Using technology to strengthen the patient-provider relationship has been a goal of most physicians, hospitals and health systems over the past several years, but new research points to issues that could arise for physicians who adopt electronic visits (e-visits).
As researchers from the Wisconsin School of Business at the University of Wisconsin–Madison stated in their paper, “The Impact of E-Visits on Visit Frequencies and Patient Health: Evidence from Primary Care,” there are plenty of frequently suggested benefits of e-visits and of electronic communication between providers and patients, such as enabling providers to give patients a low-cost alternative to visiting the doctor’s office. “Creating an online channel for care delivery offered the promise of reducing healthcare costs, while increasing the capacity of primary care physicians to see more patients by allowing them to handle routine questions or concerns through e-visits. At the same time, e-visits were seen as an innovation that could improve patient health by allowing patients to receive more attention and increased monitoring,” the paper’s authors wrote.
However, the researchers analyzed data from a large healthcare system in the U.S between 2018 and 2013, and were able to make several conclusions that support the idea that e-visits could have unintended consequences as well. These include: providers adopting e-visits experienced a 6-percent increase in office visits; the additional visits resulted in an additional 45 minutes per month of additional time doctors spent on those visits; to make up for that additional time spent on office visits, there was a 15-percent reduction in the number of new patients seen each month by those providers; and there was no observable improvement in patient health between those utilizing e-visits and those who did not.
The unnamed U.S. health system that was analyzed is involved with both research and clinical care, and operates multiple hospitals (with over 2,000 beds in total) and medical centers, along with several primary and specialty care practices in its region. In all, this totals some 2.5 million primary care encounters in those five years for more than 143,000 patients, and since the data are structured at the patient level, these encounters can be with physicians or non-physician providers such as nurses and residents.
Researchers Hessam Bavafa, Ph.D., Wisconsin School of Business assistant professor of operations and information management, along with Lorin M. Hitt, Ph.D., and Christian Terwiesch, Ph.D., of the University of Pennsylvania, say the findings suggest providers may need to structure and target their e-visits systems differently in order to improve outcomes.
Perhaps the most telling quote from the study’s authors was this one from Bavafa: “Offering e-visits seems like a great way to save time and money by reducing the need for office visits because routine questions or updates could be done via email. The problem is that healthcare is much more complicated—patients may overreact to minor symptoms or not be clear enough in describing their situation and that leads to doctors feeling obligated to schedule an office visit.”
To better grasp what implications these findings might have, I took a deep dive into the report’s specifics. It’s important to point out that while some may correlate “e-visits” with the broader term “telemedicine,” there seemed to be no video or remote monitoring interactions in this study. Rather, the examination was limited to electronic commutation between patients and providers, mostly in the form of secure messaging via patient portals.
One core finding from the paper was that providers who adopted e-visits experienced a 6 percent increase in office visits—or about one extra office visit every 100 months for the patient. But importantly, as the authors noted, “While this is not very large for an individual patient, for an average physician in our data with a panel size of 1,611 patients and 13.4-percent e-visit adoption rate, this amounts to 2.16 additional visits each month.” And, given this number, coupled with the average appointment time of 20 minutes, this equates to about 43 minutes of additional time doctors spend on these extra visits per month.
Related to this finding, Bavafa also noted that e-visits may result in doctors getting ambiguous or insufficient information that makes it difficult for them to offer a diagnosis, and that those additional communications with doctors create more potential opportunities for doctors to feel obligated to see the patient in the office.
Digging deeper, the authors wrote that there are four main possibilities to consider about where the additional visits come from: (1) the physician reduces the amount of time with non-e-visit-adopter patients (“e-visit adopters” is a term used for patients who have communicated with any primary care provider via the secure messaging service of the patient portal at least once); (2) the physician admits fewer new patients; (3) the physician works more hours to provide the additional appointments; (4) the physician conducts shorter duration appointments. Put all together, the data gathered showed that 74 percent of the new office visits generated by e-visit adopters occurred at the expense of new patient visits, and the remaining 26 percent occurred at the expense of non-adopters.