Patient Portals: An Underused Communication Tool

After a long and successful career as a clinician, nurse-administrator, and educator, my friend decided to change careers and open a cooking school. It took two years of educating herself, planning, and hustling to get the endeavor off the ground. Now, four years later, she’s making a living at the second career that she loves.

My friend told me that the most important lesson she’d learned about succeeding in business came from a class early in her education as an entrepreneur. The teacher of the basic course in how to start a business assigned each student to talk to ten people about their proposed endeavor, every week for the 10 weeks of the course. My friend did all 100 interviews, as did one other classmate. They are the only two members of that class who got successful businesses off the ground.

Scheduling and interviewing so many people, as well as making sense of what they had to say, was no easy task. But it was obviously worth it. How good are medical practices at knowing our patients as customers?

“Patient engagement” is a buzzword on everybody’s lips, and patient portals are seen as a cornerstone of this effort.

There is pressure from all over—regulators, payers, the C-suite—to demonstrate that providers and practices are meeting their patients’ needs and expectations. “Patient engagement” is a buzzword on everybody’s lips, and patient portals are seen as a cornerstone of this effort. We employ surveys from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) or Press Ganey, or we devise our own. We measure and tabulate. Sometimes we receive carrots for the reports we write, sometimes sticks. We may even learn a thing or two about how better to serve our patients.

You are probably not going to routinely make appointments with and then talk to 100 people, as my friend did. To their great good fortune, medical practices now have a way to “talk” to lots of their patients—that is, not just to administer survey instruments, but to really converse with them, at greatly reduced effort and cost. The tools reside in the patient portal that is a part of nearly every outpatient electronic medical record (EMR). As of 2017, 86% of office-based physicians used EMRs.1 Beginning in 2011, Stage 1 of Meaningful Use included, among its myriad eligibility criteria for added reimbursement, the stipulation that a practice’s EMR be able to “Provide patients with timely electronic access to their health information within 4 business days of the information being available to the EP [eligible provider].”2 Whether it is pushed by the practice or pulled by the patient, as specified in Stage 1 by the Office of the National Coordinator for Health Information Technology (ONC), the information flows in just one direction. That’s not nearly enough.

If your practice is in the market to change EMRs or is one of the few remaining without one, take a good look at the patient portal features before you make a purchasing decision. (There are dozens of other things to consider when choosing a system, of course, a topic well beyond the scope of this piece.) Think of the portal not only as a way to provide patients with their data, but also as a site for moderated conversation among patients, practice providers, and staff, as well as a vehicle for gathering data from patients and for delivering services. A well-designed portal, both the front end (patient-facing) and the back end (practice-facing) parts, can serve as a broad information conduit, improving efficiency and everybody’s satisfaction with the care given and received.

An electronic interface can yield tremendous results with even limited pieces of the medical record. A study reported in 2014 that, of the 30% of patients who responded to an offer to review their medication lists online, 89% requested changes. A reviewing pharmacist responded favorably to 68% of these suggestions.3

The Open Notes project has pioneered providing electronic access to patients of a large share of their medical record. Researchers affiliated with that project reported that over the course of a year, of the 11,155 patients who were invited to review notes from primary care office visits, 5219 (47%) had done so. Of those, 99% wished to continue reading their doctors’ notes online. Not a single physician opted out of the Open Notes program.4

As a next step, the portal can serve as the gateway to telehealth consultation, which is rapidly gaining a foothold across the country. Integrating the consultation with the EMR, including progress notes and study results, makes the telehealth encounter especially effective.

I’d like to begin consideration of the structure of patient portals from my own point of view, based on my experiences of the last few years as a patient of several medical practices, ranging from small single-specialty to gigantic medical mecca, with a brief enumeration of portal features that turned me off. Each of these practices used one or another reputable EMR.

• I was only allowed two messages a month—none if I hadn’t seen one of the providers within the last year.

• Patient message length was limited to 100 characters.

• I had no access to plenty of important information. Detailed disease management instructions, buried in a doctor’s progress notes, were neither directly available to me nor even extractable for forwarding by staff.

• I could only address one staff member at a time. If a provider had not been designated on my care team, even if he or she was someone I had seen, I could not send them a message.

• When I was preparing for an identical procedure on the second eye, I was presented with an extensive blank electronic medical questionnaire—the exact same one I had filled out for the first surgery just two weeks prior.

• It took way too long to sign into the portal. After I did, there were several slow, unintuitive steps to take before arriving at the place I needed to be.

• I received lots of unannotated reports of laboratory and imaging studies—not a big deal for me as a physician, but certainly it would have been for a layperson.

