Increasing the use of e-consultation in primary care


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Patient provider communication using secured web-messaging.

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  • PhD-project of Nicol focuses on the implementation and performance of interactive Web-based programs for supporting self-care management of patients. Particular emphasis is laid on patients with chronic conditions.
  • Pew Internet Website:
  • The statements were based on previous studies about barriers and motivations regarding the use of e-consultation in primary care among early adopters [8–11,17–24] and referred to aspects with significant impact on e-consultation use, such as convenience, self-control, self-management of care and the use of different formats for self-control.
  • Examples of member org. : National Federation of Cancer Patients, The COPD Patient Association,the Dutch Diabetes Association, the Cardiovascular Diseases Association, the Dutch Muscular Diseases Federation,Association of Patients in Mental Health Care, the Skin Diseases Federation, the Dutch Association for Patients with Hearing Problems.
  • Probability that a difference or significant happened by chanceIs the probability that the null hypothesis is through (range 0-1) midpoint 0.05 about this point there is no significance.
  • Dependent variable is not continuous data and no normal distribution exists. The data scored from 1-5
  • Increasing the use of e-consultation in primary care

    1. 1. CATCH-IT: Increasing the use of e-consultation in primary care: Results of an online survey among non-users of e-consultation<br />NicolNijland, Julia E.W.C. van Gemert-Pijnen, Henk Boer, Michaël F. Steehouder, Erwin R. Seydel, International Journal of Medical Informatics - October 2009 (Vol. 78, Issue 10, Pages 688-703, DOI: 10.1016/j.ijmedinf.2009.06.002)<br />By: Marjan Moeinedin<br />October 26, 2009<br />
    2. 2. Article information<br />Research elements<br />Background <br />Objective<br />Method<br />Analysis<br />Results<br />Discussion<br />Conclusion<br />Questions to the authors<br />Class discussion<br />Table of Contents<br />2<br />
    3. 3. Article Information<br />
    4. 4. This study was supported by The Federation of Patients and Consumer Organizations in the Netherlands.<br />Article History: <br />Received 12 February 2009<br />Received in revised form 16 June 2009<br />Accepted 20 June 2009<br />Article history:<br />4<br />
    5. 5. NicolNijland(PHD student, 2006-010)<br />Department of Psychology and Communication of Health and Risk, Faculty of Behavioral Sciences, University of Twente, Enschede, The Netherlands.<br />First Author<br />5<br />
    6. 6. Research Elements <br />
    7. 7. In spite of the substantial increase in the use of Internet as a source for health information, the use of e-consultation remains relatively low. (Pew Internet website)<br />Potential benefits of e-consultation:<br />Increased access to care. <br />Patients can ask questions from any place and at any time <br /> Increased self-management support for individuals with significant medical problems.<br />e-consultation use can empower patients’ self-control skills and strengthen their autonomy <br /> Reduced costs while maintaining the same or achieving better quality of care. <br />e-consultation can respond to an increasing demand for care in the aging society <br />Background <br />7<br />
    8. 8. The motivations for using two types of e-consultation provided in Netherlands was investigated<br />Direct e-consultation: <br />consulting a GP through secured e-mail.<br />Indirect e-consultation: <br />consulting a GP through secured email with intervention of a Web-based triage system.<br />Background <br />8<br />
    9. 9. To identify factors that can increase the use of e-consultation among non-users: patients with access to Internet, but with no prior e-consultation experience.<br />Objective<br />9<br />
    10. 10. On-line Survey instrument<br /><ul><li>Assessed the factors that could enhance e-consultation use among Dutch primary care patients with Internet access, but no experience with e-consultation.
    11. 11. The survey was pre-tested by patients recruited through the Dutch Federation of Patients and Consumer Organizations.
