Pursuing the Promise of Patient Portals
Why stop at online bill payment, appointment scheduling, and other conveniences? A handful of innovative providers are pursuing a grander vision for their online patient portals, enabling patients and clinicians to exchange vital medical data and collaboratively manage diseases.
By Sarah Stone Wunder | Print the pdf of this story
“When hospitals first stepped into the online sphere, many set up fairly static web sites,” says Mary Griskewicz, senior director of ambulatory information systems at the Healthcare Information and Management Systems Society. These sites featured general information about the hospital, contact information, and in some cases, physician referral services. Over time, these sites have expanded to provide patients with convenient online functions, such as appointment scheduling and bill payment. A number of hospitals have also added, or plan to add, personal health records (PHRs) that give patients a secure place to store and share medication lists and other health information.
There is a lot to be said for convenience, and many patient portals are making it easier for providers and patients to carry out simple transactions. Scheduling and other online request functions please busy consumers and reduce strains on call center staff. PHRs allow patients to more easily access their health-related information, and enable physicians to receive more data on their patients.
But these advances only tap the full potential of patient portals, say pioneering providers who are building more robust systems. These tech-savvy hospitals and health systems see patient portals as a key tool in building true collaborative partnerships between patients and clinicians that result in higher quality care.
The Flow of Information
At Cleveland Clinic, the patient portal has expanded from appointment scheduling and a PHR into an interactive, secure, online center where data flows in multiple directions.
Cleveland Clinic’s chief information officer C. Martin Harris, MD, MBA, oversaw the clinic’s online evolution from static web site to interactive portal. He says Cleveland Clinic realized that the most effective use of the Internet was to provide online services and tools for clinicians and patients that could help improve healthcare delivery, rather than only providing content that users could read or print out.
“When we defined our initiatives to move into the electronic age, it included tools for Cleveland Clinic physicians, tools for patients, and tools for physicians who weren’t employed by the Cleveland Clinic,” Harris says.
One of those tools was the clinic’s integrated patient portal, which now has more than 175,000 users. The portal extends beyond simple PHRs, which tend to be forms that patients are responsible for populating and keeping current. Instead, Harris wanted the portal to transform the way the clinic delivered services to patients.
The clinic began the process by integrating the portal with the clinic’s electronic health records (EHRs). Through this service, physicians upload medical information into the clinic’s EHR, most of which then automatically feeds into patients’ password-protected health records.
“That allows us to make the integrated portal a service to the patient,” Harris says. “It generates a personalized health maintenance list. So it will tell you when you need your screening mammogram, colonoscopy, or eye examination. All of that is a service to the patient.”
Patients can access medications, diagnoses, lab results, future and past appointments, vaccinations, and health reminders for follow-up tests in their PHRs. The only information that physicians upload into the clinic’s EHR that isn’t pushed to the patient portal is physicians’ notes and images because the files are large and sometimes require special software.
Real-time Results
During the past year, the clinic has started to expand on these services through partnerships with two free consumer health information services: Google Health (www.google.com/health) and Microsoft’s HealthVault (www.healthvault.com).
Through the Google Health partnership, Cleveland Clinic can receive patient information generated outside the clinic. Patients set up a Google Health account, which has connections with many retail pharmacies and retail labs, as well as a growing list of providers. Patients can pull data from those sources, such as medication refill orders and home care records, into their Google Health account. “Then, if they’re coming to the Cleveland Clinic, they can push that information to the Cleveland Clinic,” Harris says. “We can literally post that information right into our EHR for clinicians to access and also make it available through the integrated patient portal for the patient and the physician to see.”
Through its partnership with Microsoft’s HealthVault, the clinic has set up a way for patients with chronic disorders—diabetes, hypertension, and heart failure—to feed real-time medical data into the portal. Patients in the program receive an appropriate set of digital devices—such as a blood pressure cuff, a scale, a glucometer, and a peak flow meter—which they can hook up to their computers through a USB port. When patients use these devices, the information is uploaded to their Microsoft HealthVault account, which they can push to their Cleveland Clinic patient portal. “It’s collected digitally, and we can take that information and post it again into our EHR, into the patient’s portal, and make it available to them and their physician,” Harris says.
Both of these programs require minimal investment on the part of the clinic and patients. Cleveland Clinic established free partnerships with both Google and Microsoft, and implementing the programs didn’t require the clinic to hire additional staff or purchase software. Harris says the clinic did have to invest minimally in additional security software to implement the programs. For patients, the Google Health program doesn’t require any new software, and the Microsoft HealthVault program requires a free software download. Harris says patients with basic computer knowledge can use both programs.
