There are several challenges to optimization.
Cultural issues remain a major obstacle to enhancing patient portals. There has been the most resistance to implementing open notes and secure messaging. The original open notes study demonstrates that the fears of providers about opening their notes to patients are largely unfounded. At the same time, the traditional approach to medical notes needs to change to reduce medical abbreviations and medical terminology to make the notes more understandable (http://annals.org/article.aspx?articleid=745909 ). Also, there needs to be a process for patients to request corrections in their record online. Concerns about secure messaging by providers are reflective of provider time burdens. The typical complaint is that providers must already answer several phone calls by the end of the day and dread the added workload of also answering emails from patients as an additional burden. By using the same triage process as phone calls, some efficiency can be gained. Successful hospitals and practices have seen greater efficiencies with optimized portals, moving communication away from phone tag, eliminating paper processing and saving money. See the report from the Davies Award winner, University of Iowa Healthcare saw over $400,000 in savings per year by moving paper and phone communications to the portal.
Transparency of patient data has its advantages and is desirable to most patients surveyed. As noted in a New England Journal of Medicine article on transparency:
“Regardless of the setting, open notes can help improve patient safety by allowing contributions from patients and families who may catch questionable statements or clinically important mistakes in notes or find lapses in follow-up that need to be rectified. Indeed, the very existence of an environment in which patients are encouraged to identify potential errors may increase patients’ trust. But policies and processes for amending records remain in flux and vary widely among record systems and practice settings.”
But the cultural divide between patients and providers needs to close. One approach some are using is to bring the idea pioneered in patient experience initiatives, patient advisory councils, into the discussion of patient portals and data transparency.
Patient Health IT Literacy
While providers receive several days of intensive training in a rollout of an EMR, patients rarely receive even a brief orientation to a patient portal and the complexity of their own medical data. Even patients and family caregivers with some medical knowledge and/or information technology training, may not grasp what is available to them. In some cases, there is a more basic problem of simply informing patients that the portal is available according to a recent survey. Most successful portal implementations include some marketing to their patients, but the most successful approach appears to be a recommendation from a nurse or physician to use the portal. Even a simple reminder to a patient that they can secure message the doctor after the visit with questions can engage the patient in the use of the portal. Some practices have provided education at the time one signs up for the portal, such as, in the doctor’s waiting room or prior to discharge from the hospital.
The availability of the portal as a mobile phone app can make access easier if the app is designed well. Many of the features may be more intuitive for the mobile phone user although the number of features may be limited compared to a web-based portal. Some institutions are adopting a model similar to the Apple store “Genius Bar”. As hospitals and medical practices provide more information and communication electronically, the need for technical experts who can trouble shoot problems with patient and caregiver access can be helpful. On-site classes and online learning may be an alternative approach. How about an MOOC for each portal that is available? Combined with training on the portal, basic health literacy can break down some obstacles. Within the portal, a simple solution which some have available is having the lab results or prescriptions linked to lay-person definitions. However, the patient will need to know when googling the result becomes inadequate and they need to have a conversation with their provider to understand their own data.
Reducing complexity of the data can make a difference in health literacy for the patient. Data visualization is improving and the ability to show interactions between data elements, such as, lab results, mediations and diagnoses, will make the data more accessible.
Moving Ahead to Portal Optimization in 2015
For each provider organization, the way ahead this year should beg the question: how can I move past the Meaningful Use targets to meaningful use of a patient portal in my practice? My recommendations for optimization (in no particular order):
- Make sure all of your patients know you have a portal and personally recommend it to them
- Provide assistance to patients and family caregivers on how to use the portal – be creative including having patient advisors to managing the portal, classes, videos, and soliciting success stories
- Strongly consider open notes and other features which expand transparency of the data realizing that this will require changes in how you write notes as well as a process to accept patient requested error correction
- Integrate the portal into your practice workflow. Particularly if you are moving toward new practice models, such as, ACOs or Medical Home, consider how the portal can be a communication tool for reminders, home monitoring, health status questionnaires, etc.
- Find ways to help patients integrate their data from multiple providers and portals. Be aware of data integration tools that can meet this challenge but understand that this may require some technical support for patients to initiate their own Consumer-Mediated Exchange. Realize the benefits of having this data in one place, particularly for high risk and high cost patients.
Optimization is not free but can yield cost and outcome benefits. More research is needed and will be forthcoming in this year. A portal which remains static and poorly utilized is a waste of resources and is not being used meaningfully. This technology should be part of a strategy to activate patients to take charge of their own care, understand their data and participate in joint decision making. Once optimized, we are on the road to care transformation through patient engagement.
Join a discussion on this topic in the HIMSS LinkedIn Group.
HIMSS has several initiatives to support these optimizations:
- Connected Patient Committee and Task Forces
- Patient Engagement Summit – February 9-10, 2015 in Orlando
- HIMSS15 – Pre-conference Symposium, Patient Experience Forum and Connected Patient Gallery
- Connected Patient Community