The Internet Leads to Greater Patient Participation and Self-Management

The use of asynchronous, or nonconcurrent, Internet-based communication in healthcare is likely an important tool to increase patient participation and self-management, according to results of a recent literature review [J Med Internet Res. 2014;16:e19].

Evidence has shown that when patients participate in their own healthcare, adherence and health outcomes are improved. Believing an important focus of healthcare research should be evidence-based ways of improving self-management by patient participation, Catharina Carolina de Jong, MSN, University Medical Center Utrecht, Utrecht, Netherlands, and colleagues conducted a literature review to evaluate the effect of digital asynchronous communication (eg, email, discussion boards) between chronically ill patients and healthcare providers.

The researchers sought to answer 2 questions:

• Do patients and providers actually use this form of interactive communication and how do they evaluate the usability?

• Does this form of interactive communication have an effect on health behavior, health outcomes, and patient satisfaction?

The researchers used the PICO (population, intervention, comparison, and outcome) method and searched the PubMed and Embase databases, using the National Institute for Health and Clinical Excellence criteria to assess quality. Their search yielded 385 studies, of which 15 met the inclusion criteria. Most of the studies (n=11) were conducted in the United States; the mean age of the patients in 13 of the 15 studies ranged from 50 years of age to >60 years of age. Patients accessed a Web site where they logged onto a patient portal and were able to communicate asynchronously with their provider via email, view their electronic health record (EHR), or use a discussion board.

Use and Usability

Results showed patients accessed their EHR between 1.5 and 16 times a month, with frequency declining after 12 months. The sections of the EHR most reviewed by patients were clinical notes and laboratory results. Other findings showed a large majority of patients (range, 76%-100%) used email.

The most common topics discussed were nutrition, complications of diabetes, exercise, and other issues related to diabetes management.

Email was used most frequently for the following purposes:

• Scheduling appointments

• Acquiring medication refills

• Asking questions about medication

• Getting test results

• Reporting “feeling ill”

• Obtaining assistance in interpreting test results

Overall, patients felt positive about the usability of email. One study showed that 85% of patients preferred email to the telephone, using the telephone mainly for urgent messages. Almost half of the patients in 1 study reported they were willing to pay to be able to correspond online with their physicians.

Effects on Health Behavior

Seven of the 15 studies reported results on how asynchronous communication affected health behavior with regard to knowledge, healthcare utilization, and self-efficacy/self-management. One study of women with chronic illness living in a rural area showed an increase in knowledge. Healthcare utilization (eg, visits to physicians) decreased, although not significantly, among patients experiencing back pain and patients with asthma. Patients’ self-efficacy appeared to increase in cases of pain management with the use of Internet-based interventions, specifically, in using nonmedical techniques, self-care orientation in back pain, and managing dyspnea. General adherence to therapy increased for patients with congestive heart failure because of the sharing of EHRs.

Effects on Health Outcomes

The effects of Internet-based support on health outcomes, particularly clinical and physical symptoms, psychosocial outcomes, and satisfaction, were reported in 12 of the studies. Outcomes for clinical symptoms in studies of patients with diabetes showed improvements in glycated hemoglobin level, weight, cholesterol, high-density lipoproteins, and blood pressure. A study of patients with asthma showed an improvement in forced expiratory volume and asthma control. Patients with back pain and patients with multiple sclerosis experienced decreases in pain and fatigue-impact, respectively. Psychosocial outcomes were also improved, including quality of life, self-esteem, empowerment, and social support; whereas, feelings of stress, depression, and loneliness decreased.

Study Conclusions

“Using asynchronous communication between patient and provider is an interesting option,” said Dr. de Jong in an interview with First Report Managed Care. “[First,] healthcare may become more tailor-made as patients are able to communicate their specific, relevant experiences at times that are convenient for them. Secondly, it can be an effective form of delivery as it saves traveling time for the patient and consultation time for standard appointments. This form of communication, where the provider can be 'present' without needing to take action unless the patient takes initiative, deserves attention in its own right, and not as a part of an intervention."

More research is needed to determine the technical characteristics of effective asynchronous communication with patients for specific disease categories where specific health behaviors are required, according to the researchers. Additional research is needed to clarify what patients want to discuss with their providers and how shared decision-making about these issues can be effective. Finally, based on the results of this review, further study on Internet interventions as a substitute for usual care is advised.