Since launching the portal three years ago, Harris says the clinic has not yet collected enough data to know if it has provided any return on investment. In general terms, he says the portal has allowed the clinic to grow without adding incremental cost.
For example, through the portal, which adds 3,000 to 4,000 users each month, the clinic has reduced the number of calls it receives for scheduling appointments, prescription renewals, and access to records, such as children’s immunization records. “Once you get to 25 percent penetration of patients using the portal, you can reduce the number of people needed to staff the telephones,” he says.
Delivering and Gathering
The ability to generate research data while becoming more responsive to patients’ needs was the impetus behind a new portal for cancer patients at the Indiana University Melvin and Bren Simon Cancer Center in Indianapolis.
The project’s principle investigator is Anna McDaniel, RN, who works with a team of investigators from the Schools of Nursing, Medicine, and Informatics at Indiana University-Purdue University Indianapolis (IUPUI). McDaniel, who is also professor and assistant dean for research at the Indiana University School of Nursing, says the portal, which will launch in 2009, has two levels. The first level is a public level, which provides basic information about cancer and its prevention and treatment. The second level of the portal features a symptoms management system for patients who are undergoing chemotherapy. Patients log into this secure system weekly to answer a series of questions about any side effects they might be experiencing, such as fatigue, loss of appetite, or nausea. They also rate their symptoms on a scale of one to 10, with 10 being most severe. Afterward, the patients may receive self-care information or a call from their physician, depending on the severity of their symptoms.
For example, McDaniel says if patients rate problems such as nausea and vomiting at a level 4, they’ll automatically receive information within the portal about what they can do to control that problem. If they rate the problem in the 7 to 10 range, the system will automatically notify the patient’s physician at the cancer center.
The project, which is still in a research phase, will be launched with 20 patient participants. Over time, McDaniel hopes to gather research indicating the project’s affect on patient outcomes, resource utilization, and the cancer center’s and patient’s ability to control symptoms. Based on these outcomes, McDaniel and her team might consider rolling out the program across the cancer center, or possibly, to other community providers within Indianapolis or beyond. “That’s the beauty of the web,” she says. “It can be anywhere.”
So far, nurses have been supportive of the program because it may cut down on the number of calls they receive from patients about managing chemotherapy side effects, McDaniel says. And physicians are supportive because the portal will provide trending data on their patients’ side effects in an easy-to-scan, graphical format. “Physicians like to look at trends because a single data point isn’t that useful to them,” she says. “But if they can look at a trend and in context, it can be helpful.”
Informed Choices
Many portals provide patients with self-care information about specific diseases and conditions. Some hospitals, however, have gone one step further to provide patients with online decision aids—such as educational videos and interactive questionnaires—that help them understand and sort through the various approaches for diagnosing and treating breast cancer, back pain, and other diseases and conditions.
The goal of employing these decision aids is to get patients more informed and involved in the decisions that affect their health care, says Floyd J. Fowler, president of the not-for-profit Foundation for Informed Medical Decision Making (FIMDM), which works to create decision aids that provide up-to-date, understandable, and balanced information for patients facing medical decisions.
For example, if a patient is due for a colorectal cancer screening, a primary physician can give the patient a decision aid that explains the various screening options in advance of the appointment. That way, the patient will be prepared to have a thoughtful and informed conversation with the physician, Fowler says.
Working with FIMDM and others, Dartmouth-Hitchcock Medical Center, in Lebanon, N.H., opened a facility, The Center for Shared Decision Making, devoted to helping patients become more informed about medical decisions. Dartmouth-Hitchcock also has a patient portal called Patient Online, which has more than 45,000 users. Through a variety of projects, the center and the portal have been integrated to enhance both patient education and hospital research, says Kate Clay, RN, MA, program director of the Center for Shared Decision Making.
This partnership began with the hospital’s breast cancer research. Through the project, every newly diagnosed woman automatically receives a video decision aid about breast cancer in the mail, along with a paper questionnaire. The questionnaire gauges the women’s feelings about their care options and how these feelings change after using the decision aid. For example, the women are asked for their thoughts about having a lumpectomy versus a mastectomy before and after the DVD.
In addition, all women are instructed in the appointment letters to log on to their Patient Online account to fill out a self-reported intake questionnaire, which is relevant to their general health and their specific breast cancer diagnosis but doesn’t contain decision-making questions, Clay says.
