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

acp new logoA 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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