If you build a patient portal, why won’t they come?

I hate saying I told you so.  But “patient engagement is a physician-patient communications challenge and not an HIT (health information technology) challenge.”

Just take a look at the Mayo Clinic’s patient portal experience which was discussed at a HIMSS 2013.

The headline: “Mayo Clinic struggles to meet stage 2 meaningful use thresholds for engaging patients.”

Always innovating, the Mayo Clinic some three years ago introduced a web-based portal to share information with their patients.  During that time some 240,000 patients have signed up for online accounts.  That’s pretty impressive.  But there’s a problem.

According to Eric Manley, product manager of global solutions at the Mayo Clinic, they are having a hard time getting more than 5% of all the patients who registered with the patient portal to actually use it. You see in order to meet Stage 2 meaningful use requirements, and enjoy the benefits that come with meeting this criteria, people actually have to use the portal to access their own health information.  You just can’t build a portal and in Mayo’s case have fewer than 12,000 unique patients actually use it.

Actually you can.  Hospitals and physicians do it all the time, they just can’t get incentive payments for their efforts.

So what went wrong?

It’s not like the folks at Mayo haven’t tried.  Mayo’s patient portal offer all the requisite techie gizmos – giving patients access to their medical record, lab results, appointment schedule, and lots of health information.  They also recently introduced their first patient-directed mobile health app called “Patient” which makes it easy for people to access their health information online.   Mayo even has a Center for Innovation to figure this kind of stuff out.

Upon reflection, Manley admits that “simply making services available doesn’t cut it.”

“Unless you are engaging patients, you won’t meet meaningful use requirements. [Messaging and other mechanisms] need to be a part of your practice.”

Manley is quoted as saying that “patient engagement has been a part of what Mayo has done for a long time.  Meaningful use, especially Stage 2, is a catalyst to kick it up a notch.”

Let’s face it.  Meaningful use maybe a good way to get providers to adopt badly needed HIT improvements – but it not a great way to force patients to engage with you.

Here’s why.

1. Forcing patients to do anything is wrong and antithetical to the whole idea of patient-centeredness, even if you think it is in the patient’s best interest. Meeting meaningful use seems to take precedence over what the patient wants.  Manley is quoted as saying “just having it [information and portals] out there isn’t enough … it’s making the patient use them.”

2. Patients want to engage with other people regarding their health, particularly their physicians. Health after all is an intensely personal and social affair.  Mobile health apps and email just can’t give patients want they want – to be listened to and understood.  Plus, 85% of people want face-to-face access to their physician when they want it.  Patients know that HIT threatens to get in between them and their doctors.

3. The content on most patient portals is not particularly relevant or engaging after the first 10 seconds, at least from the patient’s perspective.   After all, cognitive involvement is a prerequisite of meaningful engagement and it tough to be interested and spend time thinking about information that is not in context (of a medical encounter), you don’t understand, find boring, completely inaccurate or irrelevant.

So what is the solution?

There’s no question that if done right patient portals can and do work.  One need look no further than Kaiser Permanente, Group Health and the VA for great examples.  The key to their success is integration.

Health care for patients occurs within the context of social relations with our physicians.  To be engaging the information you want to share with us needs to be relevant to us from our perspective, come from our physician and be integrated into our overall care plan.  Only then will we have the trust and confidence that the information is ours, and is something we need to pay attention to.  We focus on our health while we are in the doctor’s office.  If you really want to engage patients, do it there.

Steve Wilkins is a former hospital executive and consumer health behavior researcher who blogs at Mind The Gap.

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  • azmd

    Probably the most important reason that there is lack of patient engagement in consumer health portals is that a lot of us are sick to death of having to log on to a different website to access information regarding every aspect of our lives. Just a guess.

    Personally, I would rather receive a copy of my lab reports in the mail and if I have a health-related question, there’s no reason that a healthcare organization’s choice of information is more useful to me than what I can find by doing a quick Pubmed or Google search.

