Much Ado About Patient Portals

From Chilmark Research’s perspective, patient portals are by and large Much Ado About Nothing. Sure, plenty of healthcare organizations (HCO) talk about patient access, engagement, and satisfaction and how they wish to empower their patients. They point to their glossy patient portal and say look at this wonderful tool we are providing for our patients. But if one digs a little deeper one finds that most patient portals suffer from numerous ills including:

  • Providing a patient only limited access to their records. There are no clear and consistent policies in place today as to what a healthcare organization is obligated to provide a patient access to.
  • Do not support portability that allows the patient to export personal health information (PHI) to another site/repository that they can then control (e.g., Google Health, HealthVault or other PHR).
  • Do not allow for patient entered data nor the ability for a patient to annotate records.
  • Rarely support transactional processes such as online appointment scheduling, Rx refill requests, eVisits.
  • Are just about as user friendly as a clinician’s EHR.

The problem with patient portals is that they are not seen as an integral part of the care process. In fact, we would argue that the use of the terms PHR and EHR create an artificial division – let’s just call it a CHR (Collaborative Health Record) and be done with it. But alas, such is not the case. Ask your local HCO where funding for their patient portal comes from – 9 times out of 10 they’ll say the marketing budget. As we reported from this year’s HIMSS conference, sure there was talk of patient engagement via portals but the message was one pitched to the Chief Marketing Officer (CMO) and not the other CMO, the Chief Medical Officer.

Yes folks, today the patient portal has very little to do with the patient being an integral part of the care team. No, the patient portal is all about improving consumer/patient satisfaction scores and more tightly linking the consumer to a given HCO. Therefore, is it any wonder then that if a patient portal is not viewed as an integral part of the care process then physicians are unlikely to actively advocate its use leading to a market where consumer adoption and use of patient portals remains at a paltry 6% or so nationwide.

As with anything in life, there are no absolutes and in the case of patient portals there are some stellar examples of HCOs using a patient portal to actively engage their patients. The most publicized example is Kaiser-Permanente with adoption at roughly 35% of all patients served. Primary to K-P’s success is providing its members not only access to their PHI, but also the ability to perform a number of transactional processes, e.g., appointment scheduling, online consults, etc. Up in the Pacific Northwest, the Group Health Cooperative (GHC) has also been very proactive and reports patient adoption and use of their patient portal at over 60% (that’s an order of magnitude greater than the national average!). The May 2010 research paper that GHC published in Health Affairs is pretty clear on what has driven such high adoption: the patient portal is not about marketing, but forging tighter links between the patient and physician to improve the efficiency and effectiveness of care delivered.

Now both K-P and GHC are somewhat unique in the healthcare market for both are “vertically integrated” being both the insurer and the provider. They assume the full risk of managing their patient/member populations and thus will seek out solutions and concepts that will lower medical loss ratios (MLRs) and keep their members in less costly care settings. Therefore, it is to their benefit to actively engage members in managing their health and both of these organizations have found their patient portals to be a critical piece in the engagement puzzle. With pending changes in payment models moving from fee for service to bundled payments, HCOs of all sizes will need to adopt business strategies similar to KP and GHC, including deeper, more meaningful patient engagement.

Thus, it is with disbelief that some of the recent comments to proposed Stage 2 Meaningful Use requirements state that it is unreasonable to expect physicians to have 20% of their patients using a patient portal. Now, we do agree that it is silly to ask every physician practice in the country to provide a patient portal, but it is not unreasonable for large physician practices, hospitals and clinics to provide such. Unfortunately, it appears that the medical establishment does not see the writing on the wall; that their future success is not contingent upon another marketing initiative but in truly and thoughtfully engaging the patient as part of the care team for if they were to do so, as KP and GHC have demonstrated, achieving that 20% target is not beyond reach.

Is your HCO rising to the challenge?

 

Posted in ACO, Consumer Engagement, consumer health, Electronic Health Records, Google Health, health portals, HealthVault, policy Tagged with: , , , , ,
21 comments on “Much Ado About Patient Portals
  1. So, sir, what is the purpose of including this photo in this post?? :-)

  2. I’ll also say, btw, that this is a massive chicken & egg situation. Consumer/patients aren’t accustomed to using portals, because most consumer/patients can’t imagine having access to one. It’s nuts.

