Are patient portals a gateway or barrier to patient-centered care and communication?

Are patient portals a gateway or barrier to patient centered care and communication?A guest column by the American College of Physicians, exclusive to

Patient portals. They have great potential, but is it being met? And are we losing something in return? I ask myself these questions now that my practice offers a patient portal linked to our electronic health record (EHR). I did not expect to feel that way, because I’ve been a strong proponent of providing patients with electronic access for over 20 years. I had an email account and a rudimentary website on AOL for my practice that I coded manually in HTML in the early 1990s. In the early 2000s, I offered my patients HIPAA-compliant secure messaging.

When we implemented our EHR in 2006, I was excited about the possibilities. Patients would be able to get their lab results online, ask questions without having to use the telephone, and perhaps even get simple problems taken care of without having to come in for a visit.

Until that time, my experience with online communication with patients was a very positive one. It did not, as many feared, increase the amount of work or encroach on my free time. Patients who used email and secure messaging did so instead of calling or piling up questions until their next visit. The ability to respond asynchronously, with control over how much time I spent on the interaction, actually made my work more efficient.  Patients who accessed me electronically loved it and felt privileged to have that option.

So when we activated the patient portal that is part of our EHR, I was excited. Then reality hit. Patients signed up, but were not banging on the door to do so. Of those who signed up, many didn’t log in to activate their account. Of those who logged in to activate their portal account, many did not use it. Some had difficulty navigating the portal. Others did not go online very often. A surprising number didn’t even check their email regularly.

The result was that not all patients whose lab results were available online actually saw them. These were routine, non-urgent tests, but before there was a portal, they would receive a postcard or letter with their results. Perhaps they didn’t read those either, but there were certainly fewer barriers to opening an envelope. Some patients who were enrolled in the portal still called the office for lab results, which defeated one of the purposes of having a portal.

The number of patients using the portal to send me messages or ask questions is quite small. Some of those patients are the same ones who were using my earlier iterations of online access. There are a few new users and I hope that number will grow as word spreads and patients feel comfortable using online communication for their medical care.

Why the unmet expectations? Several reasons come to mind, beginning with incorrect assumptions. The conventional wisdom is that younger and more educated patients will flock to patient portals and elderly patients will not. Perhaps there is data to support that, but my experience is that you can’t predict who will or won’t use the patient portal. We also assume that people are online every day, if not all day, just as we are. I’m finding that not to be true, based on conversations with patients who are registered but don’t access the portal.

Another factor is the environment in which we introduced the portal. Along with the technology came mandates: NCQA patient-centered medical home recognition, meaningful use, and pay for performance programs, to name a few. We were not just making a new service available to patients who could use it if it was attractive to them. At the same time we had specific targets for enrollment, lab result reporting, and bidirectional communication that we had to meet to comply with the various “quality” programs. That made the deployment of the portal less patient-centered and focused on the preferences of the patient, and more metric-centered and fixated on enrolling as many people as possible, regardless of preference.

Before people start interpreting all of this as a declaration of failure, I’ll state that I am still a strong believer in patient portals and feel that over time, they will be used more widely, increase patient engagement in their care, and improve practice workflow and physician satisfaction. However, as is the case with physicians and EHRs, vendors need to make their portals more user-friendly. More importantly, we need to slow down and let our patients adopt portals when they are ready, not when we think they are. That means that CMS needs to rethink its meaningful use targets, as ACP advised in a 2012 comment letter, and practices need to recalibrate their goals to more realistic ones.

Finally, we need to take a more patient-centered approach to portals. Not only the user interface, but also whom we enroll and how we will manage those who choose not to enroll. We must make sure not to leave behind those who prefer older methods of communication. While we’re at it, before it becomes yet another problem we might as well develop a solution to the likely proliferation of portals that will result in a patient’s having multiple portals. Like the interoperability chasm that exists on the physician side of HIT, if we’re not careful we will duplicate that on the patient side.

Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • JR DNR

    How about flip the appointment for routine blood work? For patients who have regular blood work done, plan it at the previous appointment. Have the labs done first, then follow up to discuss in the office.

