Harkness Experience 200102

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Harkness Experience2001/02

• John Hobbs
• Partners HealthCare/Brigham and Womens
  Hospital/Harvard Medical School

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Presentation Outline

• Placement and overview of my work in U.S.
• Outline of 3 of 4 studies
• Methods adopted
• Results/Conclusions
• Ongoing work in N.Z. and U.S.

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Placement

• Partners HealthCare/Brigham and Womens Hospital
  affiliated with Harvard Medical School - Boston
• Dr David Bates Chief Internal Medicine at BWH,
  HMS and Partners Healthcare
• Building an IT infrastructure to improve
  communication between patients and doctors
• Undertake research on access by at risk
  populations to ehealth opportunities

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Overview of My Work In United States

• Survey of use of email by Patients and Physicians
  (Study 1)
• Telephone interview of Physicians experience of
  email with patients (Study 2)
• Internet as a Communication Device (Study 3 -
  Anthrax)
• Patient and Physician Email and the Digital
  Divide (Study 4)

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Physician and Patient Email Study 1 Background
Observations

• 66 of U.S. adults online (Harris, 2002)
• 80 to 90 of online pop. engage in email
• Caution by physicians over emailing patients
• Only 10-20 of physicians ever emailed patients
  (Cyber Dialogue - Dec 2001)
• Yet 90 of adults online wish to email physician
  (Harris, 2002)

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Background Physician and Patient Email (Context
cont-)

• US physicians - 15 minute email worth 57
  (Deloitte/Fulcrum Analytics, 2002)
• 37 of online users willing to pay - avg. 7 per
  email or 10 per month (Harris 2002)
• First Health PPO study - reimburse physician 25
  per email consultation
• Benefits of email heralded but limited empirical
  evidence on scope of gains

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Objective

• Examine email use and attitudes by physicians
  and
• Identify interventions that might promote its
  successful adoption

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Setting for Study

• Surveyed all physicians at 10 primary care
  practices (total of 94)
• Features of 10 clinics
• Use electronic record and on Partners intranet
• Mix of urban, suburban, hospital-based, community
  and neighborhood health centers
• Most reimbursement is fee for service
• Diverse patient population
• Survey linked to evaluation of Patient Gateway

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Survey Design

• Paper based survey questionnaire to all
• 94 physicians (January to March 2002)
• Measurements
• Physician email contact with patients
• Views on email and workload, phone use
• Views on email and quality, access
• Views on barriers to expansion of email
• Views on options to make email more attractive
• 76 response rate by physicians to survey

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Results Email Use

• 100 of physicians use email daily
• 70 of physicians email patients but limited to
  small proportion

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Results Email Time and Workload Implications

• Relatively short time to respond to email
• 80 0-5 minutes to respond to email
• 20 5-10 minutes to respond to email
• However, concern workload will increase
• 64 think email will increase workload
• 16 think email will decrease workload
• But may be modest fall in unproductive phone time
  

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Results Email and Phone Use

• Physician contact with patients
• Avg. phone use over day is 75 minutes
• Avg. email use over day is 16 minutes
• 90 make phone calls after clinic hours
• 90 of emails occur between patient visits
• A lot of phone time unproductive (43)
• Substitution? - 52 believe email could reduce
  phone workload

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Results Quality

• Views on quality of care impact
• Value of email in asking clinical questions?
• 73 agree, 14 indifferent, 12 disagree
• Quality improvements from email?
• 37 yes, 16 unsure, 46 no
• Inappropriate emails - too urgent?
• 48 none, 44 1 to 5 and 8 6 to 10

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Results Access and Barriers

• Some concern by physicians that access limited to
  certain population groups
• Main barriers to email
• Compensation 69 would increase email if
  reimbursable
• Workload concerns
• Security concerns
• Absence of triage
• Some experience of inappropriate emails

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Summary Observations

• Physicians ok with using email generally but
  nervous about using with patients
• Majority of physicians use email with patients
  but with very small proportion
• Workload concern with email - but may be some
  gain from phone substitution
• Some perceived quality gains from email but
  results not clear

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Summary Observations (cont-)

• Physicians believe patient demand for email
  exceeds availability
• Physicians would be more open to email if certain
  pre-conditions met
• Filtering mechanisms - triage to practice staff
• Payment

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What Needs to Happen to make Progress?