    But then, hospitals in general are so pathetically un-IT that this aspect of it is no surprise. SOME are getting on board, starting with technically trivial things like publishing their ER waiting times on the internet, and some even offering call-ahead ER bookings so you can then watch your queue position from home, instead of spending 3-4 hours sitting in a germy ER.

    Imagine, the gazillion dollar hospital industry catching up to something low-priced family restaurants have been doing for years! And yet most hospitals I’ve talked to about it get a deer-in-the-headlights look, like “How would someone do that???”

    I just visited a friend in a big-name hospital. She puts in a request for a physician or a med, and it’s HOURS before she has any idea of the status of her request. Suggest to the hospital that the in-room TV could have a monitor to watch the status of the request, and the headlights come on again.

    To get around to your question, I’d say the real question is whether my HCO is even asking the question of what would constitute good service to its customers. If they start with that question, it becomes sensible to redo workflow, including bringing the customer into the process. Until they ask that question, there won’t seem to be any purpose to it.

    For a rant that’s tangential to this, see my Who Gets To Define Quality?

    p.s. I sure wish you had the Comment Preview plugin…

    • John says:

      Thanks for chiming in Dave.
      The main point of this post and your even your comments reflect it to some degree, is that HCOs and the vendors that serve them still view patient portals as a marketing issue. Stage 2 may push them to think that it is also a compliance issue. What they are NOT THINKING is that they need to completely rethink this and begin looking at patient portals as a critical tool for patient engagement and make it a part of the care process. Unfortunately, very very few HCOs have begun to think in this manner.

      John

  3. “Put the Patient at the Center” is best for doctors.

    One other thing that sets Group Health apart is that it was and remains the only EHR implementation that started with the patients having access.. Dr Matt Handly one of the authors of the article give a nice overview in one online video

    They could “write” to their records via email to their providers before the providers had CPOE (so only had read access)..

    Group Health is not just an integrated system it is a co-op that is literally owned by the patient/members. The providers in fact are a different organization that contracts with them to provide services.

  4. So, Sherry, what stops the Group Health co-op from going nationwide? Or being cloned? I know some docs who would love the idea.

    • It is pretty straight forward and in the attached video both Matt and James address it up front.. The financing method is different.

      When you are able to invest in health IT or workflow changes or for that matter preventive care and you also are he insurance company all of the savings stay in house..

      It is why the VA was the first to adopt an EHR – they own their patients for life and had limited resources. Places like Kaiser went next but GHC was the only one to literally start with the patients..

      Sadly until you combine payment reform with technology (and workflow redesign) you won’t be able to duplicate it..Each time a provider or clinic finds a new way to keep people healthier or provide care outside of the hospital or clinic their income will drop and the insurance companies will get the savings (which they should share).

      Thankfully the government which now pays for over 50% of all care in this country figure it out and that is what is behind the HITECH portion of ARRA.. If they pay for the new EHR’s they thought they would get the savings. What didn’t change however is that the doctors are still in a fee for service world. I would expect direct pay and ACO’s to be the first adopters but even there they are not putting the patients first and working from their old model of provider first.

      Note: I believe that the solution will come from patients and providers working collaboratively.

  5. Dan Munro says:

    Great topic – and timely for us. We’re kind of living in the middle of this exact debate with ipatient – so for what it’s worth – here’s some of what we’re seeing (with apologies for the length) :

    1) Patient-portals are a misnomer. They’re really provider-centric solutions (that benefit the provider and tether the consumer). They can be big – like KP, GHC, Dossia and VistA – or they can be smaller solutions – but they’re still proprietary. As a patient, if I move – or change employers/payers – that data may or may not be reusable (let alone accepted) by another provider (excluding VA for a minute which is basically lifelong). Adherence to CDA/CCD/CCR is designed to mitigate this – but systems based on those standards aren’t widespread enough – especially with smaller providers. MU will affect this change – but that’s still a fairly slow (albeit steady) march. That’s just the technical side. Having large incumbent IT vendors agree that these records need to be portable for use with directly competing systems is almost a separate debate.

    2) Fully engaged patients are growing in numbers – but still a minority (notwithstanding Dave’s amazing single-handed efforts ;-). There’s both a generational and financial aspect to this (especially among all us aging boomers). We’ve grown accustomed to having the provider “handle” both the clinical and financial data on our behalf (the paternalistic model). Gen X, Y and Z tend to interact with the system less – and don’t fully understand how we’re not all iPhone/iPad based – like yesterday. Mis-aligned financial responsibility is a large part of the fault here – which brings us to #3.

