Patient Portals – What Do Patients Really Think About Them?

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There seems to be an inverse relationship between the amount of spin one hears about “the next big thing”…and reality.    First it was EMRs and virtual e-visits, then social media, and now patient portals seem poised to be next big thing.   The drumbeat of vendors and pundits is unmistakable….physician that don’t adapt will be toast.   It can all sound pretty convincing until you ask to see the evidence.  What do patients think?

Take the physician patient portal.   If you read between the lines, patient portals are frequently being positioned as the new “front door” to physician practices.   By signing on to a secure website patients will have real time access to the electronic health record and will be able to communicate with their physicians by e-mail.   Additional patient features include being able to schedule an appointment with their doctor, reading their test results and refilling prescriptions.  But despite these features, according to John Moore at Chilmark Research, “nationwide use of patient portals remains at a paltry 6%.”

Ok… so now we know what vendors and pundits think about patient portals. What about patients – what do they think?

They would love it right?  I mean who at this very moment isn’t at home trying to e-mail their doctor.  Yeah right.

If a qualitative study of primary care patients in Journal of Internal Medicine is any indication, those most interested in using a patient portal were patients who were:

  • Dissatisfied with their physician
  • Dissatisfied with their physicians communications ability
  • Dissatisfied with their ability to get medical information from their physician

 

Those patients least likely interested in using a patient portal offered by their physician are patients who are:

  • Satisfied with their physician
  • Satisfied with their physician’s communication abilities
  • Difficulty in using the portal

 

Of significant note, patients who reported good relationships with their doctors were afraid that the patient portal would potentially undermine that strength of that relationship.    In other words, patients were afraid that e-visits would replace face to face visits.  Researchers were surprised that not one patient in the study identified encrypted e-mail communication with their doctor as an advantage of patient portals.

While the findings from this study are not generalizable, the study does highlight a potentially significant unintended consequence of encouraging patients to use a new patient portal.   Patients may interpret the move as a signal from their physician that they will have less face-to-face time with their doctor…which in their mind is not a good thing.

To be sure, there are notable exceptions to the cautionary tale described here.  MYGroupHealth , the patient portal developed by patients and providers at Group Health Cooperative in Seattle, is perhaps the best example.

Take Aways

  1. Patient Portals are not going to go away.  Having a patient portal is expected to be a requirement in the final  Stage 2 Meaningful Use (MU) Requirements (June 2012) and is listed as a condition for advanced Patient Centered Medical Home (PCMH) accreditation by NCQA
  2. Ask patients what they think about a patient portal – what services should it offer, would they use it, how should it be promoted and so on.  After all, it is supposed to be patient-centered.
  3. The real value of the patient portal lies in physicians providing  patient-centered, clinical support to patients rather than promoting products and services.
  4. Integrate the patient portal into the primary care physician’s work flow and practice.  If you collect patient data on the portal then make use the physician actually uses the information during the patient visit.

 

That’s what I think.  What’s your opinion?

Sources:

Zickmund SL, Hess R, Bryce CL, et al. Interest in the use of computerized patient portals: role of the provider-patient relationship. Journal of General Internal Medicine. 2008;23.

14 Comments

  1. Dan Munro says:

    Good insight – but we think there’s still lots of opportunity for innovation in this space. Patient Portals are launching in large numbers – but they are all basically provider-centric (tethered to the provider). The ones that are consumer-centric (Healthvault, GHealth, Revolution Health) have not scaled to significant use (and 2 of those 3 have either ended service – or soon will). Healthvault doesn’t share usage stats – and they sell that software globally (as part of much larger ERP/HIT solutions) so they can easily afford to manage/maintain the U.S. version for free.

