Patient provider communication using secured web-messaging.

1. CATCH-IT: Increasing the use of e-consultation in primary care: Results of an online survey among non-users of e-consultation NicolNijland, Julia E.W.C. van Gemert-Pijnen, Henk Boer, Michaël F. Steehouder, Erwin R. Seydel, International Journal of Medical Informatics - October 2009 (Vol. 78, Issue 10, Pages 688-703, DOI: 10.1016/j.ijmedinf.2009.06.002) By: Marjan Moeinedin October 26, 2009

2. Article information Research elements Background Objective Method Analysis Results Discussion Conclusion Questions to the authors Class discussion Table of Contents 2

3. Article Information

4. This study was supported by The Federation of Patients and Consumer Organizations in the Netherlands. Article History: Received 12 February 2009 Received in revised form 16 June 2009 Accepted 20 June 2009 Article history: 4

5. NicolNijland(PHD student, 2006-010) Department of Psychology and Communication of Health and Risk, Faculty of Behavioral Sciences, University of Twente, Enschede, The Netherlands. First Author 5

6. Research Elements

7. In spite of the substantial increase in the use of Internet as a source for health information, the use of e-consultation remains relatively low. (Pew Internet website) Potential benefits of e-consultation: Increased access to care. Patients can ask questions from any place and at any time Increased self-management support for individuals with significant medical problems. e-consultation use can empower patients’ self-control skills and strengthen their autonomy Reduced costs while maintaining the same or achieving better quality of care. e-consultation can respond to an increasing demand for care in the aging society Background 7

8. The motivations for using two types of e-consultation provided in Netherlands was investigated Direct e-consultation: consulting a GP through secured e-mail. Indirect e-consultation: consulting a GP through secured email with intervention of a Web-based triage system. Background 8

9. To identify factors that can increase the use of e-consultation among non-users: patients with access to Internet, but with no prior e-consultation experience. Objective 9

11. The survey was pre-tested by patients recruited through the Dutch Federation of Patients and Consumer Organizations.

12. The survey covered 7main topics and contained a total of 45 items. Method 10

13. Topic 1: asked whether patients had experience with e-consultation (Yes/No). Topics 2–6 consisted of multiple statements, which could be answered on a 5-point scale ranging from strongly disagree (1) to strongly agree (5). Topic 2 (seven statements) examined possible barriers to using e-consultation. Topic 3 (ten statements) assessed patients’ demands regarding e-consultation. Survey Items 11

14. Topic 4 (seven statements) identified motivations for using e-consultation. Topics 5-6 (seven statements and eight statements) assessed the motivation for using two types of e-consultation: direct e-consultation and indirect e-consultation. Topic 7 questions were related to ’ socio-demographic and health-related characteristics, such as gender, age, education level, chronic use of medication, and frequency of seeing a GP. Survey Items (cont’d) 12

16. 18 years of age and above.

17. Patients with various chronic conditions and basic Internet skills who have visited health-related websites.

18. Participants were recruited through banners on frequently visited websites of 26 well-trusted patient organizations.

19. All organizations were members of the Dutch Federation of Patients and Consumer Organizations.

20. By clicking on a banner patients were automatically linked to the online survey, which was available for a period of 11 weeks.Participants Recruitment 13

21. SPSS version 13.0 Descriptive statistics, mean, sum of scores were computed for all constructs . Internal consistency of all constructs was satisfactory Cronbach’s = 0.64 to 0.84. F-tests (one-way ANOVA) were used to identify significant differences between independent variables of interest. Linear regression models were used to predict the dependent variable ‘motivation for using e-consultation’ (mean score of questions 4–6, Cronbach’s ˛ = .86). Data analysis 14

22. Independent predictors included: barriers towards e-consultation demands regarding e-consultation socio-demographic and health-related characteristics age, education level medication use frequency of seeing a GP Two-tailed significance was considered at the p < .05 level. Data analysis (cont’d) 15

23. Study participants Of the total sample (n = 1706), 1066 were eligible 163 patients (9.6%) had experience with e-consultation. Of the remaining 1543 patients (90.4%) who had no prior e-consultation experience, only 1066 patients were eligible for the analysis. Patients who had filled out only 1 question were excluded. n varied since patients could skip questions. Results 16

