Study shows more work, fewer new patients, little health benefit.
Telemedicine and other “e-visits” are supposed to be a win-win for physicians and patients alike. Doctors could spend less time on simple requests, patients would get frictionless access to their provider.
But a new study published in Management Science finds that all that access hasn’t translated into the outcomes so many had hoped for. Instead, e-visits lead to more office visits and more phone consultations without measurable improvement to patients’ health. And maybe most damaging for physicians’ practices, they’re associated with fewer new patients.
The findings may be surprising, but study leader Hessam Bavafa, PhD, of the University of Wisconsin School of Business, said they make sense when you consider the process of the usual e-visit. Patients can reach out with even the smallest concerns, he said, and that puts doctors in a bind.
“There’s an issue of obligation,” Bavafa told MedPage Today. “If you ignore the signal, who knows what’s going to happen next, right?”
The study used five years of data from a large health system with multiple hospitals and more than 2,000 total beds. It included all primary care encounters for 140,000 patients from 2008 to 2013, including office visits, phone calls, and e-visits, all cholesterol tests, and all blood glucose tests for the physicians with the largest panel sizes. It was limited, however, to those patients who had three or more office visits over the period analyzed, as the study was designed to focus on active healthcare users.
The results were stark. After adopting e-visits — in this instance, essentially an email with a subject line and generic box of text — office visits increased by 6% as physicians met with patients who had reached out online. Physicians also ended up spending 45 more minutes each month on those visits.
Oh, and the extra work of responding to patients requests did not bring extra compensation. “God knows what happens if you start paying doctors for these,” Bavafa said.
And with the increased workload came a corresponding 15% drop in the number of new patients physicians saw.
Bavafa said the findings are a natural consequence of physicians’ limited time: if one patient group is getting more of it, another will feel the squeeze.
But Peter Yellowlees, MD, president of the American Telemedicine Association, said the findings go against his own experience and much of the literature.
He questioned the wisdom of excluding patients who had fewer than three office visits. That eliminated a large group of patients, he pointed out, and may have affected the outcome.
“Effectively they only looked at two-thirds of the patients, which is a bit odd to me,” he said. “It’s perfectly reasonable that those people had problems that could be managed with an occasional email and everything’s fine and they don’t need to come in.”
He also pointed to strong adoption of e-visits in the paper as evidence of their value. The study found fewer than 100 monthly e-visits in 2008. By the end of the period analyzed, that had ballooned to nearly 6,500.
“As a physician, we don’t do things that we don’t think are worthwhile. That level of adoption is strong evidence, from my perspective, that this is a really good idea,” Yellowlees said.
He also wondered whether some other change within the system analyzed could have led to the changes observed. He said the e-visits couldn’t be considered causative.
While he didn’t agree with the findings, he said he was happy to see a study try to examine their impact.
Bavafa, too, was hopeful about the future of e-visits and other telemedicine efforts. Already, he said, some providers are toying with pricing to see if they can affect the way patients communicate with their doctors. The experiments include charging a “subscription” fee for electronic access to doctors, or even a charge for each individual contact.
He compared the current process to Amazon in the 1990s, or taxis as opposed to Uber and Lyft.
“This is the future, we just have to think about how to do it,” he said. “The ideas may not be novel, but it’s about figuring out the whole ecosystem.”