    • Yul Ejnes, MD, MACP

      Thanks for the comment. We do that in our practice, a process called “pre-visit planning.” It does reduce the number of results that we need to report outside a visit. However, not all blood and other tests can be anticipated prior to the visit, so we still need to work on improving ways to get results for tests performed after the visit.

  • southerndoc1

    “over time, they will be used more widely, increase patient engagement in their care, and improve practice workflow and physician satisfaction”

    Do you have any evidence to support these statements, or is this just a faith-based assertion?

    • Yul Ejnes, MD, MACP

      A little of both, Southern.

  • LeoHolmMD

    The portals were designed by the same people who developed the EMR. So of course, they work poorly, serve little purpose to the user, are costly and redundant, inefficient and will ultimately corrupt communication, just like our current EMR systems have done. I am shocked.

    • Patient

      I would agree. My doctor just started with a Patient Portal and I haven’t seen any benefit to it. The patient portal offers a list of all my past appointments (like I care that I was there 10 years ago for something). Past appointments are useless. The portal offers “Visit Summary”, but all the Visit Summary indicates is a list of medications that I’m taking (which are incorrect), a list of the past problems that I have had, a list of possible tests that might be needed. No notes in the note sections. SO what’s the purpose of the visit summary if we can’t read what was discussed in at my appointment? I’m sure there is another “chart” with the discussion that took place, but I’m not allowed to see. The portal offers info in regards to our statement, but I have a zero balance, yet, the portal indicates I still owe an amount. I have an email from the receptionist indicating I am paid in full and she sees no balance, yet the portal shows I owe. The portal also shows personal info. The portal also gives a list of medications you are taking, some that I’m not taking (which should be removed), doesn’t show medications that I am taking and when he added a medication at my last physical, all the other medications were removed. Must be a glitch in the system. The portal also offers my vitals, procedures, immunizations, etc. In regards to the vitals, I signed up for the portal a few months ago. The vitals that were listed were from my Visit about 6 months go, yet the date on the vitals section showed the appointment date I had in the future. Now the vitals still show the info from my appointment 6 months ago, but now indicates a date from a week ago and I wasn’t there. The portal shows lab results, but I get message after message that lab results were posted. When I look at the labs, there are no results, just what was ordered. Plus there are labs that are not listed that I had done at the same time these other 4 lab results appeared. In my husbands portal of labs — shows notes from the medical assistants that just indicate “labs pending” or “telling the MD the labs are there”. I just don’t see the benefit in the portal. When I asked my MD what the benefit was he indicated “but can’t you ask us a question”. I said ‘yes, but no drop down to pick a name in the office, which tells me my question will go to an office inbox for anyone to read and answer. To me that’s not secured messaging. If I ask my doctor a question and it’s no one elses business. Also, the email we received to invite us to join/log on to the portal states “you no longer have to call the office, you no longer have to wait for results, you no longer have to this or that”. To me, that’s unviting. Those statements tell me the doctor and staff do not want to be bothered with calls, etc. If I saw results and I had questions, I want to talk with the MD. Reading where results are sent by mail is not the right thing to do. We, as patients want to hear from the MD. Also, my doctor has a concierge practice, we already have his cell number and email address directly to him. We pay for that service. We are not paying for the service of medical assistants who should not be answering questions, triaging, etc. to contact us. Do not like the portal.

  • azmd

    The pediatrics practice at which my children are seen has had a patient portal for at least seven years. It is buggy and even after seven years of intermittently calling to complain/question the practice about it I have not been able to log into it.

    If you want patients to use a patient portal, it needs to be a user friendly product. Retail businesses have managed to figure this out, so it can’t be that difficult to do. Until healthcare gets it right, we will continue to lag the rest of the civilized world in the rational use of technology.

    • southerndoc1

      “If you want patients to use a patient portal, it needs to be a user friendly product. Retail businesses have managed to figure this out”

      Very different experience.

