Journal of the New Zealand Medical Association, 12-December-2003, Vol 116 No 1187
Is the provision of laboratory results via the Internet acceptable to patients? A survey of private patients in a large, specialist gynaecology practice
The traditional method of communicating patient laboratory results has been the telephone. Although satisfactory most of the time, it provides poor record logging of the communication and is extremely costly and time intensive. An alternative method for imparting the results was designed and this research was targeted directly to the patients in an attempt to elicit their views as to the acceptability of computer-based, Internet-mediated communication.
One of the primary uses of the Internet is to disseminate information: collecting, storing and facilitating interaction between seekers and providers of information. The health sector is an information- and technology-rich area, and the Internet presents significant opportunity for expansion and improvement in the transmission of resources and information, from both health-provider1,2 and consumer perspectives. McLeod’s prediction that the Internet would usher in ‘the next transformation in the delivery of health care’3 has already come to fruition.
The emergence of the Internet has coincided with changes within health, particularly those that challenge traditional models of health and the way they are delivered. The World Wide Web provides consumer access to web sites that post vast amounts of health information.4 This type of information has previously been inaccessible or at least extremely difficult, costly or time-consuming to gather. Patients and their relatives gain multiple benefits from Internet access, including an increased sense of control and ability to participate in decisions about their care.5 Some suggest the self-help skills fostered in patients could lead to a greatly improved and more cost-effective model for medical practitioner care.6,7
As patients are using the Internet to access information about conditions and are visiting their doctors armed with web-based articles asking for certain tests or treatments to be performed, there is no reason why the results of such and other tests could not be conveyed back to the patient via the same medium. Patients are being exposed to information overload without having the same access as doctors to peer-reviewed articles8 in preparation for consultation.
If patients find an Internet-based laboratory result facility acceptable, a doctor, in providing this service, may well enjoy the other benefits that flow on from instituting such a system. These include increased cost efficiency, as fewer staff are needed to man telephones to impart results, and a very easy logging system that ensures that patients have indeed received their results. As an Internet-based system includes automatic logging of a patient’s ‘hit’, the fact that the patient has accessed their results is recorded and patients who have not received their results are identified and are contacted by phone. The potential medicolegal benefits are considerable.
A database was designed using MS Access to accommodate all patient laboratory results in a private, specialist gynaecology practice. Fields included demographic information, a PIN number (computer generated), the actual laboratory result, an explanation of the result and a recommended course of action. Although not displayed, there was a provision for logging the web site hit to confirm that the result had been accessed.
A questionnaire was then designed and distributed to patients within the practice. The 235 respondents were a mixture of patients selected consecutively. Some were regulars who would have had the opportunity to access their results from the site previously, while others were first-time visitors to the practice and were therefore unfamiliar with the Internet-based results system. Responses were collated on an Excel spreadsheet and statistical analysis undertaken using PHStat, an Excel add-in feature.
General Internet use It was essential to determine if the respondents considered themselves Internet users. To clarify this they were asked whether they used the Internet for general matters. Of the 235 respondents, 190 (81%) classified themselves as Internet users. Respondents in their 60s were the only group who had more non-Internet users than Internet users (60% non-users). A comparatively large number of respondents in their 50s (71%) classed themselves as Internet users.
Internet-based laboratory results accessed Of the 190 respondents who considered themselves Internet users, almost 60% used the Internet to access their results. Those in their 30s and 40s made up 75% of all users of the results web site. Predictably, those in their 60s were the lowest users, making up only 5% of the general Internet users who accessed their results on the Internet.
Of the 235 respondents, 124 people (53%) did not use the Internet to access their results. Within this group, 79 people (64%) stated that they did use the Internet in general. Of the remaining 36%, the majority predictably fell in the 60s age bracket. Seventy per cent of the respondents in this age bracket stated they were not Internet users. In all other age groups the percentage of those who classed themselves as Internet users but did not use it to access their results was higher than the percentage of those who did neither.
User-friendly ratings The 111 respondents who used the site were asked to rate its user-friendliness on a scale of 1 to 5, 1 being not very user-friendly and 5 being very user-friendly. The average user-friendly rating was 4.22 (Table 1).
Table 1. User-friendliness of results web site: breakdown by age group
Future use of the Internet results site Another telling indicator of the site’s user-friendliness was whether patients would choose to use it again in the future. These results were overwhelmingly positive. Of the number who used the Internet to access their laboratory results only 13% said they would not use it again.
Security and PIN concerns Only 11% of the 235 respondents expressed concerns about security or the PIN system. To properly analyse the concerns of the respondents it is necessary to separate them into users of the Internet-based results and non-users.
Of the 111 patients who accessed the laboratory results site, the number of users with concerns about either security or the PIN system was relatively small. Only 18 people had concerns in either or both of these categories, accounting for a mere 16% of total users. The majority of these people were in their 40s.
Fifty per cent of those with security concerns would use the site again in the future. The figure for those with concerns about the PIN system was significantly higher at 88%. Of the six people who had concerns about both security and the PIN system all but one of them would use the site again in the future.
Only 7% of the 124 respondents who did not use the Internet to access their results had concerns with security or the PIN system.
