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Video visits, patient portals and other tech tools are helping to bridge the gap between physicians and their patients.
On the Friday evening of Labor Day weekend, Mark Collins, MD, was notified that a patient had been unexpectedly hospitalized for worsening dementia and congestive heart failure. It soon became clear that the patient would require home health services after being discharged.
Normally, finding a hospital bed and arranging for its delivery and the necessary home support services would take several days, even without an intervening holiday. But working through his practice’s electronic health record (EHR) and its patient portal, Collins was able to coordinate with the patient’s wife and his practice’s care coordinator to find a home hospital bed and be ready for the patient to return home the following Tuesday.
“Even three years ago, that type of coordinated care would never have happened,” says Collins, a family practitioner with Novant Health in suburban Charlotte, North Carolina. “To be able to coordinate the bed, home health services, and lab results among the hospital, family members, and care coordinators to get him out of the hospital earlier, that was a big win for him and his family.”
Collins’ experience is one example of the value new forms of communication technology are bringing to primary care physicians and their patients. Patient portals give patients 24/7 access to information such as lab results and diagnostic tests and allow them to review medication lists and request prescription refills. They also enable secure e-mail communication with doctors, representing the most common form of the new technologies. That’s due in part to physicians having to use them to attest to meaningful use stage 2.
But other forms of technology, such as telehealth, are making rapid inroads into the nation’s healthcare delivery system. And just over the horizon is the expected widespread use of remote monitoring devices and their ability to gather and transmit large quantities of real-time health data to physicians’ offices.
As with any new form of technology, however, the new communication and diagnostic tools have costs associated with them, ranging from patients misunderstanding results of lab tests to physician fears of e-mail encroaching on their free time to the possibility that they will lead to less of the all-important face-to-face contact between doctors and their patients.
Next: Patient education
Physicians and healthcare systems face the challenge of making patients aware of these new tools, and educating them in their use.
A recent survey by the website technologyadvice.com found that just under 50% of patients knew that their doctor offers a patient portal, 40% didn’t know if their doctor did or did not offer it, and 11% knew for certain that their doctor did not offer a portal.
Among patients who know about and use portals, enthusiasm for them generally is strong. “We found out early on that patients were hungry for the kind of interaction with providers that portals give them,” says R. Henry Capps, MD, senior vice president and chief medical information officer at Novant.
When Novant introduced its MyChart portal it thought the service would appeal most to mothers of young children, who would use it to schedule appointments and request prescription refills online. “What we didn’t anticipate were the large numbers of 50-to-70-year-olds who thought this was just the coolest thing since sliced bread,” Capps says. Novant currently receives 55,000 e-mails per month to its 400 primary care practices.
Novant rolled out MyChart via its Epic EHR system in 2011, at first using it just for e-mails. Subsequently it added other features, such as online appointments, open scheduling and, most recently, e-check in, which allows patients to update clinical and nonclinical information in their records before coming in for an appointment. In all, 360,000 patients, or about one-third of patients seen in an ambulatory setting, have used the portal in some form, Capps says.
Collins says about 40% of his patients use the portal. “It’s been a great tool,” he says. “My patients ranging from teenagers to people in their 90s are on the MyChart account. They use it for asking follow-up questions after a visit, getting lab results, checking prescriptions, and numerous other things.”
An unexpected benefit of the portal, says Capps, has been a reduction in the number of phone calls to Novant’s primary care practices. That, in turn, has made it easier for patients who prefer telephone communication to reach their physicians’ office. “It helps even the patients who aren’t using the portal have a better experience,” he says.
Next: Adjusting practice workflow
In common with many physicians, Collins was concerned that a patient portal would bring with it a flood of e-mails to which he would have to respond during evenings and weekends.
So far that has not happened, in part because the practice tells patients that doctors will respond to non-emergent messages received through the portal during weekday business hours. Collins notes that “telephone tag” was also time-consuming, and often meant patients had to wait days to get lab results or a question answered.
Moreover, telephone messages from patients generally would go first to a nurse, who would then relay them to the doctor, opening the possibility of misunderstanding or miscommunication. “Now it’s a much quicker response, and eliminates the need for third-party interpretation of the message because it’s coming directly to me,” he says. “That makes us much more efficient.”
Most patient portals now include a system for routing incoming e-mails so that they can be handled by the appropriate staff member, says John Sharp, MSSA, FHIMSS, senior manager, information systems for the Health Information Management Systems Society. “If you prioritize which messages should go to whom in the office, then it can be pretty much the way you now handle phone calls, and not be an undue burden on physicians,” he says.
Another possible drawback of patient portals is that patients will misunderstand their lab results or outcome of a diagnostic test. It’s a problem that Mark Friedberg, MD, MPP, a Boston-area internist and senior natural scientist with the Rand Corp. has encountered.
“My patients can see their lab results, but the way the results are displayed would only make sense to a doctor,” he says. “Every result is there, and every abnormality, no matter how minor, is flagged. And that can cause a lot of anxiety, even though an experienced healthcare professional would look at it and say everything’s fine.”
Novant encourages physicians to append a personal message to a patient’s lab results before releasing them. “Patients basically just want to know they’re going to be OK,” says Capps. “They want to hear directly from their doctor what those labs mean. It really helps to build trust between the patient and physician,” he says.
Along with e-mailing, Novant’s portal gives patients the option to conduct an “e-visit”-filling out a structured data questionnaire for treatment of some simple, noncomplex complaints, similar to what a patient might seek treatment for at an urgent care center. Unlike e-mails, which are free, e-visits come with a charge-less than $50-that is usually covered by the patient’s insurance.
Collins says that e-visit questionnaires submitted to his practice are routed to a designated inbox, from where a nurse assigns it to whoever is available to respond the fastest. The provider can contact the patient via the portal with any follow-up questions and prescribe a treatment and follow-up plan. The questionnaires also contain “hard stops”-symptoms such as blood in the urine or shortness of breath-that generate a message saying the patient should be seen that day.
“It’s been a huge patient satisfier from the standpoint of not having to leave work or arrange for child care,” Collins says.
Next: Diagnosing from a distance
Video visits offer physicians another form of technology for extending their reach and improving communication with patients, although its potential is somewhat limited by laws prohibiting doctors from practicing across state lines. Changing those laws is an important priority for the American Academy of Family Physicians, says academy president Reid Blackwelder, MD, FAAFP.
“We are very much in favor of telehealth for established patients,” he says. “Adding this service makes perfect sense for treating patients a doctor already knows.” (See sidebar, “States to consider interstate licensing agreement.”)
Novant has had video visit technology in its primary care practices for about a year. Thus far, however, patients have used video far less than e-visits, a preference Capps attributes to convenience. “Patients like the fact that there’s no appointment [with e-visits]. They don’t have to stop their day to interact with a healthcare provider.”
The ability to communicate with, and possibly diagnose, patients from a distance does carry risks, experts warn-including the possibility of losing the insights that can only be gained through face-to-face communication.
“The patient might be coming in for a blood pressure visit, but if you’re an astute clinician and have a strong relationship with the patient, you could find you’re getting into other issues because the patient trusts you,” says Friedberg. “It’s the ‘oh, doctor, one more thing’ scenario that a lot of doctors love, because often it’s the most important thing.”
“There are nuances in communication that technology can’t capture in the same way [as face-to-face visits,]” says Blackwelder. “I think we have to be careful that we don’t allow technology to take the place of relationships, but rather to augment them and allow us to provide the right care in the right place at the right time. We have to be careful that we don’t let the pendulum swing so far that everything starts being remote.”