Patient e-Visit Use and Outcomes for Common Symptoms in an Integrated Health Care Delivery System

This cohort study examines whether e-visits can adequately treat patients who have medical concerns or whether follow-up care is typically still needed within 72 hours or 7 days.


Introduction
Electronic physician visits, or e-visits, use a digital virtual care platform with structured, asynchronous exchange between patients and clinicians to provide care without scheduled appointments. 1 e-Visits can be an efficient model for receiving care during pandemics such as coronavirus disease 2019 (COVID-19). 2 Through a patient portal, e-visits collect clinician-developed, internet-based questionnaires for physician management with clinical decision support tools and electronic health record (EHR) order sets. Little evidence exists on characteristics of patients using e-visits and success in managing patients' concerns. We evaluated patients' adoption and success of primary care e-visits by monitoring the 7-day follow-up care needed within an integrated health care delivery system.

Methods
This cohort study was approved by the Kaiser Permanente Northern California institutional review board, which waived the requirement for written informed consent because it is a data-only study.
This study follows the Strengthening the Reporting of Observational Studies in Epidemiology We examined adoption of newly developed e-visits between July 1 and December 31, 2019, including demographic characteristics of all patient users. We assessed e-visit success outcomes by evaluating follow-up care seeking within 72 hours and 7 days after the e-visit, including associated outpatient appointments (office, video, telephone) or emergency department (ED) visits and any secure email messages.
We used the χ 2 test to test for differences in patient characteristics across e-visit concern type. Testing was 2-tailed, and the level of statistical significance was set at P < .05. Data analysis was performed with SAS version 9.4 (SAS Institute) from January to November 2020. a Patient characteristics show demographic characteristics (extracted from the patient's electronic health record) of patients initiating an e-visit through the patient portal. We used the χ 2 test to test for differences in patient characteristics across e-visit concern type at a 2-tailed .05 level of statistical significance. b P < .001 for all differences in patient characteristics by specific e-visit concern type. c e-Visit prescribing shows e-visit concern-related prescription orders linked with the e-visit. Cough suppressants were prescribed for URI (cold, cough, or flu) e-visits, and antibiotics for pharyngitis (sore throat) and UTI.

Results
Among 21 070 total patient e-visits (Table), 17 014 (80.75%) were women, 10 728 (50.92%) were White, and they had a mean (SD) age of 36 (12.6) years. Of all e-visits, 12 986 (62%) had prescriptions ordered, with cough suppressants for 72% of URI e-visits (5660 of 7910) and antibiotics for 19% of pharyngitis e-visits (881 of 4691) and 81% of UTI e-visits (5118 of 6297) (Figure). Patient characteristics varied significantly by e-visit concern (all P < .001, Table) e-Visits took 2 to 3 minutes of physician time. No quality concerns were identified during random medical record reviews of follow-up ED visits.

Discussion
We studied the early adoption of e-visits in an integrated delivery system and found e-visit users were predominantly less than 40 years old and female. This study had some limitations. One limitation was the lack of statistical comparison with traditional physician visits. Another limitation was the inability to assess patient symptoms independent of care seeking.
e-Visits offer quick, safe patient access to virtual health care for specific conditions without needing a scheduled visit, transportation, or time off work. This study's results suggest that a predominance of e-visits delivered clinical care successfully without follow-up visits or messages.
Further research about continued adoption, especially during shifts to virtual during the COVID-19 pandemic, is needed.