This study of a secure patient Web site in a large, mixed-model health care system found that use and satisfaction with the Web site was greatest for accessing services and information involving ongoing, active care and patient–provider communication. Viewing medical test results and after-visit summaries, requesting medication refills, and participating in secure clinical messaging with providers were the most commonly used portions of the Web site and showed the most increase in use over the course of the study. Compared with other services on the Web site, patients reported the highest satisfaction with viewing medical test results, requesting medication refills, and participating in secure clinical messaging with providers. The rate of ID verification for access to the Web site increased when these shared record services between patients and providers were integrated in August 2003. Other portions of the shared record on the Web site, including viewing immunizations, allergies, and medical conditions, had a slower uptake in use and were used less overall.
We found that access to the Web site was more common among patients receiving care in the Integrated Delivery System compared with those receiving care in the contracted network. By the end of the study period in December 2005, 33% of patients receiving care in the Integrated Delivery System had access to enhanced services (including the shared record) compared with 9% of patients receiving care in the contracted network. ID-verified members in the Integrated Delivery System were somewhat older with higher expected clinical need compared with those members who were not ID verified. In the Integrated Delivery System, patients mainly sought access to enhanced Web site services, including the shared medical record. Basic registration in this population served mainly as a stepping stone toward the enhanced services provided with ID verification. In contrast, patients receiving care in the contracted network were more likely to continue with access limited to basic services only. Fewer patients went on to obtain access to enhanced services, which for this population were limited to refills of medications and access to a medication history. Access to Web site services in the Integrated Delivery System compared with the network suggests that patients in the Integrated Delivery System particularly valued access to enhanced services.
We were surprised by the relatively common and increasing use of after-visit summaries by patients. These summaries are provided to all patients after an in-person outpatient encounter with a Group Health provider. In addition to a list of active medications, medical tests that were ordered at the visit, and referral instructions ordered at the visit, the after-visit summary also includes patient education material and documentation of care plans entered by the provider. The growing use of the after-visit summary on MyGroupHealth may reflect patients’ desire for information about their conditions and the plan of care. 17–19
Recent survey studies suggest that patients are motivated to access their medical record by unmet information and care needs. 20,21
After-visit summaries on MyGroupHealth may fill this need better than access to physician notes because these summaries can provide a patient with a focused plan of care combined with personalized educational material hyperlinked to other resources. Our results showing higher ID verification among patients with higher expected clinical need also suggests that patients may be using the Web site’s services to help manage ongoing health conditions.
Two studies have reported on patient Web sites with shared medical records that included secure messaging between patients and providers. Similar to our findings, these studies found that access to medical test results and secure messaging with physicians are used by 22
and particularly valuable to patients. 10
Both of these studies were from large health care institutions (Beth Israel Deaconess Medical Center and Palo Alto Medical Foundation) in which the patient Web site was widely available to patients and physicians. Physician adoption seemed to be important in whether patients signed up for and used online services. Weingart et al. 22
reported that 11% (or 15,504) of all primary care patients had known access to the patient Web site at Beth Israel Deaconess Medical Center; physicians had between 0 and 98% of their panels enrolled for online services. 22
More similar to our findings, Tang et al. 12
reported that 30% (or approximately 50,000) of all primary care patients had access to the patient Web site at the Palo Alto Medical Foundation; although overall physician participation was not reported, 90% of physicians reported being satisfied with the patient Web site. 10
In 2004, 490 of 550 Group Health physicians (89%) participated in secure clinical messaging with patients. 23
These early studies suggest that patient Web sites seem to have the most value and the greatest adoption when patient and providers use them together to support patients’ active health care needs.
One study has reported on an early patient Web site with more limited functionality. In that study from Kaiser Permanente’s Integrated Delivery System, members had Web site access to a medication refill service, an appointment request service, and an online structured template for asking medical or prescription drug questions. Among the over 3,000,000 patients in the Kaiser health plan for which the Web site was available, patients most commonly used medication refills (1.3% of members) and appointment scheduling (1.7% of members). At the end of the three-year study, 8.6% of patients had signed up for Web site services. 24
The pattern of uptake in access to this patient Web site was similar to that of ID verification seen for MyGroupHealth in Group Health’s contracted network. At the end of our study period, 6% of Group Health patients receiving care in the contracted network had gained access to MyGroupHealth’s enhanced services. These versions of the Kaiser and Group Health patient Web sites provided a largely similar set of functionality (Group Health patients in the contracted network could not request appointments). In both of these patient Web sites, a medication refill service integrated with a personal medication list was not enough to drive Web site access above 10% of the member population over a three-year period.