Preference for receiving results While not all of the respondents stated a preference for receiving their laboratory results, a significant number (82%) did make it clear how they preferred to access this information. When analysing these data it was possible to separate those who used the Internet to access results and those who did not. The respondents had the choice of five options for receiving their results: ‘Internet’, ‘computer phone’, ‘phoning reception’, ‘receiving a copy by mail’, or ‘being phoned only if results are abnormal’.
Of those who used the Internet to access their laboratory results an overwhelming number, 73%, stated this to be their preferred method. The Internet was the highest ranked preference for accessing results in every age bracket. The next preferred method, phoning reception, received significantly less support with only 12% of Internet results users stating this as their preference. Six per cent of this group stated no preference and not one of the Internet results users stated the computer phone as their preferred method of gaining their results. Only small numbers chose the other options: copy by mail (6%) or phoned if results abnormal (3%).
Examination of the preferences of those who did not use the Internet to access their results showed that, unlike the others, this group had no clear preferred method. Those with no stated preference made up the biggest group (29%), with the other preferences fairly closely ranked. Those preferring to phone reception made up 20% of this group. Those preferring either to receive a copy by mail or access their results themselves on the Internet were just a fraction behind with these options receiving 19% support each. However, no one in this group actually accessed their results from the Internet. Being phoned with abnormal results was preferred by 10% of this group while just 3% of the respondents rated the computer phone as their first choice.
It was also important to determine the preferred method for those in the older age brackets (50s or 60s) to see if their preferences are distinct from the group as a whole. These respondents are more likely to be unfamiliar with and resistant to technology such as the results web site. For those in their 60s, once respondents who did not state a preference (51%) were taken into account, the largest group was those who preferred to receive their results by mail (22%), followed by those who would prefer to phone reception (14%). Fewer of the respondents in their 50s did not give a preference (28%). In this group the strongest preference was to phone reception (26%) followed by receiving results in the mail (21%).
The results of this research were interesting. First, it was clear that those over 60 did not use the Internet much at all for general purposes. This is hardly surprising as patients of this age are less likely to be technologically aware.
In assessing the user-friendliness of the system, it is interesting to note that older respondents (those in their 50s or 60s), found the web site less user-friendly than younger patients. Those in their 20s found the site the most user-friendly. It would make sense that younger patients, who are more comfortable in a technology-based system, would find the results interface easier to use. Therefore, it is possible to surmise that the lower user-friendly rating given the site by older users is not a reflection of the site’s ease of use as such, but more of their own level of ability when it comes to interfacing with technology of this type. It follows that the more familiar a person is with using a medium such as the Internet the less frustrating and confusing they find a particular site.
As regards using the Internet-based system in the future, it was somewhat surprising that the group with the highest number of patients responding negatively was the 20s age bracket, in which 25% said they would not use the system again. Not surprisingly, the group with the next highest figure was the 60s age bracket, in which 17% of users stated they would not use the site in the future. However, these figures are still relatively low and the fact that almost 90% of those who used the site would use it again is a good indication of its usability. It is clear that once patients take the first step and access their results on the Internet the outcome is generally positive for them and they adapt quickly to this technology and are willing to adopt it for future use. Therefore, the challenge lies in getting as many patients as possible to access their results in this manner. If all patients were to follow this trend for future use, the natural conclusion is that having accessed their results via the Internet once they will be keen to do so again.
It was expected that security matters would be of concern to many patients. This was not the case and surprisingly respondents in their 60s had the fewest concerns of anyone. This could be a reflection of the fact that members of this age group are not aware of the potential security issues that the Internet creates. It would be tempting to surmise that since this group is more wary about using the Internet-based results they would have more concerns about security and the PIN system. However, the results disagree with this and it is possible that those who are more familiar with the Internet are more knowledgeable about the potential for a security breach.
This study shows that although people may have concerns about the PIN system these are generally not of a nature serious enough to stop them using the site again. It is possible these concerns could indicate minor incidences, such as losing the system-generated number. It can, therefore, be surmised that those who expressed concerns about the security of the site were worried about significant issues and that this worry impacted on their willingness to use the site again.
In summary, it was clear that the new system of imparting laboratory results was considered an acceptable method to the patients who made use of it. Of those who used the site there was clear endorsement of its user-friendliness. This was confirmed by the high numbers of this group who stated they would use the site again in the future and further backed up by the large majority who chose the Internet as their preferred means for accessing their results. One of the major considerations when making personal medical information available over the Internet revolves around whether patients’ privacy is adequately protected. It was therefore interesting that concerns about security or the PIN number were minimal and did not seem to act as a great deterrent to use of the Internet to access results both amongst those who used the site and those who did not. As use of the Internet increases for all sorts of information dissemination it seems clear that laboratory results hosted in this manner are only going to grow in popularity with patients as they become more familiar and comfortable with the technology required to support them.
Author information: Bernie Brenner, Gynaecologist, Pelvic Floor Clinic, Milford Auckland, and Senior Teaching Fellow, Health Informatics, University of Otago
Correspondence: Dr Bernie Brenner, Pelvic Floor Clinic, Milford, Auckland. Fax (09) 486 0817; email: firstname.lastname@example.org
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