Many believe that granting patients access to their medical information will lead to better quality and coordination of care. They contend that the easiest and most efficient way to provide this access is through portals. However, as in other areas involving health IT, there are challenges and fears.
Some challenges involve adopting and implementing technology or reconfiguring workflows to optimize benefits from portals. Other issues surround managing clinicians' concerns and expectations to gain support for this new way of communicating with patients.
Fears surrounding portals include the concern that patients will be slow to use them and that those who could benefit from better access to information won't take advantage. That worries IT executives, who fear that their ability to meet one proposed objective of Stage 2 of the meaningful use program lies outside their direct control.
Even so, as reform changes the incentives in health care, portals are expected to be a key conduit for engaging patients in their care and getting them important health care information as quickly as possible.
Portals enable health care professionals to interact differently with their patients, and patients increasingly want access to and control of their health care online. These dynamics are new and exciting to many, yet technically challenging and problematic for others. Migrating to an interactive health care delivery system that functions outside the walls of a physical building offers possibilities for improved population health. When caregivers have the ability to access daily logs of patient activities, such as diet, exercise and medication management, they will be more capable of intervening with more effective treatment options.
"I think they're going to be very widely used," Albert Oriol, CIO at Rady Children's Hospital-San Diego, said. "We're trying to engage our patients and their families in their own health and health care, and the portal will be integral to achieving that."
Still, getting past the challenges and fears will be crucial to moving these portals into mainstream use.
Rising Needs for Patient Data
Meaningful use objectives are raising the need to share information with patients. Stage 1 required eligible professionals to "provide more than 10% of all unique patients with timely electronic access to their health information." Proposed Stage 2 objectives, as they now stand, would push more hospitals to offer portals to meet the requirement, as it would require them to demonstrate that "more than 10% of patients and families view and have some ability to download information about a hospital admission" within 36 hours of discharge.
Portal approaches in health care are not new; some pioneers in the field have offered patients access to their health care records for at least 10 years. Typically, portals give patients secure, Web-based access to some portions of their medical records and enable patients to facilitate interactions with providers, such as communication, scheduling, bill payment and other functions.
Use of the portals has grown slowly over the last 10 years, as consumers increasingly have become comfortable with using the Internet for shopping and banking. Providers also have learned a lot in the interim and increasingly see how portals can help them with reform approaches such as accountable care.
For example, Rady Children's Hospital had about 13,000 unique patients active on its portal this April, compared with only 3,000 accounts a year ago. "As of April, we're averaging over 10,000 visits a month," Oriol said. "Stickiness has jumped up as we introduced medical history and other types of questionnaires."
In many organizations, physicians will play an important role in encouraging their patients to use portals. That's helped Partners Healthcare increase patients' use of its portal, Cynthia Bero, IT corporate director of clinical performance management, said. "We launched a production version of our portal in 2002. Since 2007, we've been pushing it more aggressively. We started asking our physicians to engage with it. In the last three years, we've seen year-over-year doubling in usage (by patients)."
Bero says patients are responding to the convenience that portals provide, "to interact asynchronously with physicians' offices. They really appreciate the ability to access portions of their medical record, particularly lab results."
The portal for NorthShore University HealthSystem has experienced steady growth over its eight years of existence, Steven Smith, CIO for the Evanston, Ill.-based system, said. Some 170,000 patients can use NorthShore Connect to send and receive messages from physicians, schedule appointments, refill prescriptions, pay bills, and access medical records, lab results and educational material.
One-on-one discussions with patients, often in the physician office, have proven to be the most effective way to get patients engaged with the portal, Smith said. "It's the best way to explain the benefits of signing up with NorthShore Connect," although other marketing approaches also bear results.
Scope of a Portal Project
While implementing portal technology falls within the responsibility of the IT department, many organizations now see portals as an enterprise project, involving a wide range of departments.
"It is more than an IT project," Bero affirms. "I think it clearly falls in our clinical organization, and it's very central to our population health activities, and helps us look at what we can do to better manage population health."
"It's a project for an entire enterprise," Gary Barnes, CIO at Medical System Health Center in Odessa, Texas, said. "It really becomes a marketing tool for us, and separates us from our competition."
Depending on the approach and scope of the project, other constituencies interact with the portal project. For example, at Capital Region Health Care in Concord, N.H., the organization's first priority is to create a patient portal for its outpatient record system, CIO Deane Morrison said. "When you think about the big picture, the use of a portal by patients is predominantly related to the patient-physician relationship."
Not all physicians historically have viewed portals in that way, he added. "When the portal came out, doctors perceived it as not being useful and not necessarily helping them," Morrison said. "As we've put it in, we've seen a huge positive impact on the office workflow, with things like prescription refills. A lot of patient calls have been streamlined or reduced, and through the portal, we can route requests to the right person."
Not all patient populations are anxious to use portals, and organizations will have to work hard to get patients and their families on board. For example, Henry County Health Center in Mt. Pleasant, Iowa, will be logging patients or family members into the portal at discharge, and it's planning to install a kiosk and provide live help in its lobby to sign up outpatients for the portal.
"It's going to cost us some labor, but we hope it will be worth it," Stephen Stewart, Henry County's CIO, said.
However, portal implementation is still a stretching experience for health IT departments, offering a variety of technical and related issues to overcome.
Portals pull clinical and other information from a variety of hospital information systems. While some of the major health information system vendors are bundling portal capabilities in their systems, CIOs also are turning to vendors with portal products. In either case, facilities face myriad decisions on what type of information to present to patients (only normal lab results, for example, rather than all lab results) and what level of functionality to provide to patients (requesting an appointment vs. directly accessing the scheduling system and making an appointment).
Proxy issues, involving who can view data, also can arise. For example, health care organizations need to be careful in serving the health care needs of an adolescent population, which has the right to seek certain treatments on their own -- independently of their parents. In these instances, organizations need to ensure that parents are not able to view information through portals on reproductive or behavioral health issues without the proper permissions, Oriol said.
The challenges associated with power of attorney and state privacy laws complicate access issues even further. Determining the rights and who administers these rights must be worked out effectively to ensure the correct access is granted.
At the most basic level, easier availability of patient information raises the importance of matching patients with complete precision to their information. "If we cannot be absolutely certain on identity, then we could provide the wrong information to the wrong patient," said Elizabeth Johnson, vice president for applied clinical informatics for Dallas-based Tenet Health Care. The use of a national patient identifier could solve this and a variety of other issues involving matching patients with their own data, she said. The challenges of matching patients to their data should be balanced against the drive to include patients in their care by ensuring that "the information related to their care is readily available in electronic formats," she added.
Portals also will present support challenges for IT departments, which will field more questions from consumers on technology issues. For example, Rady Children's receives an average of 100 requests for help a month, which Oriol calls "minimal so far." Still, other CIOs say consumer support will add to IT staff work.
"Over 55% of my patient population is covered by Medicare, and it's not that the Medicare population can't do this, but it is a challenge," Stewart said.
Patients universally don't have Internet access, Oriol added. "We have a high percentage of lower income [Medicaid] patients, and many of them don't have Internet connectivity, and some have literacy issues," Oriol said. "There's a portion of the population that doesn't have the infrastructure to do this."