    3) Having consumers assume more financial responsibility is (in my opinion) inevitable. Mary Meeker’s recent report (USA, Inc.) is the real eye-opener for this. Out-of-pocket consumer healthcare payments went from 47% in 1960 to 12% in 2009. That’s a staggering shift – largely attributable to the addition of Medicare/Medicaid which went from 0% in 1965 (inception) to 35% of total HC spend in 2009. [ Page 106 - http://buswk.co/dZ8TFD ]. Hard to imagine how any change won’t try to shift that imbalance back – and it does feel like that has already started.

    4) Sadly – one of the larger/single demographics being forced into this debate (our primary target with ipatient) is Mom (herself, kids, and now aging parents).

    5) PHR’s are the flip side – and I just wonder if we need (or even want) the huge multiplicity of data that comes with that. A single EHR that moves with the patient (mirroring lean manufacturing per Dave’s thinking) would seem to be the ideal – but how do we get that? Pretty sure it won’t be by having multiple versions (multiple EHR’s + PHR) everywhere to start.

    Some patients are eager to engage – some even voluntarily – but these are still big shifts in responsibility (at the national level). A “middle-ground” sounds great – and maybe that’s the ACO model – but that’s also the now infamous Unicorn quote (“we all know what it looks like – but no one’s actually seen one”). Whatever does happen – we’re still years away from a more balanced model because of the historic nature of the mis-aligned incentives (in support of a very expensive fee-based system).

    John – really like the term CHR – but we’ve got so many xHR’s now – not sure if yet another will survive – but we’re game to wave (with appropriate credit) this flag too.

    • John says:

      Dan,
      Similar to the comment to Derek, the purpose of the post is to get HCOs to consider patient engagement via IT and what it will look like within a new, updated HIT environment before they actually begin the process of implementing that new CHR. Unfortunately, the patient portal still remains under the purview of the Chief Marketing Officer and as long as it is there, it will never see broad adoption and use because the clinicians will not take it seriously. When clinicians take it seriously, they will insure that their patients take it seriously as well.

      • Dan Munro says:

        John,
        Yup – agreed (and sorry for the rant). Tend to get a little passionate (and very committed) on this topic because it’s often the entry point (outside of ER) – and the consumer UX is painful. Maybe the ACO model will empower clinicians (and their CIO’s) to reign in Marketing. The size of those budgets seems to have really mushroomed – and they seem overly focused on brand – less on actual healthcare.

  6. We’re being asked more and more to have CCD/CCR downloads for patients.

  7. Very interesting discussion and one very appropriate to the developing role of electronics in health care
    I like the concept of collaborative health records in care and the real interface that a patient might have…after all their information is theirs, whether I as a specialist or their hospital keep those records, correct?

    As a specialist new into overly complex EHR, my concern is currently the level of interface by the patient and the potential for intrusion into the office work pattern (which with our relatively recent adoption is just getting back to being smooth).

    I have a vested interest in imaging and as I gather, the interface for imaging inclusion and appropriate means for evaluation measure, and storage as part of a given patients record is still primitive or does not exist…….as an aside, this perspective is coming from Canada.
    Derek Cooke

    • John says:

      Derek,
      First, thank you for your comment, always like hearing from those truly on the front lines, clinicians!

      You are correct that the management of imaging is still more difficult then need be but happy to report it is improving. Last year HealthVault began accepting images (DICOM) and a number of start-ups are getting into the game including local vendor LifeImage who landed a second round of VC funding recently.

      As to your comment regarding complex EHRs and having life slowly return to normal after installing – this is just the issue that Chilmark would like to prevent. This post was written in the hopes that HCOs will consider patient engagement at the forefront of EHR/CHR selection and implementation in order that workflow can be built-in rather than an afterthought. As an industry, we need the Chief Medical Officer to become directly involved, if not lead the patient engagement via IT process.

  8. Hi John,

    Interesting post. The patient portal opportunity is clearly drawing lots of amateurs but there are some gems out there to be found.

