While patient portals can improve efficiency in some practices, they bring with them a host of challenges
Patient portals were intended to streamline and improve patient care. But like many technology innovations, portals have suffered from the combination of shaky initial product rollouts and user error from a population not totally sold on the concept.
The use of a patient portal requires workflow changes in a physician practice, and many doctors feel it is unfair that they must rely on the patient to log in and send a secure message to meet regulatory requirements.
The moment the patient walks out the door, physicians lose control over whether he or she uses the portal. It has been a huge obstacle for practices to meet the stage 2 requirements of the Meaningful Use program, and led to vociferous complaints about the planned stage 3 rules prior to the Centers for Medicare & Medicaid Services (CMS) announcing the end of meaningful use as it exists today.
“I have given up on the portal and qualifying for Meaningful Use,” says Timothy Leigh Rodgers, MD, a solo internist in Santa Barbara, California. “I think it is nice to have if people want to use it, but if they don’t, I don’t think I should be penalized for it.”
Rodgers has struggled to persuade his patients to use the portal for scheduling appointments or reviewing lab results. Two-thirds of his patients are older than 65, and he says they just don’t want to use the portal. Only one patient uses it regularly.
Patients reported unresponsive staff (34%) and confusing portal interfaces (33%) as the most irksome issues with portals, according to a 2014 survey of 1,540 U.S. patients by the consulting firm Software Advice. Thirty-three percent of patients were unsure if they even had access to a portal.
Physicians and staff that are seen as unresponsive damage the relationship, says Zachary Landman, MD, senior institute associate at the Harvard Business School Institute for Strategy and Competitiveness in Cambridge, Massachusetts. Previously, he was chief medical officer at DoctorBase, a consulting firm specializing in patient communications.
“If we think about why patients use any software, it has to solve some problem for them, make something easier or automate some process,” he says. The primary function of a portal typically is messaging, so the easiest way to drive behavior is be responsive, he explains. Patients take the time to create an account and send a message, and all too often that message is never returned or returned after an unacceptably long delay. “That is the easiest way to make sure that patient never uses a patient portal again,” says Landman.
Landman adds that if a practice wants to realize the full value of a portal, it has to figure out how best to triage incoming messages and respond to patients in a timely manner.
“Once [the practice] receives positive feedback, that is when it starts using [the portal] more and more and you see the engagement numbers climb,” he says.
Some practices are starting to figure this out. Wisconsin Cardiovascular Group in Milwaukee, Wisconsin went live with its portal went live in 2013, and Wisconsin Cardiovascular now is one of a small but growing number of healthcare organizations taking part in an effort called “Open Notes” that enables patients to read everything in their record, including physician notes via the portal.
Joshua Liberman, MD, FACC, a cardiologist with Wisconsin Cardiovascular says that if patients get frightening news during an appointment, often when they get home they can’t explain to their spouse or children the conversation they had with the cardiologist. “Having access to the notes from the physician saves phone calls for us with the family,” he says. For that reason, the portal is highly popular with Wisconsin Cardiosvascular’s patients.
However, Liberman practices in two settings, one urban and one rural, where the patients are mostly over the age of 70 and many do not feel comfortable using a computer. “In that setting, even though we have a wonderful system and it provides great opportunities to improve their care, my practice is going to be penalized because my patients either can’t or won’t use it,” he says.
Currently, most patients use the portal for common questions, which tend to be administrative in nature: scheduling appointments, refilling prescriptions, and office hours.
“If those requests aren’t triaged properly, and physicians start getting administrative questions, they say ‘this isn’t what I was intending to do,’ and they turn it off,” Landman says. “It becomes a vicious cycle of inadequate education for the users, who then send the wrong types of questions to the wrong provider.”
Ernie Hood, a senior research director with the Washington, D.C.-based Advisory Board Co. and the former chief information officer at Seattle-based Group Health Cooperative, is considered a pioneer in the use of patient portals. He helped Group Health develop a strategic plan around the widespread use of portals in 2000, long before they were mandatory. Today, more than 70% of its members are portal users.