This study has several limitations. The study describes patient Web site use in a limited manner, focusing on registration, ID verification, and unique monthly use; future studies should further examine demographic, health status, and other characteristics of users and nonusers of the patient Web sites. At least one other study suggests widening disparities associated with patient Web site adoption over time. 24
We did not examine the attrition rate of MyGroupHealth use by patients. The continuous increase in unique monthly users, however, suggests that overall attrition was likely to be minimal. Our measures of adoption are limited. Future metrics should attempt to tie adoption more closely with patient value and include health outcomes. We did not directly address the role of Group Health physicians in patient access and use of MyGroupHealth, which has been identified in other early patient Web site studies as a key element for engaging patients in online access to the medical record and patient–provider messaging. 7,21,22,25
We did not measure providers’ time doing phone, secure messaging, and in-person encounters with patients. Future studies should evaluate not only providers’ time in using these services, but also patients’ time in using health systems with and without this access, consistent with a patient-centered perspective. The study is vulnerable to unmeasured and uncontrolled changes in the characteristics of the Group Health population that could be associated with adoption of MyGroupHealth. Although patients in the Integrated Delivery System were older and were less likely to be on Medicaid, the differences between the two groups were modest and unlikely to account for the wide discrepancy seen for MyGroupHealth registration and ID verification. Limitations of the patient satisfaction survey included the survey’s modest response rate, which makes the results significantly vulnerable to response bias; inability to determine which aspects of a user’s experience accounted for a satisfaction rating (e.g., usability, content, response time); and surveying only active users of the patient Web site, which could have missed inactive users or nonusers that may have elected to not use the site because of a perceived lack of benefit. Patient Web sites, including Group Health’s, also remain in the early phases of development. All studies, including the one reported here, have occurred relatively early in the adoption of patient Web sites. Access to patient Web sites is likely to continue to grow, especially as new Web site functions are implemented and integrated into care. In this study, there was no visible plateau in the percent of Group Health members continuing to sign up for access to the shared medical record on MyGroupHealth.
The results of this study also should be viewed in the context of Group Health’s organizational characteristics and its broader efforts to improve patient access to care. Within the Integrated Delivery System, a Group Health patient’s care and EMR are coordinated across relationships with primary and specialty providers. In settings such as this, where most or all of the care is delivered in a single organization, patients may find particular value in shared EMRs and provider messaging. MyGroupHealth also was part of a multifaceted access initiative targeting better phone, in-person, and online access for patients. Group Health underwent large workflow, staffing, training, and incentive restructuring to support these combined access efforts. Because Group Health is both the insurance and the care delivery organization, Group Health also could be creative with addressing the widely cited barrier of reimbursement for electronic communications with patients. 26
Integrated care combined with patient-centered system reform may be important for achieving significant patient adoption of and satisfaction with Web services.
Our results should inform personal health record developers and policy makers. Personal health record efforts limited to providing a common medication list or claims data from insurers are not likely to achieve significant adoption. The use and value of Web-based medication lists and refill services seem to be tied to a larger constellation of services that are part of a shared EMR between patients and health care providers. The value of online health services for patients also seems to depend on the support of proactive communication between patients and health care providers. Personal health records focusing on the transfer of largely archived information in the EMR are less likely to be of value to patients than personal health records that connect patients and providers around medical test results, medication refills, and care plans. Because most patients receive care across a variety of separate practice settings and health care institutions, personal health record developers face a formidable challenge. Success will require interoperability of information systems and shared communication functionality across the largely fragmented U.S. health care system.
We found that access, use, and satisfaction with a patient Web site was associated with providing a constellation of shared medical record services that are well integrated with clinical care. Developers of patient Web sites and personal health records should consider focusing initial efforts on providing a set of functionality that supports patient–provider communication and engages patients with the information in the medical record that is most relevant to ongoing care.