    And the very last thing I need is tid bits of useful information being pushed at me, I already get about 200 emails a day, most of them containing that sort of content from the various organizations I am involved with.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I don’t think this has anything to do with the portal per se. 50% of Americans use almost no health care, and 80% use around 20% of resources. Why would these people log into a portal on a regular basis? What is it they would need or want there?
    The remaining 20% are either too sick, too old or trying very hard not to dwell on disease all day every day. So there you go – about 5% utilization makes perfect sense.

    • W.B.

      A point very well made!

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      I would use a portal if all my doctor’s offices had it. Years ago one of my doctor’s offices did try to have something like that. I absolutely loved it because it made it easier for me to give a more specific and detailed message about whatever question I had for the doctor in between appointments, and I loved being able to use the site to indicate to them what appointment time worked best for me. I am actually looking forward to the day when all my doctor’s offices are finally able to do this.

      • azmd

        The problem with doctors responding to emails from patients is that it probably takes about 15 minutes to read the typical lengthy patient email and carefully craft a written response that does not create potential liability. Say you have 4 such emails from patients per day to respond to ( and maybe a few other briefer, easier emails). That is an hour added on to your workday, which is an hour less you get to sleep that night, unless you take the hour out of something like helping your child with their homework. A doctor who has had an hour less sleep than he or she needs is going to provide lower quality care to the following day’s patients. I experimented briefly with making my email address available to patients and found that I was stunned by the volume of very long emails I got. It was just not sustainable.

        • MPEndoDoc

          I am a physician and have been using our medical center’s patient portal both as a patient and as a physician for several years now. I have found that the majority of messages are not time consuming – and certainly don’t take more time that playing phone tag multiple times. I find it much more efficient for communicating results etc. to patients. When we first started the system I was worried about long, time consuming messages but that’s relatively rare. In our system, the messages go to an AA first, so requests for appts and refills get dealt with without me seeing them unless my input is needed. All of the messages go straight into the patient’s EMR so it is easy to tell who said what when. I quickly went from skeptic to convert and encourage all my patients to sign up. For us the major time suck is documentation, not the messaging.

        • FL Patient

          There’s a difference between free-form/narrative emails, and “contact forms”. If patients fill out a “contact form” it helps specify what they are needing, and gives only a limited number of characters that they can type a free-form/narrative question or message into. It’s not the same as being expected to read & respond to multiple 6-page-long rambling narrative essays from people who have all the time in the world to sit down and pour their hearts out. (I’m not trying to be dismissive of patients who have a lot of their minds and a lot they feel like talking about; just pointing out that doctors don’t have the time to read and respond to such missives, and that concrete forms help give some order/discipline to any questions or concerns that come up without letting it become a novel).

        • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

          Point well taken, but here’s the interesting thing that happened with my doctor’s office that tried this. When I was writing the message I didn’t have the option to choose to have the doctor e-mail me back because that technology wasn’t available yet. So what they did was then to call me back with the reply. I would imagine that in that message center section that there would be the choice to have the doctor or the MA call the patient back with the answer. Doesn’t necessarily mean that all correspondence comes back through e-mail. What patients would have to learn how to do when it comes to the leaving the message is that while being detailed do it in a brief manner because you are correct you don’t have a lot of time out of your day to read through a lengthy e-mail. But even with the portal I would still also want to have the face to face interaction with my doctor because not everything can be discussed by e-mail. I think that there is room to have both, but it will just take some getting used to and trying to get the software and website to be easier to use for both.

        • buzzkillerjsmith

          Patient emails are energy vampires. You heard it here first.

          • SarahJ92

            I’m not a doctor, but I do believe you. It’s a time suck in everyone else’s life, why not a doctor’s? It would be better if the medical entities just said “We don’t do e-mail” than to overburden the doctors or offer a faux service.

  • Ian

    Hmmm. The doctors don’t want to spend the time and money to invest in building them and patient’s don’t want to use them. Why are these required again? Oh that’s right because the government is in bed with the big EHR vendors so its harder for startups to get in the EHR market. It has nothing to do with actual patient care. Cerner has changed very little over the years, it stil has the same interface that looks like its from 1995. Too bad the very implementation of EHR is doin the same thing to all of healthcare. More new docs are working for hospitals or big physicians groups than working for independent practices for the first time ever. Pretty soon the only option patients will have for healthcare is the mega or regional monopoly in the area. Doctors and patients will be cogs in the corporatist healthcare machine. The more I think about it concierge may be a viable business model.

