Electronic patient portals – panacea or passé?

Sitting on an 11 hour flight from London to Los Angeles I finally got round to reading this paper which was published at the tail end of 2013 in the Annals of Internal Medicine; Electronic patient portals; evidence on health outcomes, satisfaction, efficiency and attitudes. If you remember the publication was met with quite a few news stories stating we need to move on as patient portals don’t work and have no impact on satisfaction or outcomes. However, when you actually delve into the meat of the paper (something I think few commentators are inclined to do) this is actually not what was found. The researchers from the VA and UCLA trawled through a vast number of published research articles from the last twenty-three years and found quite a mixed bag of outcomes. Certainly utilization of some patient portals did appear to generate improved outcomes, both in terms of better disease management and a need for fewer face-to-face visits, although some didn’t. One of the main issues the researchers’ encountered was the fact that there was usually a paucity of information around the context of how the portals were implemented and publicized. The conclusion from the study was not that patient portals don’t work, rather we need to better understand what elements are needed in terms of functionality and how best to implement them. Only then can we better understand how to use them and ultimately quantify what impact they can have on patient care.

With so many areas of our lives digitized these days I am frequently amazed at how slow we have been in healthcare to adopt similar strategies to streamlining medical practice. After all, these days you can sit at your computer and shop for groceries, access your bank accounts to transfer money or send checks, and even purchase an exotic foreign vacation. But the chances are you won’t be able to access your medical record, communicate with your provider or book an office visit. This will change; I am convinced of that fact. Already EHR vendors are including patient portal functionality in their solutions. In many cases these are quite rudimentary and only allow for a limited scope of interactivity, but it’ a start. Undoubtedly the new patient portals need to be “tethered” to the EHR, however I don’t think they necessarily need to be part of the same software suite. My reasoning is simple, EHRs are designed with a very specific task in mind; they are optimized so that data from individual patients can be written, stored and retrieved when necessary. This is very different functionality to what a patient portal needs and to this end this is why I think innovation and practical usability will happen quicker if separate organizations create this functionality and then plug this in to the broader EHR ecosystem.

The next area is what to include in the patient portal. Research has shown that giving patients access to their medical records improves engagement and self-efficacy. Indeed, the BlueButton movement is a great example of how opening up the data stream can result in some very innovative and valuable applications. My personal feeling is that the patient portal needs to be centered around specific task, in a similar fashion to doing online banking or booking a flight on Expedia. You go to the portal to perform a specific transaction (unless of course you’re my wife who will spend hours browsing vacation spots she will never visit!). In the case of the patient portal this may well be completing a health assessment as a prelude to an annual wellness visit, the creating an advance care directive or simply requesting a prescription refill or an office appointment. Whatever the task it needs to be simple and intuitive to complete and ideally accessibly from mobile devices as well as standard “home based” computers.

Without a doubt the digital age is finally creeping up behind us in healthcare. Some will try and ignore it for as long as practicably possible, although I believe that those of us who embrace it will see real improvements in their relationships with their patients, and importantly their outcomes too.

Example of provider's dashbard of their patient's health assessments results just prior to co-creating an annual wellness plan with them. 

It's Time to Practise Better Medicine

This article from @KathyKrostof on CBS got me thinking this week. Although as physicians we're no strangers to the art of complaining, it does appear that things are really getting strained out there on the front line. Talking to friends and colleagues from many different disciplines much of the frustration seems to stem from not being able to practise the sort of medicine we want to, and indeed signed up for when we first entered medical school. Too little time with our patients, over burdensome paperwork, a disjointed system where half the time we are in the dark as to what's happening with our patients outside of the office. I know I have to frequently spend significant amounts of time trying to piece together what's been happening with patients who see other specialists in different institutions; usually by wading through a disorderly pile of faxes or letters. This isn't medicine as it should be, this is fire fighting and disaster aversion. I am constantly amazed at how backward we have been, and to some extent continue to be, in how we practice medicine and deliver care.

This blog posting by @GertiTechBlog speaks volumes about the challenges faced by many of us, especially those working in primary care. And it is my feeling that the reason many physicians are feeling unhappy at the moment is not because they've fallen out of love with the practise of medicine, rather it is increasingly frustrating trying to do a good job.

Technology has transformed many aspects of our lives. It is sometimes hard to remember that we used to have to go to a travel agency to book a flight or a vacation, or go to a book store to buy something to read. Many of us now have complete control of our finances and bank accounts via the Internet and hardly ever have to visit a branch. Yet the practice of medicine has hardly changed during the time that this revolution has occurred in other areas of our lives. Why is this?

Part of the problem is undoubtedly the fact that as providers of care we have been extremely reticent to adopt new ways of doing things, preferring the status quo of the way its always been done. It wasn't a desire to practise better medicine that drove the uptake of electronic health records, it was the huge amounts of Federal incentives that made it happen. It really is very curious that it should take what is ostensibly a "bribe" from the government to do something positive, rather than taking it upon ourselves to enhance how we practise. Of course there is the debate that EHRs have not actually made the practise of medicine more efficient, cost effective or better...but that's a topic for another discussion!

Perhaps if we spent a little time looking at how other industries have developed and utilized technology over the past decade we could get some ideas on how we could improve what we do. I really do believe that the intelligent use of technology in our day-to-day interactions with patients and colleagues has the potential to improve how we feel about our jobs and also enhance our patients' satisfaction with the care we provide.

It's no secret that most major vendors of products and services have highly sophisticated customer retention and loyalty programs. They want to stay close to their customers, recommend other services that may interest them and find out what they think about what they've received to date. Now this is not a direct analogy with delivering medical care, but there are probably some aspects that still hold true. How difficult would it be for us to inquire from our patients how they are doing, what they thought of their last healthcare interaction and whether they were on track to reach the goals agreed on their last visit? Using traditional face-to-face interaction would probably prove quite difficult (or at least time consuming) for this, however, this is where technology can help and it is where the likes of Amazon, Expedia and Hilton, to name but a few, have excelled in driving loyalty and trust.

We need to think differently about how we deliver healthcare in the second decade of the twenty-first century. Storing information in an EHR is just the beginning, there are so many other ways we can interact and influence our patients in a positive fashion. Those of us who grasp this challenge, I believe, will drive better outcomes and greater value; two facets that are going to be integral to the future of healthcare.

nGage Health's patient timeline where all interactions with the healthcare system are graphically displayed for ease of review by both patient and provider.