Methods
The quality improvement (QI) method chosen was the Plan-Do-Study-Act (PDSA)(1) method. The PDSA involves a series of iterations in which a QI plan is put together and executed, following which the results are studied, and further actions are taken based on those results. In a series of quick iterations — in our case, one week at a time — the plan is refined, and the process is repeated until an end point where the goals are achieved. We started with one physician’s office and then expanded it to the entire organization when we felt confident that the results were replicable across the organization.
At each visit, patients who did not have a portal account were educated on how the portal works. They were given QR codes to sign up for the portal account and paper printouts of how the portal works. Staff education also was provided on how to assist patients with sign-up and portal functions. We also asked patients and the front office staff what they perceived as barriers to setting up a patient portal.
Key performance indicators were designed to measure progress. We measured the number of patients signing up weekly for the portal the month before the QI project was started, then the weekly numbers signing up in the month after the QI was started. For the same period, we also compared the number of messages (e.g., appointment requests, refills, other messages) coming through the portal and the number of phone calls received (Figure 1). We also asked for and received feedback from the staff and patients about their satisfaction with the QI project.
At the end of each week, the QI team would debrief and adjust the plan, and a new cycle would start. At the end of the fourth week, it was felt that the model was working well enough that it could be applied organization wide.
Figure 1. Key performance indicators for 2023 and 2024.
Discussion
The personal health record (PHR) is a component of the EHR that is managed by the patient or their caregiver.(2) It contains the office notes, past medical and surgical history, lab results, diagnoses, immunizations, past and current medications, allergies, insurance information, and contact information of medical professionals taking care of the patient, as well as other information. When used properly, it makes the patient an integral part of keeping an accurate medical record. It also has the potential to improve communication between patients and healthcare providers, as we set out to show in our QI project.
Any change to the office workflow must be approached cautiously. It can disrupt operations, lead to revenue loss, lead to loss of staff, or, in our case, even lead to the loss of patients. The PDSA technique allows you to plan proactively for the change with iterations of planning, implementation, reevaluation, and further implementation. It can be done in small increments and in a controlled setting before it is adopted organization-wide. Specific to our project, we learned valuable lessons that we could use organization-wide going forward.
Getting patients and staff to make the conversion to the patient portal for communication involves changing long-entrenched habits and constant education. This can be tedious initially, but once it is adopted, we find that most patients and staff enjoy the product. The reluctance to sign up stems from ignorance of the benefits of the portal, on the part of both healthcare staff and patients.
The portal is not a good vehicle for emergency communication, and patients must be educated on that fact. It does not work well for patients needing same-day appointments on short notice (e.g., the mother who gets called to pick up a child with a fever from school or daycare). A warning about this must be shown when a patient accesses the portal. We found that some patients send messages well after work hours with the impression that the portal is being constantly monitored.
There is also the question of where do the messages go initially? To the receptionist for triage, or to a nurse or physician? We found that this is specific to the needs of each department, and we allowed each physician to customize it. In the future we hope that artificial intelligence will be able to direct those messages to the appropriate personnel (e.g., appointment requests to the receptionist and medication refill to the nurse or physician).
Giving patients access to a portal must be done with caution. It is quite easy to confuse patients with similar names and grant access to the wrong patient account. This is a HIPAA violation.(3) Patients who previously consented to share access with, for example, a spouse can revoke that access, and the account must be updated. If the patient forgets or is unaware that access is still given, the proxy account holder can still view those records.
Malicious actors such as lawyers or ex-spouses who possess identifying demographic information can pose as legitimate agents and try to gain access to records. Verifying the identity of the account owner is critical. In some cases, even parents of young adults may seek to gain access to the records, with good intentions, but it is still a HIPAA violation to allow them to do so.
Pediatric patients — that is, those under the age of 18 years — present a special challenge. They are minors, and the parent can control those accounts, but once they reach 18 years of age, the account is switched over to the patient. Proxy family accounts can be created where all the children are listed under a parent.