Hood is often asked how to get patients to use a portal. He responds by asking what the practice is trying to accomplish with its portal. “A lot of times, that alone is revealing because the answer is ‘because I have to have one.’ Then you probably aren’t trying to use it to do anything,” he says.
But there are lots of benefits practices could be trying to realize: greater patient engagement, improving quality of care, better patient retention, higher patient satisfaction scores, and improving practice efficiency, among others.
“Figure those out first and then let those dictate which features are most important,” Hood recommends. “It is a thought exercise that a surprising number of organizations have not gone through. They just turn on a portal without a strategy, goals, or objectives.”
Landman agrees that too many practices are only responding to external mandates rather than trying to work through how a portal is going to fit into patient care and patient flow. “Not spending time thinking about how they are going to structure it, how it is going to complement their existing practice pattern or fundamentally change it is a sure-fire way to fail,” he says.
Sherilee Baxter-Randolph, MHCI, PCMH CCE, program manager for the University of Central Florida College of Medicine Regional Extension Center (REC), which was established to help the region’s practices implement their electronic health record systems, has seen lots of practices struggle with portal implementation.
Often one of the main obstacles to achieving greater portal use is the attitude of the practice’s staff. “Employees will say they don’t have time to help the patient register for the portal or they forget to mention there is a portal or forget to collect crucial pieces of information to give the patient access to the portal,” she says.
Practices should train employees on how to help patients access the portal, including designating one person to explain the portal’s value and get patients logged on while still in the office.
But Baxter-Randolph also says the REC reminds practices that patient engagement is a team effort, so everyone has to promote the portal. “We highly recommend the physician discuss using the portal [with patients] and its value,” she says. “Studies have shown people are more likely to listen to advice from their doctor.”
Gregory Reicks, MD, says that in 2011, although it had been successful in signing patients up for the portal, his two-physician Foresight Family Practice in Grand Junction, Colorado, was struggling to get patients to send secure messages. The practice decided to survey patients, and if they responded it would put them in a drawing for a gift card. That initial promotion got more than 400 entries-enough for the practice to meet Meaningful Use’s 5% threshold while also allowing patients to experience the portal for themselves.
“If we hadn’t had something like that to motivate us to get our patients to communicate back to us, I am not sure we would have gone through all those steps we did, and now we are kind of happy we did, because we can use the portal to its full potential in terms of bidirectional communications,” says Reicks.
Some physicians have expressed reservations about using the portal for anything beyond administrative purposes, because they fear spending too much time answering e-mails from patients (and not getting reimbursed for it) and that it would reduce the number of office visits. But Landman says the opposite may be true. DoctorBase found that the doctors who used the messaging function more often had more in-person patient encounters than those who did not.
E-mail access and a patient portal are huge drivers of patient satisfaction. “The physicians who take a few extra minutes at the end of every day to respond to messages grow their practices both through word of mouth and through online reviews,” Landman says. Physicians who are open to answering simple questions without dragging you into the office are thriving.”
Besides, Landman adds, the alternative to using the portal is the telephone. If patients wants to ask their questions, they can leave a voice mail. So physicians aren’t escaping those questions. Playing phone tag with patients takes much more time. “I think that is in the folk lore category: ‘My practice is going to die if I start answering e-mails,’” he says, adding that DoctorBase research showed physicians spent on average 45 minutes per week answering calls and messages after implementing a portal.
Many physicians do see the secure messaging function as a great time saver. St. Vincent’s Family Medical Center in Jacksonville, Florida, has 30 residents and 11 faculty members, and there are not enough medical assistants and nurses to make phone calls for the physicians in response to patient queries, says Robert Raspa, MD.
“If you are in an office where you are used to making your own telephone calls, the portal is amazing. I love it because I can communicate asynchronously and have it all documented in the patient record,” he says. He admits, however, that most doctors don’t make their own telephone calls, “and then the portal becomes just an extra thing to do.”