    12. 12. The survey covered 7main topics and contained</li></ul> a total of 45 items.<br />Method <br />10<br />
    13. 13. Topic 1: asked whether patients had experience with e-consultation (Yes/No). <br />Topics 2–6 consisted of multiple statements, which could be answered on a 5-point scale ranging from strongly disagree (1) to strongly agree (5). <br />Topic 2 (seven statements) examined possible barriers to using e-consultation.<br />Topic 3 (ten statements) assessed patients’ demands regarding e-consultation. <br />Survey Items<br />11<br />
    14. 14. Topic 4 (seven statements) identified motivations for using e-consultation. <br />Topics 5-6 (seven statements and eight statements) assessed the motivation for using two types of e-consultation: direct e-consultation and indirect e-consultation. <br />Topic 7 questions were related to ’ socio-demographic and health-related characteristics, such as gender, age, education level, chronic use of medication, and frequency of seeing a GP.<br />Survey Items (cont’d)<br />12<br />
    15. 15. <ul><li>Primary target group for e-consultation:
    16. 16. 18 years of age and above.
    17. 17. Patients with various chronic conditions and basic Internet skills who have visited health-related websites.
    18. 18. Participants were recruited through banners on frequently visited websites of 26 well-trusted patient organizations.
    19. 19. All organizations were members of the Dutch Federation of Patients and Consumer Organizations.
    20. 20. By clicking on a banner patients were automatically linked to the online survey, which was available for a period of 11 weeks.</li></ul>Participants Recruitment<br />13<br />
    21. 21. SPSS version 13.0<br />Descriptive statistics, mean, sum of scores were computed for all constructs .<br />Internal consistency of all constructs was satisfactory <br />Cronbach’s = 0.64 to 0.84. <br />F-tests (one-way ANOVA) were used to identify significant differences between independent variables of interest. <br />Linear regression models were used to predict the dependent variable ‘motivation for using e-consultation’ (mean score of questions 4–6, Cronbach’s ˛ = .86).<br />Data analysis<br />14<br />
    22. 22. Independent predictors included: <br />barriers towards e-consultation<br />demands regarding e-consultation<br />socio-demographic and health-related characteristics<br />age, <br />education level <br />medication use<br />frequency of seeing a GP <br />Two-tailed significance was considered at the p &lt; .05 level.<br />Data analysis (cont’d)<br />15<br />
    23. 23. Study participants<br />Of the total sample (n = 1706), 1066 were eligible <br />163 patients (9.6%) had experience with e-consultation. <br />Of the remaining 1543 patients (90.4%) who had no prior e-consultation experience, only 1066 patients were eligible for the analysis. <br />Patients who had filled out only 1 question were excluded. <br />n varied since patients could skip questions.<br />Results<br />16<br />
    24. 24. Results (cont’d)<br />Table 1: Characteristics of participants<br />Highlights of Table 1: <br />(62.4%) Female<br />(70.2%) frequent GPs visitors <br />The mean age was 49 years old (SD = 13.5) <br />50% of the patients were highly educated (50.9%).<br />Highlights of table 1<br />17<br />
    25. 25. The most prominent reasons for not using e-consultation:<br /> 65% were not aware of the existence of e-consultation services<br />56% preferred to see a doctor<br />53% had limited access to e-consultation services, because their GP did not provide e-consultation <br />Computer or Internet skills were not expected to be a problem <br />66.1% did not know whether the use of e-consultation is refunded by their insurer<br />Results: Barriers towards e-consultation<br />18<br />
    26. 26. Barriers towards e-consultation (%)<br />19<br />
    27. 27. The top priority regarding demands for e-consultation:<br />98% agreed on getting a quick response <br />63.9 % agreed that it was important for their GP to answer their question<br />all other demands were almost equally important to the patients<br />Results: Demands regarding e-consultation<br />20<br />
    28. 28. Demands regarding e-consultation (%) <br />21<br />
    29. 29. Patients were fairly willing to use e-consultation:<br />92% to have the ability to contact a GP regardless of time <br />81.3% to have the ability to contact a GP regardless of place<br />86.3% to have the possibility to formulate questions undisturbed<br />Results: Motivations for using e-consultation<br />22<br />
    30. 30. Motivations for using e-consultation in general (%)<br />23<br />
    31. 31. <ul><li>Participants were asked about two types of e-consultation provided in Netherlands:
    32. 32. Direct - consulting a GP through secured email
    33. 33. In-direct – consulting a GP through secured e-mail with intervention of a triage mechanism for advice on whether it is necessary to see a doctor and for self-care advice</li></ul>Results: Motivations for using e-consultation<br />24<br />