There are also language barriers to portal use. Our portal offered English and Spanish (the latter does not translate into English), but nothing else. In one instance, a native Spanish speaker kept sending messages in Spanish and we had to get a translator. With the rise in the use of artificial intelligence, perhaps future versions of the software will use translation services to offer other languages. This will greatly help physicians communicate with their patients who are not proficient in English.
The best time to have patients sign up is when they are in the office. After they leave, there is a sharp drop off in sign-ups. It is also easier to verify patient identity when they are physically present, because in many cases these are people well known to the staff. Staff also can help with any technical glitches. The problem with this is that it takes time away from staff and also adds to the patients’ time in the office — but the process is quite automated, and we were able to work this into the workflow. (This added workload, we found, made it easy to relegate the portal sign-up to the back seat, however.) Unlike social media, patient portals do not garner interest on a daily basis. Portals are used intermittently, when one needs to access the healthcare system, so relative interest is much less, generally, and patients often forget to sign up, or they may have technical difficulties setting up the account once they leave the healthcare setting and then give up.
Not everyone will be able to sign up for a PHR portal account. There are older patients who struggle with technology or just don’t have smartphones and Internet access to make it possible (a workaround to this problem is to create a proxy account with a responsible adult who cares for that elderly person). Pediatric patients in temporary foster care may not be candidates for the portal because of the logistics of who they are going to stay with in the long term.
The portal does have the ability to increase efficiency and effectiveness in the workflow and, rightly implemented, can reduce front office staff and costs. It is not cheap to implement or operate a portal system, and many small to medium practices cannot afford these costs given the very thin financial margins under which many of them operate. With the Affordable Care Act, the federal government was able to get physicians to adopt EHRs, and they did this by providing monetary incentives and quality metrics to qualify for those incentives. Unfortunately, current reimbursements have not kept pace with the cost of technology. We would like to suggest that the relative value units (RVUs) be revisited to include an added value for the practice expense component of the RVU when a physician can demonstrate efficient and effective use of the portal and, indeed, the EHR as a whole.(4) As we have demonstrated using simple key performance indicators, it should be possible to identify those organizations that are truly using the technology. CMS has a Merit Based Incentive Payment System(5, 6) program that includes patient portal account invitations. This is a process-based measure that involves documenting that the patient was educated on the portal, but it does not measure the outcome of that interaction. There should be further adjustments for those who demonstrate actual use of the software in their practice.
Technologies are now available that allow for automated patient check-in. The patient portal is a vital part of this process, and this is an area where the practice can also leverage the EHR to reduce costs while improving efficiency and effectiveness.
Changes in workflow or the adoption of a new technology should be chosen and implemented carefully and subject to a QI project to make sure that the deliverables are feasible and can achieve the objectives that are desired. When done properly, QI projects can provide the organization with enhanced efficiency and effectiveness.
References
Plan-Do-Study-Act Worksheet, Directions, and Examples. Agency for Healthcare Research and Quality. Rockville, MD. www.ahrq.gov/health-literacy/improve/precautions/tool2b.html . Accessed March 2024.
Sarwal D, Gupta V. Personal health record. In: StatPearls. Treasure Island, FL: StatPearls Publishing; updated September 2024. www.ncbi.nlm.nih.gov/books/NBK557757/
U.S. Department of Health and Human Services Office for Civil Rights. HIPAA Home. HHS.gov. April 19, 2024. Accessed August 15, 2024. www.hhs.gov/hipaa/index.html .
Seidenwurm DJ, Burleson JH. The Medicare conversion factor. AJNR Am J Neuroradiol. 2014;35:242-243. https://doi.org/10.3174/ajnr.A3674
Learn about MIPS. QPP. Accessed August 3, 2024. https://qpp.cms.gov/mips/mvps/learn-about-mips .
CMS. https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf . Accessed September 1, 2024.