Dartmouth-Hitchcock has since added prostate cancer patients, hip and knee replacement candidates, and primary care patients to the program. In addition to making meetings with physicians more productive, the program also ensures that only the patients who really want to have screening tests or treatments such as surgery do so, as opposed to automatically performing tests or surgeries when other treatment options might work just as well.
Quality over Cost
Like Dartmouth-Hitchcock, Group Health Cooperative in Seattle has also implemented a joint portal-decision aid program. Group Health began integrating FIMDM decisions aids into its 163,000-user patient portal, MyGroupHealth, earlier this year. Group Health implemented the program to improve quality by helping patients become more informed and engaged in their health decisions, says David Arterburn, MD, MPH, an investigator with the Center for Health Studies at Group Health. Because the program just launched, he doesn’t have numbers yet on how the program might affect costs and resource allocation. But he says that Group Health’s focus is on improving quality first. Whether that will equate to cost savings down the road remains to be seen.
“In this economic climate, we’re looking at different strategies that will both improve the quality of care and, hopefully, will result in either a cost-neutral or cost-savings situation,” Arterburn says. “It’s possible that decision aids, delivered through web portals, could be an intervention that both improves quality of care and also reduces costs by reducing unnecessary healthcare services because you’ve got more informed patients making treatment choices.”
Implementation Insights
Implementing a patient portal can be a long and expensive, but rewarding, proposition. Project leaders from Cleveland Clinic, Indiana University-Purdue University Indianapolis (IUPUI), and Dartmouth- Hitchcock Medical Center offer some lessons learned from their portal projects.
Go Big: At Cleveland Clinic, leaders rolled out the patient portal over two and a half years. They started in the ambulatory setting and then extended the program to the full hospital. If he could do it over, C. Martin Harris, the clinic’s chief information officer, says he would have rolled out the entire program at once. “There would have been efficiencies and greater value added to the actual practice.”
Get the Right People: Anna McDaniel, professor and assistant dean of research at IUPUI’s School of Nursing, says the right team made implementing her patient portal possible. The key was getting buy in and input from all parties involved. “It should not be only a researcher’s decision to implement this or an administrator’s decision,” she says. “You have to get buy in from the grass roots.”
Gain Trust: For McDaniel, getting grass-root buy in involved gaining the trust of all the parties involved. To build that trust, McDaniel says she had to reassure physicians that the portal would help both them and their patients. “They had to trust that I was there to help facilitate, through my research, what they wanted to do, and make it easier and better for them and for their patients,” she says. “Once they realized that my goal was to help them help their patients, it wasn’t a problem.”
Incentivize: Finally, sometimes getting things accomplished boils down to giving out free stuff. Kate Clay, RN, MA, program director of the Center for Shared Decision Making at Dartmouth-Hitchcock Medical Center, says getting physician buy in to self-care aids was easier once physicians watched a decision aid video—but actually getting them to sit down and watch the video was another story. “It’s hard for them to set aside the 30 to 50 minutes required to watch the entire video,” she says. “You have to do things like offer them CME (continuing medical education), give them free lunch, or pop them some popcorn.”
A Longer Uptake
The third Health 2.0 conference was held in October in San Francisco. The conference highlighted new healthcare technologies and offered discussions on how these technologies are connecting content and people in ways that can transform the healthcare industry. Gregory Makoul, PhD, chief academic officer and senior vice president for Innovation and Quality Integration at Saint Francis Hospital and Medical Center in Hartford, Conn., provided commentary for a panel discussion devoted to platforms for patient-physician communication. Makoul, who received his doctorate in communication science with an emphasis on patient-provider communication, says that as web 2.0 technologies expand in other sectors, the dynamics of uptake will be different in health care.
“We can’t just say, ‘Look what’s working out there in terms of online communities, and let’s apply that to health.’” he says. “In some cases, that model may work. In others, it will just take a nosedive because many people view their health differently than they view other things that they might do online.”
Makoul also cautions that before hospitals implement new portal technology, they must take the time to ensure that it will significantly benefit everyone involved.
“Nobody does anything that is going to take more time or money if it’s not going to help in some other way,” he says. “If it’s going to take me an hour more of my day, and it’s not going to save staff time or expenses or make my patients better, then it’s going to be a hard sell. We want to make sure we’re developing these strategies in concert with physicians so they’re convinced upfront that this really can be efficient and more effective. It needs to work for the doctors, for the patients, and for the staff.”