24. Results (cont’d) Table 1: Characteristics of participants Highlights of Table 1: (62.4%) Female (70.2%) frequent GPs visitors The mean age was 49 years old (SD = 13.5) 50% of the patients were highly educated (50.9%). Highlights of table 1 17

25. The most prominent reasons for not using e-consultation: 65% were not aware of the existence of e-consultation services 56% preferred to see a doctor 53% had limited access to e-consultation services, because their GP did not provide e-consultation Computer or Internet skills were not expected to be a problem 66.1% did not know whether the use of e-consultation is refunded by their insurer Results: Barriers towards e-consultation 18

26. Barriers towards e-consultation (%) 19

27. The top priority regarding demands for e-consultation: 98% agreed on getting a quick response 63.9 % agreed that it was important for their GP to answer their question all other demands were almost equally important to the patients Results: Demands regarding e-consultation 20

28. Demands regarding e-consultation (%) 21

29. Patients were fairly willing to use e-consultation: 92% to have the ability to contact a GP regardless of time 81.3% to have the ability to contact a GP regardless of place 86.3% to have the possibility to formulate questions undisturbed Results: Motivations for using e-consultation 22

30. Motivations for using e-consultation in general (%) 23

32. Direct - consulting a GP through secured email

33. In-direct – consulting a GP through secured e-mail with intervention of a triage mechanism for advice on whether it is necessary to see a doctor and for self-care adviceResults: Motivations for using e-consultation 24

34. motivations for using direct e-consultation: 88.2% the possibility to ask additional questions after a visit to the doctor 78.4% the possibility to ask questions about medication use 55.5% Getting advice on how to handle a health problem 45.9% asking questions about the costs and payment of treatments The last two points were less of a motivation to use e-consultation. Results: Motivations for using e-consultation 25

35. Motivations for using direct e-consultation (%) 26

36. motivations for using indirect e-consultation: Agreement on the statements was fairly high overall 87.8 % to decide if a visit to the GP was necessary 83.7% to get self-care advice 80.3% to reduce uncertainty 47% to ask questions anonymously 41% felt no need for anonymous inquiries Results: Motivations for using e-consultation 27

37. Motivations for using indirect e-consultation (%) 28

39. high correlation between demands for using e-consultation and patients’ characteristics

40. The motivation for using e-consultation increased

41. as more demands were satisfied such as getting a timely response

42. Of all patient characteristics

43. education level and age were the strongest predictors of the motivations for using e-consultation

44. The less-educated and elderly patients seemed more strongly motivated to use the service than the more highly educated and younger patientsResults: Main drivers for e-consultation 29

45. Bivariate correlations and regression analyses: predictors associated with ‘motivations for using e-consultation 30

46. Distinct patient groups were compared regarding age education level chronic use of medication frequency of GP visits Focus was on the patient groups that have a greater change of being left behind could benefit from e-consultation because of their increasing demand for care Results: Comparison of patient groups on barriers,demands and motivations regarding e-consultation 31

47. Distinguished patient groups (n = 1066) 32

49. lower Internet skills

50. greater concerns about the costs of using e-consultation

51. Less-educated patients

52. were less aware of the existence of e-consultation services

53. had lower Internet skills

54. had more doubts about the reliability and privacy of information

55. Face-to-face contact was

56. preferred more strongly by the chronic medication users

57. The frequent GP visitors had

58. stronger preference to visit a doctorResults: Comparison of patient groups on perceived barriers towards e-consultation 33

59. Comparison of patient groups on perceived barriers towards e-consultation 34

61. The elderly patients

62. had stronger demands, to obtain evidence-based answers from their caregivers

63. The less-educated patients preferred

64. to receive instructions about e-consultation use

65. to receive information about the possibilities and restrictions of e-consultation

66. to use e-consultation free of charge

67. The chronic medication users had a greater desire

68. to obtain an answer from their own GP

69. to have their e-consultation stored in their medical record

70. Frequent GP visitors preferred

71. To be informed about the possibilities and restrictions of e-consultationResults: Comparison of patient groups on demands regarding e-consultation 35