• Triage emails in structured fashion
• Use of guidelines by physicians that identify
  best email practice (e.g. AMIA)
• Consolidation of evidence - net gains?
• Michigan 2002 study - email has improved
  communication but increased workload
• First Health study on payment mechanisms - using
  diabetes and hypertension as a case study
• Examination of patient health outcomes needed

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Physician Interviews Study 2

• Telephone interview of group of physicians (10)
  who are using email with patients to assess
• Practice methods adopted e.g. triage?
• How covering costs of email?
• Profile of emailers and message content?
• Impact on overall efficiency and quality?
• Physicians academic/not fulltime
• Chosen on basis of email utilisation

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Observations

• All physicians 1st point of email contact and
  limited triage not sustainable
• No consistent approach to establishing email
  contact with patients trusted patients or new
  patients
• No systematic use of Guidelines
• Payment for email not overriding concern but
  vechicle for gaining market share
• Increased efficiences (email for phone)
• Particular advantages patients on
  business/holiday, chronic conditions, deaf,
  medical issues of the day

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Internet as aCommunication DeviceAnthrax
Case Study 3

• Opportunity Oct/Nov 2001 anthrax attacks
• Considerable alarm in U.S. re personal health
  risk
• Interested in relative role of traditional media
  and Internet in communicating with public
  anthrax as a case study

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Anthrax Events in 2001Summary

• Early Oct 2001 1 physician noticed irregular
  lesion on patient
• Few physicians had seen case of anthrax
• Next 3 months tremendous alarm and dysfunction
  among public services, medical professionals and
  public
• Ultimately 4 letters contained anthrax

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Objective

• Explore the role the Internet played and its
  potential in communicating information to an
  alarmed public, using anthrax as a case study
  and
• Discuss policy developments that could improve
  use of Internet as a communication device

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Anthrax EventsInformation Confusion

• Traditional media lots of information provided
  but not always validated by health authorities
• Public health authorities and politicians not
  co-ordinated who was taking lead in conveying
  info?
• Politicians not well informed down played the
  risks initially e.g.
• Thompson .. The first inhalation case was
  isolated. Anthrax happens naturally and there is
  no evidence of terrorism.

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Information confusion (cont)

• Poor communication to local businesses e.g.
  postal workers how long to take anti-biotics?
• Poor communication between public health
  authorities, physicians and field workers
• People took things into own hands in spite of
  warnings of Surgeon General re anti-biotic use
• With conflicting information public had
  opportunity to search for information on Internet

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Data on Anthrax Events

• Endeavoured to get data on utilisation and
  searching behaviour Medscape/WebMD, CDC, Dr
  Green, BWH/Partners, Beth Israel Deaconess
• Concerns over sharing information Commercial
  and sensitive
• Collaborated with Pew American Internet Life

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Data on Use of Internet versus other Media

• Use of different media between typical day in
  month of August 2001 with October/Nov 2001
  showed
• Television up from 57 to 65
• Internet use up from 56 to 61
• Internet use for health information up from 5 to
  7
• Google searches during week of September24,
  2001 anthrax 3rd , and 1st in October
• cipro 5th most frequent query in October 2001
• CDC www.bt.cdc.gov increased by 100 in
• Oct 2001

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Use of Internet continued
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Use of Internet continued

• Data on utilisation suggests that
• Internet likely to have played an important (but
  relatively minor) role throughout period of
  anthrax threat
• Possible that those who were familiar with
  internet used it more intensively and selectively
  
• Not a significant switch between traditional
  media and Internet
• Overall difficult to draw firm conclusions about
  searching behaviour from data available at the
  time
• Decided to undertake our own survey

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Benefits of Internet Applications Over Period

• Customisable source of information eg for
  researchers, health workers, consumers,
  asthmatics etc
• Speed and versatility provides multiple
  branches of information all accessible almost
  simultaneously
• Alternative source of information has potential
  to scrutinise information provided by traditional
  sources e.g. Tommy Thompsons comments

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Benefits continued

• Accessibility information available at any time
  of day and increasingly from own home e.g. CHESS
• Relatively safe form of communication
• Source of emerging risks easier for
  epidemiologists to rapidly assimilate information
  about emerging risk, drawing on data from shared
  electronic medical records 5 of US physicians
  use EMR (Bates)
• Physician and patient email more targeted
  information to be delivered to patients quickly

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Cautions of Using Internet

• Quality 200 sites marketed bioterrorism related
  products antibiotics, gas masks, air filters
  71 of these sites required to remove claims as
  not supported by evidence
• Access not all have access to technology and
  associated benefits
• Uncertainty about impact on behaviour

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Conclusions

• Internet played small but important role vis a
  vis traditional media
• Internet functioned as a complementary source of
  information
• Internet has enormous scope, flexibility and
  potential to improve communication with an
  alarmed public

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Conclusions continued

• However
• Research needed into use of internet in times of
  stress
• Research into how provider and public health
  authorities use this medium to convey information
  
• How to promote quality accredited sites,
  guidelines to apply to website content and role
  of Search Engines
• Research into how website content influences
  behaviour and varies by demographic factors
• Wider use of doctor/patient email role of
  CDC/AMA
• Greater integration of shared electronic medical
  records in tracking emerging events

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Ongoing Work in U.S.and N.Z. in 2003

• Study 1 and 3 accepted for publication
• Complete manuscript on interviews with physicians
  (Study 2)
• Survey of 500 patients use of Internet over
  anthrax period (2 low socio-economic primary care
  clinics) complete manuscript (Study 4)
• Replicate physician/patient survey in NZ
  (collaborate with David Bates)

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Contact Details

• John Hobbs
• Manager
• Sector Policy Directorate
• Ministry of Health
• John_hobbs_at_moh.govt.nz