Easy Online Access Changes Doctor-Patient Relationships

Photo: File/Thinkstock
Photo: File/Thinkstock

The days of waiting on hold and playing phone tag with the doctor’s office are diminishing for patients across the state and nation as more and more health providers implement patient portals.

These interactive sites, which allow patients to message physicians, refill prescriptions and schedule appointments online, are bringing medical interactions into the digital age and prompting dramatic changes in doctor-patient relationships.

Information that once required an office visit or phone call, like lab results, can now be checked easily on mobile phone apps. And, in some pockets of the country, patients can even view their complete medical record, including physicians’ notes.

Many providers say the portals are altering the face of medicine, encouraging patients to become more active participants in their care. Instead of waiting on the doctor’s office to disseminate information and communications, patients can log on anytime to view health data or initiate contact with a physician.

“The old model is more parent to child,” said Lawrence Shore, a San Francisco family medicine physician who uses a patient portal. “The new model is more adult to adult.”

The electronic shift and the collaborative approach it encourages between doctors and patients has already led to some dramatic improvements in health. At Kaiser Permanente, which was an early adapter of portals in 2007, members who used the secure email function experienced a 2 to 6.5 percent improvement in glycemic, cholesterol and blood pressure screenings. Kaiser also reports a fall in emergency department visits for diabetics and an increase in well child visits for members who use the portal.

Smaller practices that use portals are seeing benefits, too, easing demand for office visits at a time when the Affordable Care Act is inundating primary care doctors with new patients.

“We keep saying we’re underserved, that we don’t have enough resources,” said Riverside family medicine physician Tarek Mahdi. “But we need to learn to work more effectively in managing those patients. The portal gives them the ability to be connected with care.”

Meaningful Use Accelerates Implementation

Thanks to a government incentive program, health systems throughout California and the country have an additional motivation to adopt these online sites.

The government initiative, called Meaningful Use, is part of The HITECH Act, one component of the 2009 economic stimulus plan. The HITECH Act’s goal was to improve American health care delivery and patient care through investing in health information technology.

The program is divided into stages and offers carrots – and later sticks—for health providers and health systems that become “meaningful users” of tools such as electronic health records.

This year, health systems can receive financial rewards for letting patients access their medical information online in a patient portal.

Some larger health systems in California such as Kaiser have already offered these services before the HITECH Act, but the government incentives are expanding the prevalence, clarifying the focus and speeding up the implementation timeline for many providers.

The government standards specify exactly how much interaction patients need to have with the portal to meet each stage’s goals. It’s not enough to simply sign a patient up and give them access; ultimately, they need to use the portal.

“Everyone is still trying to understand what will entice patients to use the portal and be engaged,” said Deanna Wise, the chief information officer for Dignity Health, which has 32 hospitals throughout California. “What is that magic?”

Challenges for Smaller Practices

Putting patient portals in place means facing the same challenges of overall electronic medical record implementation: larger organizations with more resources and deeper pockets tend to be the leaders while smaller mom-and-pop shops struggle, experts say.

“It’s a matter of money and people,” said Carl Bergman, who blogs about electronic health records. “General practitioners aren’t making bundles of money. If it’s a small practice, it’s hard for them.”

Fresno family medicine physician Nikki Donaldson experienced this difficulty firsthand. When the federal mandates on Meaningful Use came down, her small physician group had to replace its software and find a new system in order to meet those electronic records guidelines, a costly endeavor. In the process, they decided to merge with a larger physician group, in part because the financial benefits added up. For one, software is less expensive with group rates. And while the financial “carrots” are nice, they’re not enough to make up for the additional implementation costs.

The financial pressures of implementation – and the penalties that can follow those who don’t implement – are enough to push some older physicians to retire rather than comply, she’s noticed.

But size alone isn’t the sole determining factor in successful patient portal implementation, pointed out health care IT consultant Michelle Holmes with ECG Management Consultants, who has advised numerous health systems on patient portals.

“A two-doctor practice could have outrageous success and a multi-state health system could throw millions at this and fail,” she said.

