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For about a decade, patient portals have been hailed as the wave of the future. However, many still require some work before they reach peak functionality, partly because many patients are reluctant to use them.
Rebecca Jaffe, MD
For about a decade, patient portals have been hailed as the wave of the future. However, many still require some work before they reach peak functionality, partly because many patients are reluctant to use them. Although a CMS incentive program has driven patient portal adoption, it has not provided a direct incentive to make the portals user-friendly, University of Pittsburgh researchers say.
Patients with cancer stand to benefit greatly from portal access. Such patients often see many specialists and submit to frequent blood tests. Having 24-hour access to a portal, which consolidates patients’ lab results and their other medical records, can relieve tension and increase their sense of involvement in their healthcare, proponents say.
Adopted by a handful of large healthcare organizations in the late 1990s, patient portals entered widespread use around 2006. Since then, these secure websites have been a familiar element of oncology practice. Supporters say the technology can increase a practice’s efficiency and give it an edge over the competition while simultaneously improving patient satisfaction and meeting the Meaningful Use criteria of the CMS electronic health records (EHRs) incentive program.
Barriers to successful implementation persist, however, and implementing a portal is not a panacea for problems with patient engagement, said University of Pittsburgh researcher Taya Irizarry, BSN, MSN, who conducted a 2015 state-of-the-science review on patient portals with 2 colleagues.1
Launching and maintaining the technology can strain a small practice’s finances, said Alex Seleny, senior director of portal and patient services for McKesson Specialty Health. Patient portals are often tied to EHRs, which HealthIT.gov estimates cost between $15,000 and $70,000 to purchase and install. Many portals are run by outside vendors, some of which charge a fee per patient or per physician. A physician at a small family medicine practice in Delaware was alarmed to learn, in 2014, that a portal vendor she was considering would charge $5000 per physician, plus training costs and a per-use fee. Posting about her quandary on the American Academy of Family Physicians website, Rebecca Jaffe, MD, wondered if satisfying Meaningful Use criteria was worth what could be an “unfathomable” expense.2
Whether patient portals prove useful depends largely on patients’ comfort with them and doctors’ willingness to encourage their use, Irizarry said (Table). It helps when the medical records available on a portal are accurate, clearly explained, and laid out in a way that makes sense to a patient with a low degree of health literacy.
If the information isn’t meaningful to the patient or the information is outdated or not right, it becomes a source of frustration and anxiety, which is the opposite of what we want people to feel when they’re engaged in their healthcare with this kind of information tool,” Irizarry said.
On the other hand, if information is intelligible, accurate, and complete, and physicians embrace the portal (thus encouraging patients to do the same), the tool’s benefits to a practice can be enormous, Seleny said. Portal features allowing patients to securely message doctors and access helpful information about symptoms can even keep patients out of the emergency department (ED).
“Patient engagement has become much more important,” Seleny said. “Now that we’re moving toward value-based care, it becomes a financial requirement for the practice to do everything it can to help ensure that a patient does not go to the ED, that they have as positive an outcome as possible.”In 2013, the US Oncology Network’s partner organization, McKesson Specialty Health, began marketing My Care Plus, a portal that runs in conjunction with the EHR system iKnowMed. Used by the US Oncology Network’s group of independent physicians, the portal is designed specifically for oncology and hematology patients. It includes several features common to all portals: a secure messaging service, medical records, lab results, and educational resources. Several of these features are mandated by CMS’ Meaningful Use criteria, which constituted the most significant driver of patient portal adoption in the United States, Irizarry said. The program, launched in 2011, makes up to $44,000 in incentive payments available to eligible providers whose EHRs and patient portals meet certain criteria.
However, the criteria do not require providers to make their health records easy to understand, Irizarry said. Nor are the portals required to be easy to use. “At the majority of healthcare organizations of the larger variety, their patient portals are more like a checkbox. They’re meeting a requirement, but it’s not necessarily ‘meaningful,’” she said. “At this point, there’s not a clear value on designing patient portals for people to truly use them.”
