providers
Is Associated with a Greater Use of
Clinical Services
Ted E. Palen, PhD, MD, MSPH
Colleen Ross, MS, BSN
Stan Xu, PhD
Institute for Healthcare Research
Kaiser Permanente Colorado
of COLORADO

2. BACKGROUND
• Studies indicate patients want online
access to medical records which allow:
– review test results
– schedule appointments
– request refills
– communicate with their providers by email
of COLORADO

3. BACKGROUND (cont.)
• Institute of Medicine report, "Crossing the Quality
Chasm: A New Health System for the 21st Century”
– electronic patient–physician messaging as a promising technology to
improve the quality and efficiency of healthcare
• Some researchers estimate that 25-70% medical care
does not require a face-to-face appointment
• Department of Veterans Affairs: eHealth technologies
– important model of healthcare to incorporate into clinical practice to
increase access to care
of COLORADO

4. BACKGROUND (cont.)
• Prior studies on the impact of secure
online messaging and the use of other
health care services have reported
conflicting results
• Early MyChart experience in Kaiser Permanente
patients with access to secure online messaging
– decreased office visits
– increased scheduled telephone contacts
– compared to non-users of the service
of COLORADO

5. OBJECTIVE
• To investigate the impact of member online
access to their health record on the use of:
– office visits
– telephone contacts
– after hour clinic visits
– emergency department use
– hospitalizations
• We hypothesized that as the proportion of our
members using online access increased, we
would experience a proportional decrease in the
use of “in-person” services
of COLORADO

6. METHODS
• Inclusion criteria
– registered MyHealthManager users (≥13 yrs) for longer than 6 months
– used at least one MyHealthManager feature
– were continuously enrolled as KPCO members during the study period
• Study period
– For the MyHealthManager user cohort
• Pre-registration period was 12 months before registration date
• Post-registration period was 12 months after registration date
• Propensity scoring matched cohorts of non-MyHealthManager users
– identify a matched cohort of non-MyHealthManager users and used the
matched MyHealthManager users registration date as index date for
analysis
• Pre-registration period was 12 months before index date
• Post-registration period was 12 months after index date
• Analysis
– calculate the difference in use of services between the pre- and post-
periods
– assess statistical significance with the generalized estimating equations
of COLORADO

7. METHODS
• Since implementation of the MHM in KPCO in April 2006
member use increased
– 25% at end of 2006 to >50% by June of 2009
– 53.8% (375,620) as of June 2009
• Initial study cohort (≥ 13 years of age)
– 83,804 non-MHM users
– 89,340 MHM users
• Propensity score matching used to refine cohorts
• Age
• Gender
• Race
• Chronic health condition (Asthma, Diabetes, CAD, CHF)
• Stratified by index year and office visits
– Refined cohorts each contained 46,925 members
of COLORADO

8. RESULTS
46,925 KPCO members ≥ 13 years of age
non-MHM user MHM user
• 52.8 % female • 53.8% female
• Ave. age 42.2 years • Ave. age 43.3 years
– < 20 yrs. 7.5% – < 20 yrs. 7.5%
– 20-39 yrs. 37.1% – 20-39 yrs. 36.9%
– 40-59 yrs. 41.8% – 40-59 yrs. 41.9%
– 60+ yrs. 13.6% – 60+ yrs. 13.7%
• Race • Race
– White 52.1% – White 51.8%
– Hispanic 11.3% – Hispanic 11.3%
– Black 3.8% – Black 3.8%
– Other 4.0% – Other 4.0%
– Unknown 28.8% – Unknown 29.1%
of COLORADO

9. RESULTS (cont.)
46,925 KPCO members ≥ 13 years of age
non-MHM user MHM user
• Chronic Health Conditions • Chronic Health Conditions
– None 85.4% (N = 40,065) – None 85.1% (N = 39,951)
– 1 13.1% (N = 6,138) – 1 13.4% (N = 6,291)
– 2 1.3% (N = 615) – 2 1.3% (N = 591)
– 3 0.2% (N = 100) – 3 0.2% (N = 88)
– 4 0.01% (N = 7) – 4 0.01% (N = 4)
• Chronic Condition • Chronic Condition
– Asthma 7.8% (N = 3,677) – Asthma 7.9% (N = 3,726)
– Diabetes 5.9% (N = 2,790) – Diabetes 6.0% (N = 2,834)
– CAD 1.6% (N = 762) – CAD 1.6% (N = 749)
– CHF 1.0% (N = 467) – CHF 0.9% (N = 444)
of COLORADO

10. Encounters Before and After MyHealthManager Activation
(NOTE: Activation Index Date Derived from User of MyHealthManager and Applied to Non-users
4.5 #
*
* Significant change within group 4.0
4.0 # Significant change between groups
3.7
3.6
Encounters per 12 Months
3.5
3.5 # *
3.1
3.0
2.5 2.6
*
2.5 2.3
2.0
1.5
1.0
0.5
0.0
non-MHM User MHM User
Office Visits Pre Office Visits Post
Phone Contacts Pre Phone Contacts Post
of COLORADO