In Holmes’ experience, providers with a very specific patient-oriented target – such as using the portal to bring in women who need mammograms – produce more rapid results.

Another key indicator of success is how invested physicians are. If doctors are engaged in the portal initiative, they’re on the front lines sharing that enthusiasm with patients. On the contrary, just posting signs in the waiting room or handing out fliers doesn’t usually inspire the patients to use a portal.

“You see a lot of IT-lead initiatives,” she said. “They’re putting it in as a check mark to go after incentive money or to avoid a penalty without appreciating the impact it can have on the quality of engagement with patients.”

Digital Divides

The population of patients who are actively using portals doesn’t exactly correspond to stereotypes.

It’s true that those with access to computers are more likely to log on, but many physicians interviewed say that the elderly have been among the first to embrace the new technology.

Seniors can give their adult children portal access, allowing them to monitor a parent’s medications online, and email the physician if they notice something’s missing.

Mobile devices also have leveled the technological playing field so that accessing portals becomes available to anyone with a smart phone.

But the digital divide does persist, especially in rural, underserved areas of the state. Clinica Sierra Vista, which serves many low-income residents in California’s Central Valley, hasn’t implemented a patient portal yet, though CEO Stephen Schilling predicts that could happen in the next year.

Schilling questions how useful portals will be for practices serving mostly low-income patients. Most of Clinica’s patients, for instance, don’t have computers or Internet access. But, he adds, “That will change over time, and, in a few years, I see some utility to it.”
Security of Personal Info

A key description of portals that everyone’s quick to mention is “secure.” That’s an important label for sites that may contain everything from health histories to a patient’s date of birth. It’s also a big part of complying with the Meaningful Use guidelines, with providers required to perform a risk analysis and ensure encryption. And it’s a critical component of building user’s trust in the new communication system.

“Every patient has the right to be concerned about the security of their data,” said Albert Chan, the medical director for Sutter Health’s My Health Online, who described his organization’s effort to secure portal data as “tremendous.”

But despite providers’ best efforts, security is an area where failure can happen, said Ogden Murphy Wallace health care attorney Elana Zana. Data is only as secure as the company providing it. As more vendors move into the electronic health record space, Zana predicts security could become more of a concern.

While large hospital systems often have sophisticated service agreements with big technology companies, smaller providers might not have the time or money to appropriately secure data while still delivering quality patient care. Hospital chains typically have multiple people working in their IT departments, while a solo practitioner or small group may just have an office manager.

“Imagine a three-person physician clinic,” she said. “They just don’t have the same amount of money or personnel ready to help them.”

The often-complicated guidelines for ensuring compliance with the government’s Meaningful Use add to the stressors.

“You’re dealing with all of these new rules and they can’t keep their heads straight,” she said.

Still, smaller groups can outsource help, and some portal software is being geared to fit their distinct needs, she added.

Zana isn’t aware of any large-scale breaches in patient data from the portals yet: “If you ask me a year from now, though, I think the answer would be ‘yes.’”

A Tech-Savvy Future

Patient portals are one step in the process toward empowering patients to take charge of their health, said Sutter’s Chan. Much of health care once was confined to the exam room, but technology is helping to shift it outside those boundaries.

Chan envisions a future where providers, patients and technology – such as devices that monitor fitness, food intake, or blood pressure – all work together to improve health.

“Most of health care that affects health – such as exercise or eating—happens outside the exam room,” he said. “Can we make that data more accessible and take advantage of the moment in which we could change something?”

San Diego-based Sharp HealthCare is already taking the next step.

This month, they’re implementing a new and improved portal that will enable patients to connect home monitoring devices – such as glucometers, weight scales and blood pressure devices—to the portal.

Holmes, the health care consultant, has heard talk of a future that goes even further, such as censors in patients’ socks that transmit activity data to the portals.

Ultimately, though, there’s still a lot mileage to come from simply taking health care online.

“At some point more is just more and not better,” she said. “I still strongly believe we haven’t even started using the technology that’s available to us now.”

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