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Patient-Centered Care in Dermatology: An Online System That Provides Accessible and Appropriate Information to Guide Patients’ Decision Making
Günther F. L. Hofbauer, MD;
Rachel P. Neuhaus Bühler, BA;
Lars E. French, MD;
Maria Brockes, MD;
Eberhard Scheuer, PhD
Arch Dermatol. 2008;144(9):1225-1227.
Health care is traditionally structured around the conventional office consultation. Complaints about this system include insufficient counseling on management options and insufficient attention to patient concerns and beliefs.1 In addition, patients frequently cannot remember the basic structure of their care plan.2 A patient-centered access model has been suggested to improve availability, appropriateness, preference, and timeliness.3
The University Hospital Zürich in Switzerland has offered an Internet-based question-answering service to the general public free of charge since 1999 (https://www2.onlineberatung.usz.ch/question/faq.aspx?qst_cat_id=17). While most inquiries are answered by a general practitioner, some are referred to specialists, dermatologists being the most requested specialists, which suggests that our specialty is in generally high demand.
Methods
From 2000 to 2005, 16 106 questions were submitted to the University Hospital Zürich Internet-based question-answering service. Of these, 937 questions from 648 online questioners (hereinafter called contacts) concerned dermatology (5.8%). A Web link to an Internet-based questionnaire was e-mailed to these dermatology contacts. Institutional review board approval was obtained for the study.
Results
A total of 175 contacts returned the questionnaire (27%). The mean age of contacts was 35 years; 38% were male, 62% female. The countries of residence included Switzerland, 95.6%; Germany, 2.7%; and France, 0.5%. A general physician answered 75% of questions, while a board-certified dermatologist answered 25%.
The differences in distribution of International Statistical Classification of Diseases, 10th Revision (ICD-10), diagnoses were significant within the online contacts as well as within dermatology department outpatients (Figure 1). Both populations differed significantly in diagnosis distribution (except for L50-L54, ie, urticaria and erythema). Inflammatory skin diseases (L20-L30) were most frequent among outpatients, while skin appendage disorders (L60-L75) were most frequent among online contacts (Figure 1). Average online contact age differed significantly: 30 years for infections of the skin and subcutaneous tissue (L00-L08) and disorders of skin appendages (L60-L75) and 43 years for papulosquamous skin disorders (L40-45) (data not shown).
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Figure 1. Distribution of diagnoses according to International Statistical Classification of Diseases, 10th Revision (ICD-10), code within the patient population of the outpatient clinic of the Department of Dermatology (gray bars) (n = 18 928 patients in 2004) and the contact population of the ehealth online consultants of the University Hospital Zürich (black bars) (n = 937 dermatological questions out of 16 106 total contacts). Sex distribution was 49% male and 51% female at the Dermatology Department, and 38% male and 62% female within the online contact population. The distribution is significantly different between the 2 populations (P < .001 by the  2 test). Within the outpatient population, inflammatory skin diseases such as dermatitis (L20-L30) were most frequent. Within online contacts, skin appendage diseases (L60-L75) were the most common.
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For 53% of contacts, online contact was their first physician experience. For 71%, their question was answered "mostly" or "very much." Ninety-three percent of contacts understood the answers "mostly" or "very much." New information was provided to 46%. Fifty-seven percent of contacts considered the reply "mostly" or "very much" helpful, and 34% ultimately saw a physician. Twenty-nine percent of contacts felt that the reply substituted for an office consultation.
Online contacts usually did not intend to have an office consultation at the time of question submission (Figure 2). Answers recommended consultation to 61 of 106 contacts who did not originally intend going to an office visit and to 229 of 438 contacts who did have such intention. Impact was small in the positive intention group: 48 of 61 who received positive recommendations and 31 of 43 who received negative recommendations still intended to visit a physician. Actual reported visits were far below the stated intentions in all groups: 20% of all patients who maintained their intention to visit a physician actually visited one.
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Figure 2. Intentions to consult a physician and outcomes for persons using the online question-answering service (hereinafter called contacts). Of the 544 contacts, 106 voiced an intention to seek consultation, and 438 did not intend to seek a regular consultation with a physician when submitting their inquiry to the online consulting physician (dark green box). The online consulting physician recommended a regular visit in 61 and 229 inquiries, respectively, and did not recommend a regular physician visit in 43 and 196 inquiries, respectively (red box). Resulting intention is shown in the light green box. Follow-up revealed low actual frequency of regular physician visits in this online contact group overall (blue box). However, recommendation to visit seemed to sway a previous intention not to visit a physician, while recommendation against a visit lowered the rate of actual physician visits. Numbers provided are absolute numbers except for percentages of actual visits over intention stated last, which are individually labeled with a percent sign.
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However, impact was pronounced in the negative intention group: 55 of 229 who received positive recommendations and 6 of 196 who received negative recommendations subsequently intended to visit a physician. Actual reported visits were far below stated intentions in all groups. However, a change of mind in the intention group lowered the consultation rate. A recommendation to consult in the negative intention group increased the consultation rate (Figure 2).
Comment
The persons making use of our online question-answering service differed from our outpatients: they were younger, more likely female, and had different ICD-10 diagnosis codes. Published studies report a similarly skewed population with higher income and education associated with Internet use for health information.4
Patient-centered access requires availability, appropriateness, preference, and timeliness.3 For half of our contacts, we were their first physician contact, indicating high availability. Most of our answers were judged to provide new information and to be comprehensible, helpful, and complete, indicating appropriateness. Contacts in need of consultation were identified, thus addressing preference. In summary, our online question-answering service delivers major components required for patient-centered access to health care with high contact satisfaction.3
Internet use for health care information is widespread, but its contribution to patient-centered access is unclear.5 Our recommendations affected intended and actual office visits. The larger portion of our contacts, those who originally did not intend visiting a physician for consultation, responded to our recommendations with increased consultations.
In summary, online contacts report high rates of satisfaction as well as changes in intended and actual office visits following online recommendation. Our online question-answering service seems to bridge the gap between self-help and a conventional office visit. The appropriateness and cost-efficiency of our recommendations were not verified and will have to be assessed in further studies.
AUTHOR INFORMATION
Correspondence: Dr Hofbauer, Dermatology Department, University Hospital, Gloriastrasse 31, 8091 Zürich, Switzerland (hofbauer{at}usz.ch).
Author Contributions: Study concept and design: Hofbauer and Brockes. Acquisition of data: Neuhaus Bühler, Brockes, and Scheuer. Analysis and interpretation of data: Neuhaus Bühler, French, and Brockes. Drafting of the manuscript: Hofbauer and Neuhaus Bühler. Critical revision of the manuscript for important intellectual content: Neuhaus Bühler, French, Brockes, and Scheuer. Statistical analysis: Neuhaus Bühler and Scheuer. Obtained funding: Neuhaus Bühler. Administrative, technical, and material support: Neuhaus Bühler and Brockes. Study supervision: Hofbauer, Neuhaus Bühler, French, and Brockes.
Financial Disclosure: None reported.
Funding/Support: This study was supported by the Department of Online Health and the Department of Dermatology, University Hospital Zürich.
Additional Contributions: Günter Burg, MD, provided help and support with this project.
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