11. Encounters Before and After MyHealthManager Activation
by Age Group
6.0
* Significant change within group * *
Encounters per 12 Months
# 4.9
Significant change between groups # 4.9
5.0
4.5
4.3
4.0 # # *
3.5
* 3.6
3.3
3.1 * # 3.0
2.9 * 2.9 2.9
3.0 2.7
2.3 * 2.3
2.1
2.0
1.0
0.0
<50 yo non-MHM user <50 yo MHM user ≥50 yo non-MHM User ≥50 MHM User
Office Visit Before Office Visit After
Phone Visit Before Phone Visit After
of COLORADO

12. Encounters Before and After MyHealthManager Activation
by Health Condition
14.0
* Significant change within group
Encounters per 12 Months
# Significant change between groups
12.0
# *
10.0
*
8.0 *
*
6.0
* #
# * *
4.0 # *
# * *
*
*
2.0
0.0
No ChrDz No ChrDz Asthma non- Asthma Diabetic Diabetic CAD non- CAD MHM CHF non- CHF MHM
non-MHM MHM User MHM User MHM User non-MHM MHM User MHM User User MHM User User
User User
Office Visits Before Office Visits After
Phone Visits Before Phone Visits After
of COLORADO

13. Encounters Before and After MyHealthManager Activation
by Location of Service
200 * Significant change within group
Encounters per 1000 patient-yrs
# Significant change between groups
182.2 181.7
180
#
160 *
150.8
140.5
140
#
120 *
100.2
100 * 88.2
84.7 #
78.6
80 *
70.8
63.2 63.6
60 50.9
40
20
0
non-MHM User MHM User
After Hrs Before After Hrs After ED Visits Before
ED Visits After Hosp. Before Hosp. After
of COLORADO

14. Encounters Before and After MyHealthManager Activation
by Age and Location of Service
200 * Significant change within group
184.7185.4 # Significant change between groups
Encounters per 1000 patient-yrs
177.8177.7
180
160 #
149.2 *
147.4
143.3
140 130.9
#
120 *
105.9
97.7 # *
100 91.9 93.4 #
90.1
*
81.9 84.1 *
81.2
80 # * 72.5 72.2 67.8
66.2
62.8
60 54.6 *
50.2
44
40
20
0
<50 yo non-MHM User <50 yo MHM User ≥50 yo non-MHM User ≥50 yo MHM User
After Hrs Before After Hrs After ED Visits Before
ED Visits After Hosp. Before Hosp. Afer
of COLORADO

15. Encounters Before and After MyHealthManager Activation
by Disease and Location of Service
*
600
Encounters per 1000 patient-yrs
* Significant change within group
# Significant change between groups #
500 *
400
300
200 #
* # * *
#
*
#
100 *
*
*
0
No ChrDz No ChrDz Asthma Asthma Diabetic Diabetic CAD non- CAD MHM CHF non- CHF MHM
non-MHM MHM User non-MHM MHM User non-MHM MHM User MHM User User MHM User User
User User User
After Hrs Before After Hrs After ED Visits Before
ED Visits After Hosp. Before Hosp. After
of COLORADO

16. CONCLUSIONS
• MyHealthManager Users compared to non-Users
– rate of utilization of office and phone visits I n c r e a s e d
– 18% increase in office visits
– 9% increase in phone visits
– In addition, the rates of
• After hours clinic visits
• Emergency department visits
• Hospitalizations
Increa sed
• This general trend was true for members:
– <50 years of age and ≥50 years of age
– Without chronic illnesses
of COLORADO

17. CONCLUSIONS (cont.)
• Incorporating online access into patient care
may
– highlight health concerns needing in-person evaluation
• Patients might have activated their access to
online services in anticipation of health needs
• Patients may use this technology to
– gain even better access care
• rather than to substitute for other types of contact with the health
care system
of COLORADO

18. CONCLUSIONS (cont.)
• Providing patients with online access to their medical
record may actually INCREASE demand for more
traditional contacts with the healthcare system to
address medical issues.
• Further research is needed to evaluate:
– Reasons patients use online access to the healthcare services
– If MHM users have different health outcomes compared to non-users
– The cost/benefits of online access to healthcare services, e-visits, and
clinical decision-making
– The impact on the allocation of clinical resources to deal with the
potential increase use of clinical service as eHealth applications
become more widespread
of COLORADO

19. Acknowledgements
• David Ryerson, Data Specialist/SAS Programmer
• J. David Powers, Biostatistician
• John Steiner, MD, Dir. Institute for Healthcare Research
• Cristy Geno, Project Manager
• QUESTIONS????
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