Patient Portals to the Future? (Part II)

Jan. 17, 2014
In my previous post on patient portals we looked at some of the ways patient portals are being used to enhance patient’s engagement in their own care and to facilitate the transformation of the healthcare system from one based on volume to one that promotes value.

In my previous post on patient portals, we looked at some of the ways patient portals are being used to enhance patient’s engagement in their own care and to facilitate the transformation of the healthcare system from one based on volume to one that promotes value. 

I began by noting that both government mandates in the form of meaningful use stage 2 requirements and consumer demand is driving the deployment and optimization of patient portals. But the opportunities go far beyond meeting these basic demands. Patient portals offer the potential for dramatic improvements in workflow that are a win-win for patients and providers. They will also play an increasing role in population health management programs and could transform today’s manual and semi-automated processes into more fully automated and intelligent systems.

I also noted some of the challenges and cultural barriers to implementing a robust patient portal strategy.  So lets take a look at some of the strategies being deployed at the Cleveland Clinic where I serve as the Chief Medical Information Officer.

Like a number of other forward thinking organizations, we take this pretty seriously here at the Cleveland Clinic. We are busy implementing and refining several different strategies aimed at developing robust activated and engaged patients, dramatic improvements in workflow and better positioning for self-care and population health. These key strategies include:

  • Driving initial enrollment by moving from and opt-in to an opt-out model for patients. In the past patients had to actively choose to opt-in to our patient portal. Now all patients are automatically enrolled[LP1]  unless they actively choose to opt-out, a very rare occurrence in our experience. All they have to do is create a username and password and they are good to go.
  • Promoting transparency and information sharing by extending our open medical records policy to the online portal. We have had an open medical records policy for several years. Now we are actively moving more and more information onto the patient portal. Our goal by year end 2013 is to have all of the relevant medical record available to patients. This goes way beyond just simple lab results and includes pathology and imaging reports, medication and problem lists, office notes, and useful inpatient documentation like admission history and physicals and discharge notes. We are doing this in a step-wise fashion and so far, despite concerns from some that this would result in chaos, we are finding it works quite well. This is consistent with the experience of other heath systems around the US.
  • Thoughtful design, implementation and optimization of workflows using multidisciplinary teams. We like the local innovation and spread model for this work. We typically pick a practice location that is interested in being the pioneers, work with them to develop best practices and then leverage that as both showcase and model for spread across the enterprise. We find this minimizes the dumb mistakes (or at least contains them in the pilot site!) and helps break down barriers to adoption when we go to implement at the enterprise level.

Lori Posk, MD, an internist and Medical Director in the Clinical Systems Office here at Cleveland Clinic leads our patient portal efforts. One of the things she keeps reminding all of us about is that there is a difference between an “enrolled” patient and an “activated and engaged” patient. Boy is she right!

“Like most health systems our initial focus has been on implementing these systems by driving enrollment and developing workflows that benefit patients and providers alike. This a great place to start but it doesn’t go nearly far enough. We want patients to be actively engaged and using the portal to care for themselves and to be true partners with us in their care. Just giving them a logon won’t do the job in most cases.

We think of patients as moving through several stages: awareness, activation and engagement.  The first phase is about making patients aware that the portal is available and making the case for why they would want to use it. This is about basic marketing. Activation is when they move from awareness to actually having an account with secure login. We moved to an opt-out model to lower the barriers in this stage and the results have been pretty dramatic.

True engagement is the last stage and its still hard to do and a bit elusive. We believe that one key is offer real value to patients after every encounter and as soon after activation as possible. For example, we work hard to make sure there is something valuable waiting for the patient after each office visit. I love it when my patient’s results are waiting for them when they get home from their office visit – and they do too! Like I said, this one is still a challenge and we are starting to draw on the lessons learned in other industries and to develop metrics that help us measure and manage portal engagement – for both patients and caregivers!”

Dr. Posk adds, “Here’s an example of real engagement: I am starting to see patients becoming more proactive. Some are utilizing the messaging feature to plan ahead for their next office visit by making sure lab work is ordered before the appointment. Others are using the portal to make sure they are up to date with their health maintenance and messaging us if something is needed in between appointments such as a mammogram

What are her colleague’s reactions to the push to develop robust patient portals? It’s pretty consistent with what Leventhal reports was found in that survey where only 36% of physicians shared the belief that patients should have full access to their EMR.

Dr. Posk deals with this every day. “No question that feelings are mixed and that’s understandable”, says Dr. Posk.  “This is a major change in how we work and how we work with patients. Some of our caregivers are very enthusiastic about these initiatives and readily adopt and leverage them for the benefit of their patients and themselves. Others are more cautious and are taking a wait and see attitude. They are concerned about how patients will handle this information and the potential flood of phone calls and office visits that might result. Certainly there are some legitimate concerns that releasing information might be harmful to patients under some circumstances but we think those are likely very rare and we have tried to be thoughtful about what those might be.

We definitely believe the upside value of this approach far, far outweighs any downside. This is consistent with the experience of other health systems. The legitimate concerns about what might happen just don’t seem to play out in the real world. Giving patients more information and better access hasn’t blown up anyone’s practice”

But it will help transform our healthcare system into one that provides much greater value.

 [LP1]I am concerned when we use automatically enrolled, the patient still has to create a user name and password

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