Irizarry added that making medical information as easy to understand as possible is key to creating a user-friendly patient portal experience. She recommended placing records in chronological order so patients can get a sense of how their health has changed as their disease has progressed. She likes when portals include space for doctors to upload their notes or type a message next to medical records to explain them. My Care Plus contains this feature, Seleny said.
“One of the areas of biggest confusion in our specific world is lab results. If you take the number in a white (blood cell) count to Google and ask, ‘Is this normal?’ odds are it’s going to say, ‘No,’” Seleny said. “So, any time a lab result is released to a patient, the physician has the opportunity to add a comment to it. Right next to the lab result, there’s a comment from the physician saying, ‘Don’t panic. I know this is a little high, but as we talked about, it’s going to be a little high, and it’s less high than we expected, so don’t worry. Breathe. Relax.’”
When patients log into My Care Plus, they are presented with a dashboard that contains content specific to their disease. “If someone logs in and has lung cancer, they’re not going to see information about a sarcoma,” Seleny said. By digging a little deeper, patients can access more information about their disease and their care plan.
The portal tells patients what form of chemotherapy they’ve been put on and what the chemotherapy does. It gives them resources from the practice, cancer foundations, and the drugmakers. It also includes what Seleny calls “pragmatic info”—how to talk to your family about cancer, how to explain the disease to small children, and how diet, exercise, massage, drinking enough fluids, and yoga might help. These are “tools that anyone can have access to, to make the journey easier,” Seleny said.Smaller practices may wonder if implementing a patient portal is worth it. The tool, after all, can confound patients who have low technological literacy. Irizarry recently conducted a study in which she asked focus groups questions about their level of comfort with patient portals. The study determined that the biggest predictor of patient involvement with a portal was their comfort level with technology.
“People with higher health literacy and people who have more ability to navigate an online world were the people who could prioritize and make sense of those data fields or go onto the Web and find out what they are,” Irizarry said. On the flip side, those with lower health literacy and less comfort with technology were more wary of the portal despite still being interested in it, she noted.
Physicians can coax patients to use portals if they enthusiastically adopt the tool themselves, Irizarry and Seleny said. Patients can sense when a portal is an afterthought for a physician rather than a true commitment, Irizarry added. A patient is likely to become more engaged if a physician endorses portal use, answers questions about it, and incorporates the portal into the workflow. Some physicians tell patients to view their lab results online, Seleny said. “You’d be surprised how much not printing out the lab results leads to portal adoption,” Seleny said.
To the question of whether a patient portal would be worth it for a small practice, Seleny said he thought practices should conduct a “very, very rigorous cost-benefit analysis” before deciding. He said that he considers portals a valuable tool for patients who want more access to healthcare information and practices that want to save time.
Many portals offer a feature allowing patients to fill out paperwork at home, which saves time during office visits and sometimes even leads to more accurate paperwork, he said. “More often than not, patients will have better recall of their issues if they’re at home. It’s easier to get paperwork about what medicines you take filled out if you’re by your medicine cabinet,” Seleny said.
“The whole intent behind a patient portal is to increase value for our patients, but also help the practices increase efficiency.” He recommended that smaller practices buy portals from a company that offers different pricing options based on the amount of features a portal provides. An inexpensive, simple portal might be all a small practice needs, he said. However, he recommended that all practices purchase portals that can be accessed on smartphones. “We have seen mobile use increase faster than any other metric we have,” Seleny said. “A lot of people may say, ‘OK, but we only serve an older population.’ Well, the average age of a user on our portal is 67.”
Top performing practices are aggressive about registering patients for portal use, according to Josh Gray, vice president of athenahealth’s Athena Research.3 These practices make sure that portals have functions that patients will find useful and that the interaction component of portals is 2-way, meaning that providers respond to patients’ messages. In addition, staff members need to be trained on techniques for getting patients involved with portals; otherwise, patients may never access these tools for expanding their healthcare experience. It is better to tell patients that they have an obligation to use their portals rather than merely invite them to do so, according to Gray.