    Here’s one I’m sure you’ll find interesting: http://PatientsKnowBest.com

  9. Larry says:

    In order for health care to meet the requirements of the six aims of the IOM (safe, effective, patient-centered, timely, efficient, and equitable) communications between and among the patient, providers and care givers must coalesce around a plan of care. The plan of care is both a virtual and an actual document of information structured for human comprehension. The plan of care provides the linkage that enables the health care system to transform from a series of sectors to a system of health care. The health care setting is an often unorganized series of handoffs between doctors, nurses, pharmacists, home care, patient advocates, insurers, friends and relatives, as well as the patient to name but a few. At each point along the way there are opportunities for miscommunication, a lack of communication and misunderstanding of the communications. The Plan of care is the ‘glue’ that can, if appropriately structured and implemented, bind all of the participants in the patient’s episode of care.

    Health care is undergoing a transition driven by the new health reform laws (ARRA and PPACA), by costs that are unsustainable by about almost any measure, and stakeholders driven by the dual goal of driving down costs and maintaining margins.

    Effective use of data, first turning it into information and then applying the knowledge that it generates may well be the key to the Triple Aim.

    The Triple Aim developed by the Institute for Health Improvement (IHI) and its leader, Don Berwick, calls for the simultaneous achievement of 1) improving population health; 2) enhancing the patient experience (including quality, access and reliability); and 3) reducing, or at least controlling, the per capita cost of care.

    In order to make this a reality the health sector must refocus its efforts into a completely patient centered approach. It must consider all three of these aims simultaneously. Not to do so, signals a lack of understanding of the complex interrelationships of healthcare. It is these complexities that drives the need to have flawless communications at every step of the episode of care among all of the caregivers and between caregivers and the patient.

    In testimony before the Senate Finance Committee on November 17, 2010, Don Berwick said that, “beginning in 2011 Medicare will cover an annual ‘wellness visit’ at no cost to the beneficiary, so beneficiaries can work with their physicians to develop and update a personalized prevention plan” (p.12). While that’s a beginning, it goes well beyond this early initiative to shift focus. A prevention plan is the first phase of mapping out the care required for a complete episode of care. It comprehends a patient and a provider. The healthcare system is much more complex than the singular doctor patient relationship.

    Just a couple of months earlier an influential panel of healthcare stakeholders were convened by the Institute of Medicine. The panel set a goal that, “by 2020, 90% of clinical decisions will be supported by accurate, timely and up to date clinical information and will reflect the best available evidence.”
    Americans should expect at least that, given the huge investments tax payers, employers and patients have made in both health research and technology. Why have we failed to do so up until this point? The answer is embedded in a complex series of systems and economic constructs.
    The health care sector is plagued by a nearly perfect storm. Patients who up until this point have paid little for the care they receive, a Hippocratic oath that requires the provision of care without regard to cost and dramatic medical advances that have improved functionality and length of life. There has been an emphasis on technology development and knowledge acquisition, but relatively little focus and attention on wide ranging, rigorous application of the knowledge. At the same time, until now, there has been a dearth of expenditure on document technology and process communication. Rigorous application of knowledge requires comprehensive document technology spanning both paper and electronic documents.
    The lack of process, communication and document technology has manifested itself in shortfalls in provider knowledge (versus what is possible), inadequate care coordination, poorly measured processes and outcomes and therefore misaligned incentives. Each sector of the healthcare system acts autonomously and has little access to the information of a related, but unconnected third, fourth or fifth contributor to the patient’s episode of care. Electronic medical records, when implemented will alleviate some of the fragmentation among providers, but without a universal tool to link all of the parties to the episode of care the system will remain fragmented.
    The National Quality Forum (NQF) mission includes, “Endorsing national consensus standards for measuring and publicly reporting on performance.” In its 2010 consensus report on, “Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination” , it laid out a series of Preferred Practices. These practices call for a formal Plan of Care. In doing so, it defines the attributes and required pre-requisites for Plan of Care development. Preferred Practice 3 states: “The healthcare home shall develop infrastructure for managing plans of care that incorporate systems for registering, tracking, measuring, reporting, and improving essential coordinated services.

    The patient portal is one integral part of the whole system of care. To ignore this aspect is to deny people the benefit of both research dollars and the power of technology.

  10. Kourtney Gorvro says:

    Excellent post – thanks for sharing it. I agree with you and am a support of patients being active in their healthcare and overall well being.

    I had a great conversation with a hospital CEO over the weekend and her concern was the lower income individuals. The patients who participate in their overall health are generally better educated and more affluent. How do we better close the gap? What are your thoughts on that?