    34. 34. motivations for using direct e-consultation:<br />88.2% the possibility to ask additional questions after a visit to the doctor<br />78.4% the possibility to ask questions about medication use<br />55.5% Getting advice on how to handle a health problem<br /> 45.9% asking questions about the costs and payment of treatments <br />The last two points were less of a motivation to use e-consultation. <br />Results: Motivations for using e-consultation<br />25<br />
    35. 35. Motivations for using direct e-consultation (%)<br />26<br />
    36. 36. motivations for using indirect e-consultation:<br />Agreement on the statements was fairly high overall <br />87.8 % to decide if a visit to the GP was necessary<br />83.7% to get self-care advice<br />80.3% to reduce uncertainty<br />47% to ask questions anonymously <br />41% felt no need for anonymous inquiries<br />Results: Motivations for using e-consultation<br />27<br />
    37. 37. Motivations for using indirect e-consultation (%)<br />28<br />
    38. 38. <ul><li>Regression analysis showed
    39. 39. high correlation between demands for using e-consultation and patients’ characteristics
    40. 40. The motivation for using e-consultation increased
    41. 41. as more demands were satisfied such as getting a timely response
    42. 42. Of all patient characteristics
    43. 43. education level and age were the strongest predictors of the motivations for using e-consultation
    44. 44. The less-educated and elderly patients seemed more strongly motivated to use the service than the more highly educated and younger patients</li></ul>Results: Main drivers for e-consultation<br />29<br />
    45. 45. Bivariate correlations and regression analyses: predictors associated with ‘motivations for using e-consultation<br />30<br />
    46. 46. Distinct patient groups were compared regarding<br /> age<br />education level<br />chronic use of medication<br />frequency of GP visits<br />Focus was on the patient groups that<br /> have a greater change of being left behind<br />could benefit from e-consultation because of their increasing demand for care<br />Results: Comparison of patient groups on barriers,demands and motivations regarding e-consultation<br />31<br />
    47. 47. Distinguished patient groups (n = 1066)<br />32<br />
    48. 48. <ul><li>Elderly patients appeared to have
    49. 49. lower Internet skills
    50. 50. greater concerns about the costs of using e-consultation
    51. 51. Less-educated patients
    52. 52. were less aware of the existence of e-consultation services
    53. 53. had lower Internet skills
    54. 54. had more doubts about the reliability and privacy of information
    55. 55. Face-to-face contact was
    56. 56. preferred more strongly by the chronic medication users
    57. 57. The frequent GP visitors had
    58. 58. stronger preference to visit a doctor</li></ul>Results: Comparison of patient groups on perceived barriers towards e-consultation<br />33<br />
    59. 59. Comparison of patient groups on perceived barriers towards e-consultation<br />34<br />
    60. 60. <ul><li>the target patient group (with no e-consultation experience) had a greater e-consultation demands than other groups
    61. 61. The elderly patients
    62. 62. had stronger demands, to obtain evidence-based answers from their caregivers
    63. 63. The less-educated patients preferred
    64. 64. to receive instructions about e-consultation use
    65. 65. to receive information about the possibilities and restrictions of e-consultation
    66. 66. to use e-consultation free of charge
    67. 67. The chronic medication users had a greater desire
    68. 68. to obtain an answer from their own GP
    69. 69. to have their e-consultation stored in their medical record
    70. 70. Frequent GP visitors preferred
    71. 71. To be informed about the possibilities and restrictions of e-consultation</li></ul>Results: Comparison of patient groups on demands regarding e-consultation<br />35<br />
    72. 72. Comparison of patient groups on demands regarding e-consultation<br />36<br />
    73. 73. Significant differences were found between the patient groups’ motivation to use e-consultation.<br />The elderly patients, the less-educated patients’ and the chronic medication users were significantly more motivated to use e-consultation than their counterparts.<br />Results: Comparison of patient groups on motivations to use e-consultation<br />37<br />
    74. 74. Comparison of patient groups on motivations to use e-consultation in general<br />38<br />
    75. 75. The results on direct e-consultation showed<br />elderly and less-educated patients were significantly more motivated<br />e-consultation enabled them to ask questions about the costs and payment of a treatment<br />to seek advice about certain health problems<br />The chronic medication users were also more motivated to use e-consultation, especially to pass on their medical data<br />Results: Comparison of patient groups on motivations to use direct e-consultation<br />39<br />