Sally Ginsburg, MD, FAAP, a pediatrician with Pioneer Valley Pediatrics, which has eight physicians and offices in Massachusetts and Connecticut, says secure messaging with parents of her patients is a big efficiency gain.
“It is a great convenience for me,” she explains. “Instead of playing phone tag trying to get back to parents, I now just respond as soon as I have time to answer the question. Parents can update family history and medications on the portal and that information gets integrated into the patient medical record, so that saves us time as well.”
Ginsburg notes, however, that there are still difficult privacy issues with portals for teenagers between 13 and 18 years old, and whether their parents have access to all their records. “Most pediatric practices have found this complicated and there is not a consensus of opinion on how to handle it,” she adds.
It is far too early to judge whether or not patient portals are a success, but questions have emerged as to whether the use of portals will have any significant impact on patient outcomes.
A 2015 review of findings by researchers at Texas State University found that 37% of papers reported improvements in medication adherence, disease awareness, self-management of disease, a decrease of office visits, and an increase in preventative medicine. In a study published in December 2015 by researchers at Kaiser Permanente, one- third of patients with chronic conditions who exchanged secure e-mails with their doctors said that these communications improved their overall health. That study is among the first to examine how the ability to exchange secure e-mails with doctors affects patient behavior, preferences and perceptions about their own healthcare.
Part of the reason many providers are not enthusiastic about portals may be that the first generation of software was built to meet a requirement rather than solve a problem. “You don’t want to think of portals and secure messaging tools as standardized. They are not all good,” says Robert Tennant, senior policy advisor with the Medical Group Management Association. “They range from reasonably good to extremely bad for both physicians and patients. Vendors are trying to make portals easy to use and secure, and that has been a challenge for the industry. But if you do find that balance, they can be extremely effective.”
The user interface and workflow design can have a huge impact on portal uptake, yet difficulty with one portal solution doesn’t spell disaster, says Michael Munger, MD, a family physician at 10-physician St. Luke’s South Primary Care in Overland Park, Kansas. When it first tried using a portal several years ago, the practice encountered problems both from the patient side and in terms of office work flow.
“Some patients who tried that portal found it too confusing to use,” Munger says. That portal was not tied into the clinician workflow, so providers had to remember to toggle to the portal screen to check for messages. In 2015, St. Luke’s South changed its EHR, and Munger said the new portal is much better integrated into the practice’s workflow, the software is much easier to use and has more features for patients, such as the ability to make online appointments and to see their lab results within 24 hours. Now the challenge is getting all the patients transferred from the old portal to the new one.
The next generation of portal software could be more customizable, with mobile apps that better fit the needs of patients and providers. Some portal vendors are looking ahead to the era of value-based care and adding features to allow for remote patient monitoring and patient-generated data in the belief that portal use will become more attractive to physicians.
“As you get compensated more for outcomes and the data that patients give you helps you isolate patients who are more in need of your care, the portal becomes critical to understanding who you should focus on,” says Raj Amin, co-founder and executive chairman at Mana Health, based in New York City. In a partnership with Texas’ Healthcare Access San Antonio, Mana’s Patient Gateway portal allows users to connect activity tracking devices such as FitBit and portable medical devices such as glucose monitors.
Amin also predicts there will be an evolution in reimbursement codes for treating patients electronically. “Right now there is no easy way to get paid for e-mailing your patients,” he says. “That is a complaint I hear from the primary care field. To support the delivery of care through email, telemedicine, or secure chats, the reimbursement codes need to be there to support that.”
Landman agrees there is huge potential for portals to help patients with behavior change to improve health.
“The more we can incorporate devices that track weight and exercise, connected glucometers, or sleep charts, the portal becomes part of chronic care maintenance or a health and wellness program,” he adds. “Behavior change and health occurs in the 99% of the time the patient is not logged in and sending a message. We are standing at the very beginning of that change.”