    Per John/Chilmark’s definition – I don’t think we’ve really seen a Collaborative Health Record (CHR) yet. KP, GHC and Dossia are working for well defined/group populations (using a “walled-garden” model), but usage within those systems continues to be hard fought/won – and the data itself is difficult to port to other systems in the event that I move or change employers. Given the current system which has been designed around volume – and where EHR’s have not been widely deployed in small practices – the data repositories we do have are largely filled with billing, PBM data. That’s not all that helpful. Everyone claims patient-centricity – but the UX isn’t – at least not yet.

    • Dan,

      I am not sure that I would call GHealth, etc. as patient-centric so much as “directed at the patient” vs. directed at clinicians. Patient-centric, like patient-centered implies that consumer/patient input helped guide their development. Results clearly suggests otherwise.

      The fact remains that patient portals, if not done properly, run the risk of further disintermediating physicians from patients – at least in the minds of patients who have a decent relationship with their docs. Frankly, I am not sure that for many vendors this isn’t where they believe health care should go. If that is the case I suspect we will see more GGealths to come. I happen to believe that it is all about the physicians-patient relationship – tamper with it at your own peril.

      Steve

  2. Dan Munro says:

    Basic agreement – yes – but I think we’re also reaching a crossroads. The days of non-participatory, ill-informed patients is coming to an abrupt close – especially as the cost of HC shifts ever more directly to them. Simple $20 co-pays and unlimited testing or procedures aren’t effective – or sustainable.

    My own opinion of providers has begun to shift – as have others I know personally. Presenting patients with a “patient portal” that is owned by the individual provider – is primarily for their benefit – and needs updating for every provider and each family member won’t scale – and is most definitely not patient-centric. Providers that demand compliance with that limited and dated model are also at peril.

    For these – and many other reasons – I do tend to like John’s use of the term CHR – Collaborative Health Record – whereby the patient-provider relationship is itself entering geeky adolescence – if not full adult maturity. I’m also beginning to think it’s the only way forward if we hope to succeed with moving the system as a whole from volume to value.

  3. (corrected typo)
    Well speaking as someone who implemented the first EHR in the country to give patients access to their clinical data first (at Group Health Cooperative patients had read write access to the EHR before the providers did ) I can assure you that not only do patients like them (over 55% use it) but when implemented correctly they will be the new standard of care.

    They allow you to will extend the relationship between provider and patient outside of the walls of the practice if you provide real value to the patient in terms of time. convince or improved outcomes. The goal isn’t the technology but how to change both the providers and the patients workflows.

    Over 30% of all visits are now done remotely via email or telephone encounters, the entire system for over 620,000 patients shifted to the medical home model and they are even removing waiting rooms from he clinics as the technology has allowed them to streamline the workflow around the patients needs not just the providers. None of this would be possible without patients actively involved in their care outside of the doctors office.

    What is missing? The business case for providers (ie they aren’t paid to answer mail or have a virtual encounter at most practices yet)

    None of the untethered PHR (personal health records – Google Health, Health Vault, Dosia)) provide real value to patients and are akin to hand entering your bank data into quicken. Nor are the stand alone portals a real solution.. (think of going to your bank your brokerage accounts your credit union vs the MINT model).

    In one small RWJF funded project up in Whatcom county (Shared Care PLan) they actually implemented a patient designed an EHR that when combined with nurse case managers was so successful at keeping people with chronic conditions out of the hospital and when the funding was over so was the project as the doc’s were losing money.

    John Moore (who has never worked in health care) and I disagree on this health care is fundamentally different from most industries and the technology is just a tool not the process itself that we are tying to transform. Personally I believe we could have integrated patient centered EHR/EMR’s almost over night if we changed how we compensate providers (on outcomes not piece work).

    So ask the 10 million plus patients at Kaiser, or the half million plus at GHC, what they think of an effective patient portal designed around their care and find the lessons learned to apply to the small providers out there (80% of all docs practice in clinics with from 1 to 5 providers). Use Health IT and patient portals to transform and leverage expensive care teams and drive down the cost and improve the quality of care (well documented in Health Affairds) by putting the patient at the center.