72. Comparison of patient groups on demands regarding e-consultation 36

73. Significant differences were found between the patient groups’ motivation to use e-consultation. The elderly patients, the less-educated patients’ and the chronic medication users were significantly more motivated to use e-consultation than their counterparts. Results: Comparison of patient groups on motivations to use e-consultation 37

74. Comparison of patient groups on motivations to use e-consultation in general 38

75. The results on direct e-consultation showed elderly and less-educated patients were significantly more motivated e-consultation enabled them to ask questions about the costs and payment of a treatment to seek advice about certain health problems The chronic medication users were also more motivated to use e-consultation, especially to pass on their medical data Results: Comparison of patient groups on motivations to use direct e-consultation 39

76. Comparison of patient groups on motivations to use direct e-consultation 40

77. The results on indirect e-consultation indicated that the less-educated patients were more motivated than the more highly educated patients to use a Web-based triage application, especially for uncertainty reduction. Results: Comparison of patient groups on motivations to use indirect e-consultation 41

78. Comparison of patient groups on motivations to use indirect e-consultation 42

79. The results of the study showed that 70% of the study population, patients with no e-consultation experience (n = 1066), were frequent GP visitors e-consultation may be especially beneficial for these patients with a higher demand for care it can help them decide whether it is necessary to see a doctor and teach them self-care techniques in order to prevent unnecessary encounters The most prominent barriers towards e-consultation were: unawareness of the existence of e-consultation e-consultation not being provided by a GP the preference to see a doctor Discussion 43

80. Education and examination of user expectations can provide a solution for these barriers, for both patients and caregivers alike. Patients are dependent on a GPs’ provision of e-consultation. Therefore, it is important to advise caregivers on the mutual benefits of e-consultation, its consequences and implementation into regular practice. It is also important for GPs to ask their patients about e-consultation since patients are unlikely to request electronic GP access, simply because they are unaware of the option. Also, non-users of e-consultation may have no clear ideas or assumptions about the benefits and disadvantages of e-consultation. Discussion (cont’d) 44

81. The results demonstrated that non-users were fairly motivated to use e-consultation, but only under certain conditions certain patient groups, such as less-educated patients, elderly patients and chronic users of medication were especially motivated to use e-consultation but also perceived many barriers towards e-consultation The elderly patients, perceived a stronger lack of Internet skills than younger patients the less-educated patients were less aware of the existence of e-consultation than the more highly educated patients Discussion (cont’d) 45

82. Non-users might have a limited view on the possibilities of e-consultation for self-care. Future research could focus on the motivations of early adopters in comparison to the motivations of non-users. Another did not reflect on motivations, demands and barriers of patients without access to a computer or Internet or patients with GPs without e-consultation services. The study was directed solely at Internet users, because this population had the potential to use e-consultation in the near future Limitations of this study 46

83. Increase in use of e-consultation will occur through solving existing barriers among non-users and through addressing patients’ demands, preferences and skills when developing e-consultation systems. Patient profiles should be taken into account. Special attention should be paid to patients who can benefit the most from e-consultation. In a patient centered healthcare system, it is expected that patient expectations and demands will be a major force in driving the use of electronic communication. Conclusions 47

84. Nicol Nijland, Julia E.W.C. van Gemert-Pijnen, Henk Boer, Michaël F. Steehouder, Erwin R. Seydel, International Journal of Medical Informatics - October 2009 (Vol. 78, Issue 10, Pages 688-703, DOI: 10.1016/j.ijmedinf.2009.06.002) Reference 48

85. There was no mentioning of REB in the paper. Was there a need for obtaining patients informed consent in an online survey study? How was the survey developed? Was it validated? Authors did not comment on the development and validation of the online survey. How did the authors handle incomplete questioners? How did the authors handle duplicated surveys? Was there a method to prevent that? Was it beneficial to do a comparisons between the excluded patients and included patients in the study? Why should a patient use e-consultation if a telehealth service exists? Reported sample size in tables and graphs revealed that between 200-300 out of 1066 patients skipped at least one question. Could this large number of missing values severely biased the statistical results? How did authors account for that? Questions for the authors 49

86. Class discussion 50

87. Thank you 51