    76. 76. Comparison of patient groups on motivations to use direct e-consultation<br />40<br />
    77. 77. The results on indirect e-consultation indicated that<br />the less-educated patients were more motivated than the more highly educated patients to use a Web-based triage application, especially for uncertainty reduction.<br />Results: Comparison of patient groups on motivations to use indirect e-consultation<br />41<br />
    78. 78. Comparison of patient groups on motivations to use indirect e-consultation<br />42<br />
    79. 79. The results of the study showed <br />that 70% of the study population, patients with no e-consultation experience (n = 1066), were frequent GP visitors<br />e-consultation may be especially beneficial for these patients with a higher demand for care <br /> it can help them decide whether it is necessary to see a doctor and teach them self-care techniques in order to prevent unnecessary encounters <br />The most prominent barriers towards e-consultation were: <br />unawareness of the existence of e-consultation<br />e-consultation not being provided by a GP <br />the preference to see a doctor<br />Discussion<br />43<br />
    80. 80. Education and examination of user expectations can provide a solution for these barriers, for both patients and caregivers alike.<br />Patients are dependent on a GPs’ provision of e-consultation. Therefore, it is important to advise caregivers on the mutual benefits of e-consultation, its consequences and implementation into regular practice.<br />It is also important for GPs to ask their patients about e-consultation since patients are unlikely to request electronic GP access, simply because they are unaware of the option.<br />Also, non-users of e-consultation may have no clear ideas or assumptions about the benefits and disadvantages of e-consultation.<br />Discussion (cont’d)<br />44<br />
    81. 81. The results demonstrated that<br /> non-users were fairly motivated to use e-consultation, but only under certain conditions<br />certain patient groups, such as less-educated patients, elderly patients and chronic users of medication were especially motivated to use e-consultation but also perceived many barriers towards e-consultation <br />The elderly patients, perceived a stronger lack of Internet skills than younger patients<br />the less-educated patients were less aware of the existence of e-consultation than the more highly educated patients<br />Discussion (cont’d)<br />45<br />
    82. 82. Non-users might have a limited view on the possibilities of e-consultation for self-care.<br />Future research could focus on the motivations of early adopters in comparison to the motivations of non-users.<br />Another did not reflect on motivations, demands and barriers of patients without access to a computer or Internet or patients with GPs without e-consultation services. <br />The study was directed solely at Internet users, because this population had the potential to use e-consultation in the near future<br />Limitations of this study<br />46<br />
    83. 83. Increase in use of e-consultation will occur through solving existing barriers among non-users and through addressing patients’ demands, preferences and skills when developing e-consultation systems.<br />Patient profiles should be taken into account.<br />Special attention should be paid to patients who can benefit the most from e-consultation.<br />In a patient centered healthcare system, it is expected that patient expectations and demands will be a major force in driving the use of electronic communication.<br />Conclusions<br />47<br />
    84. 84. Nicol Nijland, Julia E.W.C. van Gemert-Pijnen, Henk Boer, Michaël F. Steehouder, Erwin R. Seydel, International Journal of Medical Informatics - October 2009 (Vol. 78, Issue 10, Pages 688-703, DOI: 10.1016/j.ijmedinf.2009.06.002)<br />Reference<br />48<br />
    85. 85. There was no mentioning of REB in the paper. Was there a need for obtaining patients informed consent in an online survey study?<br />How was the survey developed? Was it validated? Authors did not comment on the development and validation of the online survey. <br />How did the authors handle incomplete questioners? <br />How did the authors handle duplicated surveys? Was there a method to prevent that? <br />Was it beneficial to do a comparisons between the excluded patients and included patients in the study?<br />Why should a patient use e-consultation if a telehealth service exists? <br />Reported sample size in tables and graphs revealed that between 200-300 out of 1066 patients skipped at least one question. Could this large number of missing values severely biased the statistical results? How did authors account for that? <br />Questions for the authors<br />49<br />
    86. 86. Class discussion<br />50<br />
    87. 87. Thank you<br />51<br />