Every one of the flaws listed amounts to the same basic issue: it is an impediment to conversation. No successful business ought to tolerate such dysfunctional communication channels with its customers.

Issues of privacy and security are solvable. Here it is, straight from the ONC: “Many people don’t realize that the Health Insurance Portability and Accountability Act (HIPAA) actually enables information sharing.”5 Nevertheless, more than half of providers are not in compliance with HIPAA’s patient right of electronic access to their medical information.6 Rather than give you a long list of dos and don’ts about what to look for in the patient-facing aspects of their portal—features such as reasonable message length and frequency, intuitive navigation with minimal latency, flexibility of addressing, ease of incorporating data and documents into messages—I’ll offer a few guidelines:

• At vendor demonstrations, staff and providers should try out the patient portal from the point of view of the patient. If you can swing it, get some representative patients from the practice to put the system through its paces. Anyone should be able to use the patient-facing portal with minimal instruction.

• Constantly solicit detailed patient feedback about their experience communicating with the practice by electronic means (including by phone; but that’s another whole topic) about what could be improved and what further features they’d like to see in this communication channel.

• Act on that feedback, which means choosing a vendor and developing a relationship with them that allows as much customizability as you can wring out of their EMR. Every practice is different, as is every patient panel.

As important as customizability is to the front-facing part of the EMR, it is even more so to the back-end piece. Providers, weary of all the unreimbursed hours spent fielding phone calls and doing paperwork, worry about how much will be taken out of their overworked hides by an unreimbursed torrent of electronic messages that arrive straight from the patient portal.

In addition to gains in efficiency resulting from improved distribution of work, tasks themselves can be handled more expeditiously using the portal.

A well-designed system for managing email flow can actually reduce provider paperwork. Forms and messages about insurance problems can be forwarded to the insurance department before they ever touch the inbox of the provider. Prescription refill requests can be handled by a nurse who is educated and empowered to choose when the provider needs to be consulted. A nurse—or, better, a designated nurse practitioner or physician assistant—can answer most immediate medical questions, with the needed patient information right at their fingertips in the EMR, as well as the ability to refer appropriately up the chain of expertise. Well-designed information flow shortens providers’ task lists, leaving them free to handle those problems they are uniquely qualified to address. At the same time, pushing responsibility down the pyramid gives staff opportunities to function at a higher, more challenging level. Everybody is happier.

In addition to gains in efficiency resulting from improved distribution of work, tasks themselves can be handled more expeditiously using the portal. Take, for example, test results. They can be signed off and annotated by the provider and forwarded to the patient at the moment they are reviewed. Keystrokes can be saved with a well-chosen selection of macros that will serve most of the time to close the loop with patients, messages like: “Normal. Congratulations”; or “Better. Repeat in three months.”; or “Let me know if this needs some explanation.”

There should always be room to write an individualized message. Imagine how thrilled a patient would be, as soon as lipid results are available, to receive a message from his clinician that says, “Howard-Your LDL (bad cholesterol) is high, but so is your HDL (good cholesterol). Come see me to discuss what to do next. No hurry.” The reviewer can at the same time order a repeat lipid profile in three months and put a note in the electronic tickler file for the team nurse or aide to call the patient if they have not gotten the test or come in to see the clinician.

These sorts of subroutines cannot be developed in a vacuum, not even by the smartest consultant in the world. They are embedded in the warp and weft of the highly complex moment-to-moment functioning of a medical office. You need someone local to lead the process, as well as a champion or three. At the outset, develop and empower as diverse, enthusiastic, and respected a team as you can from among clinical staff, providers, schedulers, laboratory, receptionists, and any other departments. Initially they will need to meet often to establish the outlines of the information flow process, then bring questions and decisions back to their home groups. Lean on vendor experts or engage a consultant to guide and train the team early on. After things are up and running smoothly, the EMR steering committee should continue to meet at reduced frequency—but probably forever—hewing to the principles of process improvement.

Then there are the advantages of collecting data from patients via the portal. There should be a clearly visible, ubiquitous message, starting on the home page, inviting comment from patients about anything they want to say: a complaint about a long wait time; suggestions of interesting magazines for lobby and exam rooms; compliments for a scheduler who did a bang-up job; insurance companies that ought to be added to the practice; kudos to a nurse practitioner who made a difficult diagnosis; problems with signing on to the portal; and so on. The VA reports very good results obtaining and acting on 10 years of data collected by a continuous voluntary survey that resides in its patient portal.7

A good portal should generate many opportunities for dialogue between patients and practice.