  11. I applaud your comments. As a former CIO and early adopter of a PHR that was teathered and complete, and as a consumer health professional, engaging patients is not aout entertainment, but collabortive care.
    Patient access is still too passive. An order for patient tests, and medicine warrants a response to the record. What about patient instructions? Why is there not patient reponse included in the chart? Asking the patient to learn about diet, or their treatment and getting answers back? PHR have in general been only about what interests the patient. To have a collaborative care record, let’s as a first step, acknowledge that the clinician ordered items for a patient to achieve have an expected response?

  12. Doug Dormer says:

    Thanks to John and all commentators. This is an excellent and important conversation.

    Disclaimer: I am head of a company that sells what we call a “Patient Access Platform.” That’s our way of bridging the constituents and vernacular–Patient Portal, PHR, mHealth, CHR. I am also a patient/consumer who has been involved all my life in an earlier version of this theme sometimes referred to as the Independent Living movement.

    As I read John’s excellent post and the wonderful comments, it strikes me that one notion is missing: John (and several others in the thread) properly points out that K-P and GHC have financial incentives for patient engagement that are not applicable–or at least recognized–by other separated providers and insurers. While there are various initiatives that are driving us towards bundled payments (ACOs, etc), there is one more dynamic that may be even more important: The role of the employer as the ultimate payer (aside from Medicare/Medicaid).

    Since more than 55% of employers who offer health insurance are self-funded, it seems only a matter of time until they exercise their influence on the market. The present increases in cost cannot be ignored. Once employers, and through them consumers, change their expectations and begin to demand the same level of participation they have in managing their financial portfolios and every other aspect of life through an online prism, healthcare will follow.

    As with so many transitions, the anticipation is often worse than the reality. In this case, there are two key characteristics that may allow progress driven by the market:

    1) Expansion of the role of care coordinators. We see this in certain disciplines already (e.g. the increasing role of nurse navigators in cancer programs). In this sense a profound change in process can be accomplished without requiring physicians in particular to make a whole-sale change in their individual behavior.

    2) More focus needs to be on the CHR as the backbone while the UI must expand to suit the needs of the diverse population. As an example, for certain segments of the patient community with little access to or interest in an on-line application, a low-tech cell phone may need to play a much larger role as the UI. Similarly, the convergence of Patient Portals, PHRs, mHealth (including integrated devices like glucometers, scales, etc.) which allow for the use of the CHR where there is neither a cell phone or a computer, will allow for the broadest engagement across the population.

    In short, we believe this critical shift will come. While the focus on technology first may have the cart in front of the horse, we are glad there is a cart. We know how the horse will behave. As in every new market, the “horse” will follow the money.

    Once employers leverage their power, insurers and providers will follow. Engagement of employers may be the critical piece that builds upon the mandates to achieve the point of inflection, and we’ll be glad for these early infrastructure mandates.

    The question is, how long will it take till insurers and providers see this level of patient engagement and empowerment as being in their personal, financial benefit?

    Personally, I don’t see how key employers, insurers and providers can ignore the accomplishments of K-P and GHC (and a few others) much longer. I think we are close to seeing other early adopters show the necessary leadership. Change will come.

  13. John,

    Could you provide any citations for the following comment?

    “use of patient portals remains at a paltry 6% or so nationwide.”

    Thanks,

    Steve Wilkins

  14. Dave Chase says:

    Outstanding post, John. And the comments are just as good as the article.

    The only quibble I have is your statement “Now, we do agree that it is silly to ask every physician practice in the country to provide a patient portal.” Yes, it’s silly with today’s flawed reimbursement model and overpriced software but I don’t accept that we are doomed to both of those fates. Fortunately, I see reimbursement model alternatives that are flourishing (and there’s a Trojan Horse of sorts in the new health law virtually no one knows about – Google “Health Insurance’s Bunker Buster” for my reporting of that on the Huffington Post). Overcoming the overpriced software barrier will happen when Moore’s law hits the healthcare IT arena (disclosure: we are doing that) and drives down the price by orders of magnitude as has happened in many other categories of software.

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Chilmark Research is the only industry analyst firm focusing solely on health IT. We combine proven research methodologies with intelligence and insight to provide cogent analyses of the emerging technologies that have the greatest potential to improve healthcare. We do not shy away from making tough calls, and are respected in the industry for our direct and thoughtful commentary.