    • Sherry,

      Thanks for your comments. As I noted in my original post, Group Health is a “notable exception” in so many excellent ways…whether it be their patient portal or Medical Home approach. Notwithstanding the positive experiences that Group Health has had…and to a lesser extent Kaiser and a few others…experience has not been great with patient (or member portals) offered by physicians, hospitals or health plans. Often for the reasons you mention.

      Most patients have not had the experience of “growing up” in a Group Health-like system. Aside from the HIT, there is an acculturation that occurs over time with patients in systems like Group Heal, Kaiser, Health Partners, etc. Patients that have grown up in traditional small practice settings have an entirely different patient experiences, fear and expectations compared to their Group Health counterparts. The point of the study and my post was simply to point out the not so obvious fear that patients have (probably in the majority of delivery settings) that physicians will use the “patient portal” and e-visits as one more reason to spend less time with patients. It no doubt will lead to a whole bunch of good things for the doctor but not in the eyes of every patients – call it an unintended consequence of HIT.

      You say ask the “millions” at GHC and Kaiser what they think? I’d love that chance. But I ‘d love even more to talk to the millions of members in those plans that are not active users of patients portals.

  4. John Norris says:

    I think we can all agree that personal, clinical, value needs to be there from the patient’s point of view.

    I’d like to add that we are also dealing with adoption rates that probably follows the Gartner hype cycle, needs to cross Moore’s chasm as well as the digital divide. So there are other things at work than merely “value”. (Reimbursement is another big issue, as already noted.)

    I’d hope the learnings from Sherry’s successes can be leveraged outside of group health. It’s great to hear that for some this is working out.

    Interesting study, post, and comments. Much thanks everyone.

  5. Nadine A. Bendycki says:

    Thoughtful piece. Thanks for posting. I am trying to convince a 6-MD GI practice to add a patient portal to their web site, as a way of distinguishing themselves in the marketplace. I am also interested in determining the use of patient portals as places where patients can talk to each other and build community. Do you have experience with using pt portals this way?

  6. Thanks for the thoughtful reply.. It is a real challenge to take the lessons learned from large integrated practices (where not only are providers on salary but the savings stay in the system) out into the 80% of practices that are from 1 to 5 providers.. It isn’t about the technology but the payment mechanisms we use.

    One of the keys remains the business case.. How do you move to a model where up to 50% of all provider patient encounters are now happening remotely if you are only paid when you see the patient in person?

    It is also frustrating from the patients workflow to be asked to log onto multiple providers portals if you are caring for someone with a chronic condition (if you aren’t at GHC).In most other practices if you keep your patients healthy out of the hospital the savings go out the door to the payer.

    In Massachusetts providers won’t be able to be licensed soon if they don’t have an EHR and I believe that the game changer might be large self insured employers who will require that providers on their preferred panel not only have an EHR but one with a patient portal.

  7. Dan Munro says:

    FYI – there are CPT codes that address e-Visits (# 99444 and # 98969) but the point is well taken. Even these codes need updating for a much wider variety of billing scenarios. The way they are today – the provider can only bill these to existing patients – and only once in a 7-day period. Highlights the antiquated nature and billing-centric model we’ve been using for decades.

    I don’t question the need or value of a patient portal – I just question the portability and USABILITY of the data. I don’t want billing data. I don’t want my whole health history in a digital filing cabinet – and I don’t want to have to re-key the exact same personal data (for myself and other family members) into every providers individual portal (for THEIR patients). In some ways – it’s like entering the same data into each Costco branch. Big yuck!

    KP, GHC, Dossia – and others – do have some compelling usage metrics – BUT – they still don’t address many of the use cases where as a patient I move (out of state), change employers, change payers (by choice), add or change a provider (by choice or referral), add a family member (infant or aging parent), or have a need to see a provider while traveling – maybe even to another country. KP, GHC, Dossia – and others – may be skirting the technical definition of a tethered PHR – but it sure sounds tethered to me.