    • buzzkillerjsmith

      Well said indeed.

  • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

    Interesting article. However, I am curious to know something. What is the most common age group that uses the services of Mayo Clinic? The reason I ask that is in part because of the comment made by Margalit Gur-Arie where she talked about the 20% of people that are too sick or too old, or trying very hard not to dwell on disease all day long. Especially for some that fall in to certain age groups the technology may be hard for them to master, and there are yet others who just do not like change no matter what. That some feel that the old way is better than the new.

    • FL Patient

      I am 46 years old and (as a patient) am with Mayo in Florida. I have a Patient Portal and the iPhone app, but I am pretty healthy (touch wood!) and generally only see my Family Doctor once a year in October for a check-up and a flu shot. I like the idea that Mayo has a neat health app, but I don’t find any reason to use it except to check the date & time of my annual appt and change it if necessary. And I have used the map to find where I’m going, because I’m HOPELESS that way!

      I consider myself very internet-savvy, but there’s just no reason for me to be logging in to my Mayo portal all the time. It’s still a positive for me that they HAVE it, because one day I might NEED it. But for the time being there’s no UTILITY in it for me. I think a lot of ordinarily healthy patients my age and younger would be in the same boat. Much like Margalit Gur-Arie points out above.

  • http://twitter.com/NYCPatient NYC Patient

    As a patient, I have found that of all the doctors I see, all at the same academic institution, all use the same Epic blah blah blah, only 2 1/2 of the 6 doctors I see actually use it; 1 more so than the other. One doctor received a 1/2 rating because they do not use it to communicate with the patient, although they (or someone in their office) actually reads the messages, which a patient can tell via Epic’s MyChart.

    1 of the 6 doctors will respond via straight email, and another is responsive to emails via calling you back, or having someone contact you with relevant information as to the nature of your email. Good luck with the others.

    It’s not just that patients won’t use it, but doctors don’t either. While all the doctors are supposedly able to see who I saw when and what was done, link to note (withOUT requiring navigation) etc., few, if any, actually do. Several doctors don’t even use the computer during a visit while a few spend more time navigating through screens and typing than anything else. Then there are the scores of times I go to a visit and they can check me in, look this or that up because the system is down.

    The systems are too cumbersome and too high maintenance. They are not practical and there is no accountability throughout practices that require all doctors actually use it.

    There should also be a dashboard of sorts that gleans data from the various systems (no point in hoping only 1 system will ever be used, right?) to be integrated to the main EMR system where the doctor can see past 5-10 visit history, recent imaging reports, etc., that is tied with the schedule for any specific date. Instead they have to log out of one and into the other than back to the original one…if a patient can easily tell how cumbersome it is for doctors, why on earth would they want to use it?

    I do use the portals…however, not 1 provides all the records a patient should have which requires securing them usually in paper form from the office. If I was so vigilant about having all my records and actually reviewing them for accuracy (thanks to horrid charting error experiences at the nation’s “#1″ Orthopedics Hospital…), I would hardly ever use it…

    • azmd

      The bottom line is that EPIC is terrible. The doctors who are not getting back to you via EPIC are probably not doing so because the hour or two of their time per day that they maybe previously had to respond to patient questions is now spent on inputting data into EPIC. I know my workday has expanded by about 90 minutes since my hospital went up on EPIC last year. If you have docs spend an hour plus per day doing data entry, that is that much less time they have to spend on patient care.

  • buzzkillerjsmith

    The solution is obvious. Every time the patient uses the portal for a certain length of time, enroll him or her in a lottery with the chance to win a free Big Mac and large fries at the local Mickeydee’s. Next case.

    • southerndoc1

      Or just charge patients a fee to talk to a breathing human being, as we strive to become more like Cheesecake Airlines.

      • Jan

        I recently spent a few years in Australia, my bank there charged a $5 “counter fee” if you wanted to go in and actually have a human being do some of the basic things you could have done online or from an ATM. The US Embassy there too charged a fee if you wanted to go in and do something (ie renew your passport) in person rather than online & through the mail.