      People go on retail sites driven by the strongest force known to man, consumer lust. They can interact with the site – they look at different models, colors, sizes, and then get the thrill of clicking on “Buy Now.” Logging on and staring at a normal chemistry panel isn’t in the same category of experience. Why not just be passive and wait for the results to come in the mail?

  • jgamero

    Hello. As a patient, and an Ambulatory EMR Professional for the past 10 years, I am shocked by other healthcare professionals negative, non-constructive, Internet postings about EMR’s and Patient Portals. Those kinds of posts, from clinical and non-clinical professionals, are a disservice to patients.

    I read every post associated with this article (although new posts have been made since I typed out this response.) It’s part of my nature to read everything and collect information so I can help make EMR’s and Patient Portal’s better OVER TIME.

    As a patient I am in awe how I now have access to some of my health information. Is it perfect and complete? No but it’s getting there. I have been known to say to providers, that know me well, “EMR’s have been around for about 10 years and they continue to get more user friendly every year. HIV and Cancer have been around for a longer period of time. Is it fair to say doctors are not doing their best to find cures in the same timeframe?”

    Here are some answers to some of the statements made against this post:

    - Yes Patient Portals
    right now are not what they will become. I especially liked the post about past appointments and visit summaries. Ultimately I agree this information looks useless, kind of like getting a bank statement monthly, the previous months statement is now useless. But long term those visit dates match your life events over time. Babies born today will have a rich electronic health repository. Only the future knows how those future patients use this information. I’m 48 years old so I won’t see a life long EMR as new patients will.

    - Test Results! Test
    Results! Test Results! As a patient I WISH I could get my test result data in my portal so it is trend able. Here is a fact: this is a struggle for
    EMR’s to do because they receive the test result information from specialty services computer systems. The two largest are Lab and Radiology computer systems.

    Lab results are a struggle because health systems do not always agree on test names let alone results that can be shareable. Lab systems must also deal with testing equipment that needs to be calibrated differently between Lab locations. As lab departments and systems create standards EMR’s and Portal’s will benefit.

    As for Radiology results I know the following, I feel bad for Radiologists. Prior to EMR’s their result information was created for physician-to-physician communication. Now with EMR’s radiology result terminology is being delivered to patients. How we as patients, Providers who ordered the tests and Radiologists come to an agreed
    set of understandable terminology is a huge endeavor.

    So what should we be encouraging patients to do with their portal information?

    As a patient I am 100% vested in questioning, monitoring and asking for corrections to the following three topics. I believe this is where patients should review monthly just as they do to their online banking statements.

    - Allergies. Make sure you get the practice to document any drug allergies, latex allergy, egg allergy, shellfish allergy or contrast allergy. Ask your practice about each of these items.

    - Medications. If you cannot print out a medication list from your portal then do a screen shot of the list and print that list. Compare the list to what you take and have at home. If you find a medication on your list that you do not have at home any longer, or you see duplicates, then demand they remove the medication from the active list. It is your list of medications.

    - Accurate medical problems. Look at the list with your provider. Some medical diagnoses have clinical terminology that you never knew, but if you feel a medical problem on your list has been resolved then ask that it be moved to history.

    In my personal and professional opinion Practices, Patients and Providers should focus on these three areas as a starting point to understanding the huge amounts of information that becomes available within the Patient Portal.

    Are providers and patients being used as EMR Test Rats? Probably. But I would like to think the first person that bought the first automobile was also a test rat. That car could have exploded. What we are
    doing now with EMR’s will benefit future patients. As a patient I don’t mind being a part of this process and discussion.

    • Yul Ejnes, MD, MACP

      Thanks for your thoughtful reply.

  • RalBeck

    If you have seen one patient portal that’s all you have seen. Content is what is important, not just the portal. As a patient i use a portal that lets me schedule appointments (see the available slots and pick one), get mail order refills of prescriptions, get results of tests, send messages to my doctor — and always get a reply the same day, get comments from specialists through my primary care doctor, get same day appointments for urgent matters and get billing questions answered. If other people don’t use this amazing tool they are really missing something great — it’s just a matter of time before really good portals are available in other places. Bad portals will never get much use.