  8. lucienengelen says:

    Great post Stephen !
    might want to read this with common angle on it where i wrote on why we made healthcare into a eGo system in stead of an eCo system.
    Patient portals may help on this frontier, but also have the risk of even strengthen the eGo system.
    http://lucienengelen.posterous.com/lets-turn-healthcare-into-a-eco-system-instea-19730

  9. Very good articles and posts. Thanks to everyone. My thoughts are that a list of properly aligned incentives are the most important factors that will grow the adoption of patient portals. The lessons learned from high adoption solutions are valuable in pointing out what should be on the list. New ideas for incentives need to be integrated into both the PPO and HMO models of care. Broad scale improvement in adoption/use of patient portals will come from various mandates (physician, government, employer, insurance co, and “self-interests”) as well as documented improvement of patient’s health , wealth, and knowledge. The mandates will lead us to the documented benefits.
    My questions are:
    1. How will the scheduled government mandate to purchase health insurance impact engagement rates for patient portals and what features for this engagement are currently lacking ?

    2. How do we improve the “self-interest” mandate ?

    3. How can the model of bundling services and devices by ATT, Verizon, and Sprint be applied to the bundling of patient portal services ?

  10. Deanna Nielson says:

    Excellent post and comments. I share Sherry’s initial comment, which applies to SoCal KP’s patient portal: “They allow you to [.] extend the relationship between provider and patient outside of the walls of the practice if you provide real value to the patient in terms of time. convince or improved outcomes. The goal isn’t the technology but how to change both the providers and the patients workflows.”
    As a former member of KP, I made use of the portal and came to rely on it for quick communication with my provider, which I was able to do for a couple of months after I moved out of state and needed to arrange for medication refills outside the KP network. Beyond the simple appointment scheduling, refills, secure provider communication (which I used without feeling distanced from my provider), and test results availability, I had much more health-related information access that made me more aware of what I could do to engage in healthful behaviors. What I gained from the patient portal was: access to test results with the ability to monitor my results over time – either in a table or chart; information about the tests (what’s normal, what might an abnormal test result mean) so I could discuss results more knowledgeably with my provider; access to other health care opportunities through their “HealthMedia” partnership,and more.While I was very saddened to leave my KP providers, who I had know for 10+ years and with whom I developed a close rapport, I was equally saddened to lose the connection to the patient portal information that was offered.
    The comments regarding interoperability outside the “garden wall” provider system are of concern to me now as a patient. My current providers also use Epic (same as KP), but the patient portal is “out of the box” and not well developed, so doesn’t offer the same added services beyond scheduling, test results, and secure communication. It also doesn’t seem to be of any value that both providers use Epic, since I still haven’t been able to get records transferred to the new provider – they still need to come via “paper” – a.k.a. fax or CD.
    Technology will not replace the physician-patient relationship. It will not improve poor communication between patients and provider. But it can enhance the overall health care experience of patients if viewed from a patient-centric health care (wellness) experience. I know the issues are complex, but there are models from which we can learn without starting from ground each time. I’m looking forward to the challenges and hope the journey, while sometimes taking the scenic route, doesn’t get bogged down in the swamps and quicksand.

  11. Lori says:

    I love Patient Portals! As a patient, I cannot understand why more docs aren’t using them. I mean, how little effort is needed to avoid playing phone tag, having patients travel to come in just to ask a simple question. My PCPs office policy – not his policy, the company that owns the practice- will now allow them to use email of any kind, nor can patients make inquiries via the phone. There is a hard front-line that’s almost militaristic that will NOT take a message and forces the patient to make an appointment. Every phone call query is met with an inquisition.
    Gateways become problematic when the doc doesn’t respond to any messages/queries, even though s/he participates in the gateway. Isn’t that negligent? Is that the same as a doc not returning phone calls to patients (if they are, in fact, allowed to leave him/her a message)?

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