        So it’s not that far-fetched!

      • buzzkillerjsmith

        You keep this up and I’m changing my name to cheesecakesmith.

  • http://www.mightycasey.com/ MightyCasey

    Those numbers will shift as the demographic of patients who are volume users of healthcare shifts. Margalit sees 5% adoption at Mayo as what could be expected at this point in time, and I agree.

    The real question for me is this: what did Mayo do to make their portal seem like a good idea [to] patients? Did they just say, “Hey, it’s here, use it!” without making a solid case about why it might be a good idea?

    I have a dream of a nirvana where all my records are available to me in a single login. I can even envision that being somewhere like, say Google Drive, with some heavy securitization. Yeah, I’m a dreamer …

  • http://www.facebook.com/raychelle.sims Raychelle Angelie Fernandez

    As a patient I believe physicians have the perfect opportunity for patient education and communication thru an effective Patient Portal. It’s more about the way it is presented by the physician and explained to the care giver or patient. Ensure the information patients are seeking is available even when physicians aren’t.
    As a Mother with 4 children I believe a Patient Portal that is accessible from my Smartphone would be vital during ill baby episodes. How often exhausted mothers are trapped rocking an ill baby for hours in the middle of the night? How much easier could my children’s Pediatrician have made it on me to have info at my fingertips instead of providing instructions jotted down on a piece of paper shoved in the diaper bag downstairs when I needed them next to he bathtub or in my hand while in the rocking chair.
    As Direct of Operations at Dynamic Health IT knowing the challenges and expenses physicians are facing with the demand to incorporate electronic medical records there must be a return for the physicians as well. 2014 Edition (Stage 2) ONC Certification requires a facilities Patient Portal provide the ability to send Healthcare Information via DIRECT. This will allow the patients to share medical history with any physician or entity accepting DIRECT transmissions. ConnectEHR DHIT’s 2014 ONC Certified solution contains a Patient Portal which provides the basics for a Direct Patient Portal experience. At the least a Patient Portal with allow physicians and patients to cut back on faxing, calling and submitting endless forms. One day patient info will be available at your fingertips for sharing of data which in time will lead to better patient care.

  • http://www.facebook.com/gpark1018 Gregory Park

    This article and comment section illustrate the multitude of problems with Patient Engagement (i.e.Portals). It’s like the old saying, you
    can lead a horse to water but you can’t make him drink. Apparently the same goes with patients, you can buy patient engagement technology, they may even follow you to its registration process, but you can’t make them continue to use the service. I have had the same experience with my
    primary, I used his patient portal with gusto initially, but over time it lost
    its appeal. Why? Cause I got all it could deliver and moved on.

    This is serious bad news for healthcare providers who MUST achieve a certain level of patient usage in order to obtain year 2 Meaningful use funds. Also note the focus here is ambulatory providers. Hospitals are going to have an even harder time achieving MU requirements for patient engagement.

    Some of the responses are very enlightening. Why portals have not gripped the patient’s attentions can be boiled down to incentivizing the patient, both on an intellectual and financial plane. How can the data the physician collects be made real and new every day so the patient will see a benefit in the portal?

    I think the portal has to connect the patient both to other patients
    with similar situations, but also to new and emerging clinical data geared towards patient consumption.

    If I am right then this opens up a new market converting highly technical medical data into publically consumable information. I am not sure how much this occurs today outside of high profile ailments like breast cancer and Aids (I am guessing guys so if I am wrong please say so).

    Secondly it would seem to open a market for a Facebook of Health. A tightly knitted social platform with healthcare as its focus. I am not sure the current HIPAA regulations would permit for a platform like this to exist.

    I also wonder what practices do to make it appealing to their population. Did they install the technology and say “here it is! How Wonderful…now use it!”?, or did they have a well-played marketing campaign to allure patient use? Did they offer the patient any financial incentives, i.e. lessening of their co-pay etc? I think financial incentives should be part of the portal – Consider how much a practice would save it over 80 percent of their patient’s actively used the potential of a patient portal – HUGE SAVINGS.

