ABSTRACT & COMMENTARY
Do Telephone- and Internet-based Communications with Patients Increase Office Visits?
By Rahul Gupta, MD, MPH, FACP
Clinical Assistant Professor, West Virginia University School of Medicine, Charleston, WV
Dr. Gupta reports no financial relationships relevant to this field of study.
SYNOPSIS: In an integrated health plan and care delivery system, before and after a medical home redesign, proportional increases in copay-free secure messaging and telephone encounters were associated with additional primary care office visits for individuals with diabetes.
SOURCE: Liss DT, et al. Changes in office visit use associated with electronic messaging and telephone encounters among patients with diabetes in the PCMH. Ann Fam Med 2014;12:338-343.
Despite the widespread use and advancements of information technology that facilitate communication modes, little evidence exists that systematic telehealth or Internet-based communications are widely used in primary care when communicating with patients despite evidence suggesting that it leads to improved outcomes. For example, studies have demonstrated that telehealth interventions appear to have the potential to reduce the risk of hospital admission in severe asthmatics.1 Similarly, data suggest that some Internet-based interventions can assist smoking cessation, increase access to care, and improve control of type 2 diabetes and hypertension in care management interventions.2,3 Chronic diseases such as diabetes, asthma, heart disease, and chronic obstructive pulmonary disease affect people’s lives over a long period of time. As a result, there is a substantial burden placed on the health, economic status, and quality of life of such individuals, families, and communities. With the aging American population and the increasing burden of chronic diseases, it is expected that a significant proportion of health care resources will continue to be utilized by this cohort of people. To improve the quality and effectiveness of long-term disease management, a systematic approach is needed, comprising proactive health care systems that provide an active role for patients in self-managing their disease.4,5 In any disease management approach, communication between patient and health care provider plays an important support role in both disease monitoring and education and can take several forms. It can range from care providers sending patients reminders to self-monitor or attend to their care as well as face-to-face conversations, phone conversations, e-mail messaging, or the use of online portals. Previous studies on the impact of the use of an online portal to communicate with patients on office visit frequency have been mixed.
In their study, Liss et al investigate the association of patients’ use of primary care office visits with the use of secure electronic messaging and telephone encounters in a large health care system that featured these care modalities in a patient-centered medical home (PCMH) redesign. Investigators used an interrupted time series design with a patient-quarter unit of analysis to examine whether use of copay-free secure messaging and telephone encounters correlated with office visit use in patients with diabetes. Data were collected for 18,486 adults with diabetes in three periods before, during, and after a PCMH redesign in an integrated health care delivery system. The researchers observed a 28% increase in the mean quarterly number of primary care contacts between the pre-PCMH redesign baseline and the post-implementation periods. The increase was mainly due to increased secure messaging and an 8% decrease was noted in quarterly office visit use. In the regression analysis, 10% increases in secure message threads and telephone encounters correlated with 1.25% (95% CI, 1.21-1.29%) and 2.74% (95% CI, 2.70-2.77%) increases in office visits, respectively. For all study periods and patient subpopulations, proportional increases in secure messaging and telephone encounters remained associated with increased office visit use.
Overall, studies have supported the use of mobile phone messaging applications in the self-management of chronic diseases. However, the evidence base for the implementation of this technology is currently very limited, at best.6 In this study, Liss et al found that in an adult patient population with diabetes, proportional increases in telephone encounters and, to a lesser extent, secure message threads, were associated with proportional increases in primary care office visits.
Secure patient-physician messaging is a convenient and useful addition to the health care infrastructure. However, little remains known about the long-term effectiveness, risks, limitations, as well as consumer satisfaction with these types of interventions. The advent and wide use of smartphones may conveniently allow more complex interventions that use a combination of web-based and mobile phone messaging technologies (such as Apps) to be utilized to impact health care in the future. Therefore, it would be expected that the identification of secure providers, integration with reimbursement systems, and initial uptake by larger health care organizations will speed up the adoption of such information technology into routine health care.
A word of caution would be to ensure that while the inclusion of such technology into long-term patient care sounds reasonable, it is vital to develop the evidence through randomized, controlled trials with appropriate controls to demonstrate the benefits of such technology. It is also important to remember that for interventions that are designed to support the self-management of long-term illnesses, special emphasis should be directed to their effects over longer periods of time. In essence, policy makers should take note from this study that as primary care is increasingly being delivered as a team approach in the form of PCMH design, the clinician would be able to communicate frequently and efficiently, offering personalized services in the form of telephone and other web-based services. However, such patient-centered care delivery will require new payment models to be established and tested.
- McLean S, et al. Telehealthcare for asthma: A Cochrane review. CMAJ 2011;183:E733-42.
- van Baar JD, et al. Understanding reasons for asthma outpatient (non)-attendance and exploring the role of telephone and e-consulting in facilitating access to care: Exploratory qualitative study. Qual Saf Health Care 2006;15:191-195.
- Green BB, et al. Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: A randomized controlled trial. JAMA 2008;299:2857-2867.
- Balas EA, et al. Electronic communication with patients. Evaluation of distance medicine technology. JAMA 1997;278:152-159.
- Guilcher SJ, et al. Spanning boundaries into remote communities: An exploration of experiences with telehealth chronic disease self-management programs in rural northern Ontario, Canada. Telemed J E Health 2013;19:904-909.
- de Jongh T, et al. Mobile phone messaging for facilitating self-management of long-term illnesses. Cochrane Database Syst Rev 2012;12:CD007459.