Patient Portals to the Future? (Part I)

Are you thinking about and working on ways to connect with patients? If not, you should be.

Two recent articles written by Rajiv Leventhal for Healthcare Informatics highlight both the coming push to implement patient portals as part of meaningful use stage 2 and the desire of patients to have this kind of access. Leaving aside the brute force of meaningful use (MU) there are other very compelling reasons to pursue patient portals.

The gap between our experience as patients in healthcare and as consumers in almost every other sphere of our lives has become a yawning chasm. Seriously, can you imagine doing business with a bank where you had to ask permission to see your balance, physically go to the bank to make a deposit or wait until the end of the month to get a statement? Of course not!

As I like to say, “Every day I work in healthcare and then I go home and live in the 21^st Century."

Patients recognize this of course. Pleas for “Give me my Damn Data” abound. And they are clearly ready to reward healthcare providers that make it easier to get data and conduct transactions like getting a refill or scheduling an appointment.  As Leventhal reports, a recent survey found that 41 percent of U.S. consumers would be willing to switch doctors to gain online access to their own electronic medical records (EMR). This squares completely with my own experience. I’ve lost count of the number of times I have heard patients say some variation of, “I’ve been with Dr. Jones for 15 years but he doesn’t have an EMR that lets me see my results or get a refill. I feel bad but I am going to switch to Dr. Smith because she does.”  As one of our patients recently wrote to us:

“I LOVE Cleveland Clinic MyChart. I recently switched to a doctor in a Cleveland Clinic office. She's sending me for various tests and specialists.  It’s SO nice getting the results quickly and without having to deal with getting hold of a doctor or nurse. I had an appointment today with my non-Cleveland Clinic ob-gyn. She was going to send me for blood work until I pulled out my recent blood test results. I want to change all my doctors to Cleveland Clinic!” 

Another reason to pursue patient portals is the potential for dramatic improvements in workflow. We often encounter resistance from clinicians and administrators when we first introduce the idea of the active patient portal. A pretty common response is, “You mean now I am going to have to deal with a flood of email on top of the phone calls, regular mail and my double booked schedule?” And they are right to be concerned because if you just “slam it in” you are likely to create even more chaos because you just “paved over the cow path”. The real opportunity is to step back and carefully think about how these new tools might enable more efficient workflows and actually reduce the amount of phone calls, email, etc. This takes a multidisciplinary team and a willingness to examine previous roles and responsibilities.

Take refills for example. From a patient’s perspective this is often a nightmare of several rounds of phone-tag that might include both the physicians’ office and a pharmacy. This is no fun and very inefficient for everyone. It’s also rife with well-known opportunities for medical errors due to miscommunication, dropped hand-offs, and transcription or transposition errors. A patient portal provides the opportunity to streamline this process but that opportunity must be carefully planned, tested and refined. Clinicians, nurses and front-desk staff must all work together to define workflows and protocols that make it easy to document and allow everyone to function at top of their professional licensure[LP1] .

For example, do we really need an MD to spend much time thinking about and approving a refill for an antihypertensive medication on a long-term stable patient? Wouldn’t a well-designed nursing refill protocol work just as well? Take this approach and you can create a kind of escalating ballet of refill management that is pleasing to patients and providers alike. Administrators like the added productivity and everyone is happy to be spending less time on the telephone!

Yet, another reason to pursue patient portals is that they will play a key role in population health management programs. These programs are a cornerstone of value-based care and seek to manage large cohorts of patients with similar characteristics. Most efforts today focus on processes that identify and stratify patients in support of telephonic case management. The results have been mixed.

It’s easy to imagine how patient portals could transform these semi-automated processes into more fully automated and intelligent systems. Get 10,000 diabetics collecting and entering glucose measurements into their portal, link that to the EMR, use it to drive risk-stratified protocols that either automatically provide decision support and education directly to patients or escalate the case to a care manager and you are on your way towards building a powerful system of population health management. It’s seems pretty obvious that leveraging a robust patient portal is a key part of this strategy.

In my next post on this topic we will take a deeper dive into some of the specific patient portal strategies being deployed at the Cleveland Clinic where I serve as the Chief Medical Information Officer.