    • Jan

      Patients who are generally healthy have real lives and aren’t interested in fixating on a “health portal” or a “facebook (cringe! thinking privacy breaches here, facebook has a bad name) of health” every day. Life is busy enough.

      A flu shot reminder once a year, that’s the most a lot of people would want, but Walgreens and CVS apps will push that out to you if you request it anyway. My Walgreens app even let me set an apt time to come in and get it, using my iPhone. Easy peasy. Plus I got rewards points for having it.

      Unless over 80% of the patients on any given practice’s books have active, ongoing health problems, I can’t see that many people being interested. Not everyone is a sicko, not everyone’s life revolves around doctors and medical care.

  • southerndoc1

    Another solution in search of a problem.

    • Tom33

      Bingo.

  • SarahJ92

    Here’s why I don’t use the “service” offered by my local hospital:

    1) My messages don’t go to my doctor. They go to some unnamed stranger who decides if my doctor needs to see it. Bleeaaccchhh!!!!!
    2) When my doctor writes back I can’t hit reply and have a conversation. Nope, I have to start a NEW conversation (with that unnamed stranger). This destroys any semblance of continuity.

    3) When it first started I had to CALL the office to get my tests put on the portal site. What’s the point? I just called and had them mailed to me so I can scan them and keep them in my own system.

    It’s hard to imagine what kind of mind thinks this is a “service.”

    • southerndoc1

      Are you sure it’s your doctor who is writing back? How do you know your messages aren’t going to some e-mail response center in some third world country?

      • Suzi Q 38

        Good point.

    • azmd

      Why would you expect your doctor to have an email conversation with you? If you have a matter to discuss that is more complex than a simple question requiring a single answer, why wouldn’t you go and visit your doctor face to face?

    • Cris

      Your doctor is not your pen-pal. If you are trying to engage your doctor in long involved email conversations, ur doin it wrong.

  • Guest

    “Being in the HIT space…”

    The HIT space? What is this wankery?!

    I’m starting to understand why these programs suck so much.

  • http://ducknetweb.blogspot.com/ Medicalquack

    And…quit selling the patient data, it’s an epidemic with policies written by lawyers that only they understand. I gave a great idea and solution I have been floating around on this, license and tax all those who sell data. Banks and companies buy a license, pay quarterly taxes on their earnings, simple enough model like a sales tax.

    Consumers would win as they would have a federal site to go look up in one place who sells what kind of data and to who. We don’t have that right now and it gets better with using those funds to keep the FDA and NIH funded with science and research. Walgreens made just under $800 million selling data in 2010 so does that give you an idea on how big the profits are here, in the billions and nobody ever talks about it as they understand how servers running 24/7 can generate all this money and data, it’s out there. This is a big reason right there and I too will agree with the fact that we have no role models in government that really push it as it’s always “for those guys over there’…ever heard of a Senator or Representative talk about a portal or PHR? Do they know what one is?

    http://ducknetweb.blogspot.com/2013/02/time-has-come-to-license-and-tax-data.html

    Here’s an example of data selling right here, de-identifed or not, data selling and if you listen to any talented Quant they as well as myself will help dismiss the myth that it can’t be re-identifed. It’s more difficult today as systems become more complex but it has never been really impossible for many data sets, I seem to be the lone person out here who digs into the data selling to help educate but the even the guys at Forbes caught this one and said “selling data, nice business when you can get it”…so I didn’t feel so alone this time. Again, transparency with data selling would make a huge difference with mHealth especially.

    http://ducknetweb.blogspot.com/2013/04/more-data-for-sale-soon-with-shared.html

  • Suzi Q 38

    I am not sure that Kaiser has a portal, but the HMO encourages online interaction between doctors and patients. I don’t have Kaiser as I have a fairly good PPO that allows me the freedom to go to any doctor.

    I have 50%-50% participation with my doctors.
    I don’t abuse the privilege.

    I appreciate the doctors that give me their business card, and ask me to write to them about any acute or troublesome symptoms that they may be abe to help me with. One actually said: ” If you have any questions, please call or write to me…here is my email address.”

    This way, they know what is going on.

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