The practice needs to be explicit about how and to whom this information flows and what they do with it. If a response is merited, and it almost always is, it must be clear who addresses which issues. When it’s not clear, then the practice needs to know to whom to refer the issue for investigation, resolution, and response. Please do remember that whatever is entered into a message is discoverable by attorneys, so act accordingly, but not paranoiacally.

A good portal should generate many opportunities for dialogue between patients and practice. That means having a system unlike anything I’ve seen so far in the EMR realm, which tends to be about as flexible and intuitive as the plain vanilla e-mail systems we all depend on to conduct the business of the rest of our lives. (I have a lot to say about why, when it comes to information technology, healthcare lags so far behind almost every other industry in America. But that’s a whole other topic.)

Just because the sort of information captured in dialogue with patients is unique to each conversation, these one-off, qualitative data can be of enormous value in aggregate. You can start with a log of patient dialogues. Put it in the right hands—even hire an expert in qualitative data analysis if you need to—and you will begin to see patterns emerge, patterns you can act on. There is a place for formal questionnaires, too, much more efficiently administered electronically via the patient portal than on paper.

As I was writing this article, the results were released of the 2019 Healthcare Consumer Survey, commissioned by Cedar, a patient payment and engagement platform. Of the 1607 respondents, “1 in 5 . . . had left a provider because of a poor digital experience” and “41% said they’d consider switching to a provider who offered a better digital experience.”8 Take these results with a grain of salt, because the survey was paid for by a company that provides just the sorts of online services the survey says people want most and because the data were collected online. Nevertheless, sooner or later patients will come to expect the same sort of online experience that they get from banks and airlines and vote with their feet if they don’t get it.

To summarize, here are the things that a well-designed and executed patient portal can provide for a practice:

• Efficient workflow for communicating with patients;

• Happier staff and providers who work nearer to their true range of competence;

• Happier patients who receive timely, appropriate feedback and whose needs are addressed expeditiously;

• An efficacious channel for real dialogue between patients and practice;

• An avenue for telehealth; and

• Data that can be used to meet patient needs.

I will end this piece as I do nearly every article I write and talk I give about information technology in healthcare. Healing, which is what all healthcare endeavors are ultimately in the business of, critically depends on good communication. Using information technology to enhance healing is a matter of using it to enhance communication. You have to get the technology right. But the bigger challenge always comes down to managing the people who use the system and who make it go.

References

1.    Office-based physician electronic health record adoption. Office of the National Coordinator for Health Information Technology. https://dashboard.healthit.gov/quickstats/pages/physician-ehr-adoption-trends.php. Accessed October 11, 2019.

2.    Patient and family engagement meaningful use Stage 1 vs. Stage 2 for providers. Office of the National Coordinator for Health Information Technology. www.healthit.gov/public-course/interoperability-patient-family-engagement/HITRC_lsn1087/docs/MU_Stage_1_vs_MU_Stage_2_for_Providers_Fact_Sheet.pdf. Accessed October 13, 2019.

3.    Hirsch MD. Patient review of medication lists can improve accuracy of their EHRs. Fierce Healthcare. www.fiercehealthcare.com/ehr/patient-review-medication-lists-can-improve-accuracy-their-ehrs. Accessed October 6, 2019.

4.    Delbanco T, Walker J, Bell SK, et al. Inviting patients to read their doctors’ notes: a quasi-experimental study and a look ahead. Ann Intern Med. 2012;157:461-470.

5.    How HIPAA supports data sharing. Office of the National Coordinator for Health Information Technology. www.healthit.gov/topic/interoperability/how-hipaa-supports-data-sharing. Accessed October 9, 2019.

6.    Muchmore S. Most providers not fully compliant with HIPAA access requirements, research shows. Healthcare Dive: Healthcare and Health IT News. www.healthcaredive.com/news/most-providers-not-fully-compliant-with-hipaa-access-requirements-research/560954/. Accessed October 19, 2019.

7.    Nazi KM, Turvey, CL, Klein DM, Hogan TP. A decade of veteran voices: examining patient portal enhancements through the lens of user-centered design. J Med Internet Res. 2018;20(7): e10413. Published online 2018 Jul 10. doi: 10.2196/10413. Accessed October 12, 2019.

8.     2019 Healthcare consumer survey. Executive summary. Cedar.com. https://cdn2.hubspot.net/hubfs/5672097/ContentAssets/PatientSurvey2019/Patient_Survey_Exec_Summary_Final.pdf. Accessed October 11, 2019.