Is There a Patient Portal in Your Future?

Your practice implemented an electronic health records (EHR) system and your team has worked together to stabilize workflow. Despite all of the work your team put into the EHR, you find that workflow efficiency has not changed. Your support staff continues to play phone tag with patients throughout the day managing appointments, prescription refills and simple inquiries. If this scenario sounds familiar, you may want to consider implementing a patient portal for your practice. This article will help you weigh the pros and cons of this technology and determine if it is right for your practice.

Patient portals are secure, web-based tools that enable around-the-clock email communication between patients and their care team.  Patient portals are perfect for  appointment, refill and referral requests. Portals can also be used internally to provide reminders, lab and procedure results, self-management tools and more. In addition, all communication through the portal can be stored in the EHR.

CAFP past president Joseph Scherger, MD, MPH, now Vice President at Eisenhower Medical Center's Primary Care 365 in Rancho Mirage, CA calculated that an average of 2-3 minutes is needed to complete one email communication. Dr. Scherger added in that order to be successful, a patient portal requires a physician to champion its benefits with patients, staff and other physicians in the practice.

Dave Ehrenberger, MD, Medical Director of Broomfield Family Practice, also uses a patient portal and said it improved staff efficiency in making appointments and messaging. According to Dr. Ehrenberger, the practice benefits because there is "no more phone tag and staff time spent listening to voicemail messages now that we're using the portal." Some of Dr. Ehrenberger's colleagues vowed never to use email for patient communications, but that vow quickly changed when they used the portal. The same colleagues now request immediate access to the portal because they realize how much time it saves them in documentation as well as responding to patient voicemails.

The software can be seamlessly integrated into an EHR product or interfaced with the EHR via vendor products. Click here to watch a 3.5 minute video on a patient portal (a tutorial for the patients of a multi-specialty clinic in Norman, OK). In addition, a variety of vendor portal demonstration videos can be found via Internet search with the key words "patient portal" and "video."

Portals can also be used by family members who have "proxy access" to manage care. For example, parents can request an appointment on behalf of a child or review a child's medical record with proxy access. Family members with proxy access can also better understand and manage the care of the elderly.

Dr. Ehrenberger found that 80 percent of his patients have registered for the portal and use it. An additional 10 percent registered, but do not use the portal and the remaining 10 percent did not register because they did not have email access. In order to pay for the service, the practice paid a one-time fee of $2,000 plus an ongoing fee of $40-$50 per provider per month for service charges. The costs were offset by the time staff saves through the use of the portal. Instead of negotiating appointment times via phone, patients simply indicate their reason for a visit as well as first and second choices for appointment dates and times.

One study of patient portal use found that up to 77 percent accessed the portal at least monthly, most commonly for laboratory and radiology results and sending clinical messages to their providers. Portal users were younger and more affluent and had fewer medical problems than non-users.[1]

The portal has been an "incredible crowd pleaser" for patients at Dr. Ehrenberger's practice. In addition, since implementing the portal three months ago, phone communication dropped by 20 percent and is predicted to drop by 50 percent. At each visit, nursing staff asks new and existing patients if they would like to receive email communications; patients who choose to use the portal get a print-out with instructions. All routine communications are then sent via email to participating patients. Incoming patient messages can be routed to clinical support staff, which most sites recommend, or go directly to the physician. Based on his experience, Dr. Ehrenberger said many physicians find it easiest to respond directly to patients instead of routing responses through support staff.

Effective implementation also requires training physicians and staff about the key distinctions between written and oral patient communication. There is no need for correct punctuation and spelling on the phone, but there is on the portal. It is also important to avoid medical terminology and jargon. For example, "sore throat" and "itching" are more likely to be understood by patients than the terms, "dysphagia" or "pruritis." Patients, of course, should be warned that with emergent issues such as chest pain, email is not appropriate. While many care teams respond sooner, 24 hours is a common response time and patients should be made aware of the possible delay.

Dr. Scherger finds that portals enable self-management by patients seeking more immediate access to lab and procedure results, as well as self-care information, including videos. Some portals enable direct medical record access for patients. Dr. Scherger cautions that while many think of portals as an "add-on," they are actually a new communication platform enabling care to be continuous and proactive rather than episodic and reactive.

In a randomized controlled trial with 606 patients from an academic internal medicine practice, 44 percent of portal user patients reported that communication improved with the clinic vs. 12 percent of controls. In addition, 59 percent of portal user patients described care as very good or excellent versus 48 percent of controls. Physicians received one portal message per day for every 250 portal patients. Patients were also more likely to send informational and psychosocial messages by portal than by phone.[2]

Enhanced email communication may reduce office visits. Kaiser Permanente has seen a 25 percent drop in visits following implementation of its portal and EHR. Reductions may, however, indicate that some visits are unnecessary visits or that some care is better managed via electronic communication.

At GreenField Health in Portland, OR, physicians use patient emails, e-visits and an interactive website to communicate with patients. The innovative internal medicine practice now does 40 percent of all patient interactions through web messaging, 35 percent via telephone and only 25 percent via traditional one-on-one office visits. Most of the physicians' time is spent answering questions and resolving issues such as interpreting test results or adjusting medications. GreenField physicians are paid for this work through an annual "retainer fee," from $350 to $650 depending on the patient's age, as payment for this work is not currently covered by insurance plans.

Email communications can also be leveraged to improve care and outcomes. In a randomized clinical trial, William Lester, MD, MS of Massachusetts General Hospital, found that a simple email to primary care physicians resulted in a clinically significant reduction in LDL levels in high-risk patients.[3]

Patient portals are a way to improve connection and access for patients, bringing providers closer to patients in a way that is familiar to them.  We hope this article provides you with practical information that will help your practice decide whether a portal will work for you and your patient population. 

Suzanne Houck serves as President of Houck & Associates Inc., a leader in ambulatory care redesign consulting and training. Sue is the author of What Works: Effective Tools & Case Studies to Improve Clinical Office Practice, the first comprehensive book on ambulatory care redesign. She also has experience as an ambulatory care manager and nurse practitioner throughout the United States and Africa.

DISCLAIMER

The articles provided in Practice Management News are general.  They do not constitute legal, practice management or coding advice in any particular factual situation or create an attorney-client relationship.  Consult your attorney or other professional for advice in your particular situation.

Copyright © 2010 The California Academy of Family Physicians - San Francisco, CA, USA.
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[1] Weingart, S.N., Rind, D., Tofias, Z., Sands, D.Z. (2006). Who Uses the Patient Internet Portal? The PatientSite Experience. Journal of the Medical Informatics Association, Volume 13, 91-95.

[2] Lin, C., Wittevrongel, L., Moore, L., Beaty, B.L., Ross, S. (2005, Jul-Sept). An Internet-Based Patient-Provider Communication System: Randomized Controlled Trial., Journal of Medical Internet Research, 7, 4.

[3] Lester, W.T., Grant, R.W., & Barnett, G.O. (2006, January). Randomized Controlled Trial of an Informatics-based Intervention to Increase Statin Prescription for Secondary Prevention of Coronary Disease. Journal of General Internal Medicine, 32, 1, 22-29.