A team of Dutch scientists has conducted a review of published studies that looked at how electronic communication between doctors and patients -- like email or messaging through a patient-facing EHR portal -- affects care outcomes, health behavior, and patient satisfaction. In the paper, recently published in the Journal of Medical Internet Research, researchers looked particularly at studies focused on chronically ill patients.

"Asynchronous communication is used by patients and it helps to increase the effects on health behavior and health outcomes, at least for some," authors Catharina Carolina de Jong, Wynand JG Ros, and Guus Schrijvers wrote. "Patients seem to be interested in using email and understand how to use it. They use email for questions about biomedical concerns, medication, and test results, as well as to inform the providers about non-urgent health issues. They tend to prefer email to telephone for this communication."

Out of 385 candidate studies, researchers selected 15 that met their criteria for the review. The studies were conducted around the world, though most were in the United States, and studied a range of diseases, including unspecified chronic illnesses, chronic pain, diabetes, asthma, chronic obstructive pulmonary disease, chronic neurological conditions, and congestive heart failure. Only one study was a randomized control trial.

Researchers found that the studies that had been conducted had different outcome measures, which they divided into health behaviors, health outcomes, and patient satisfaction.

Seven of the 15 studies reported an effect on health behaviors, but the effect wasn't always significant. Only two studies reported a decrease in clinic visits due to the availability of communication tools, and neither of those decreases were statistically significant. Better results for health behavior were in the areas of self-care and adherence to therapies, which improved in four studies including one on back pain and one on heart disease.

Twelve of the studies reported an effect on health outcomes, including a decrease in symptoms. For instance, four studies looked at diabetes, and all four reported a drop in HbA1c levels.

The researchers also included psychosocial outcomes in the category of health outcomes.

"In one study, personal well-being increased for both intervention groups (interactive and information only) in comparison to the control group with usual care," the authors wrote. "[Another study] showed improvement in quality of life for asthma patients. An increased acceptance of the illness was also shown, as well as increased self-esteem, empowerment, and social support ... Patients seemed to feel better when they had an Internet-based connection with their providers."

Only one study tracked satisfaction with overall care, and found that it improved.

The most important question to look at going forward, the authors concluded, is whether outcomes are due to particular facets of communication, or whether the connection itself is enough to improve care.

"Does having the connection at your fingertips give a reassuring feeling?"  the authors ask in their conclusion. "Does sitting down and logging on to the connection feel like the first step in self-management and being assertive about your needs? Some results on health behavior may point in this direction. The two studies that used an intense (with an online coach) and a less intense intervention (without an online coach) show that a less intense intervention is just as effective. This again raises the question of whether the connection alone is enough to improve health behavior, or whether a more complex intervention is necessary to gain an effect."