Patient Portals: Beyond Meaningful Use

During the past year, there has been an upsurge in the number of doctors using patient Web portals, say healthcare consultants and EHR vendors. While the drive to show "meaningful use" of EHRs is fueling much of this new interest, the value of a patient portal can go far beyond that, some physician practices have discovered.

Medhavi Jogi, a Houston endocrinologist, says that the patient portal interfaced with his GE Centricity EHR has helped him and his partner build their 7-year-old practice. When consumers go to the practice's website, they can click on a link that takes them to the portal, where they can register as new patients. Three or four people a day do this, he says. Meanwhile, letting patients make their own appointments on the portal has reduced his practice's call volume by 20 percent to 30 percent. That, plus the elimination of most faxes, has allowed the practice to get by with just two support staff per doctor, Jogi adds.

Efficiency has also increased at Desert Ridge Family Practice in Phoenix, Ariz., over the year since it added a patient portal to its NextGen EHR, says family physician Tiffany Nelson. Phone calls are down, and the staff has to play phone tag with fewer patients as a result of the portal, she says. Moreover, the portal has turned out to be a terrific channel for patient communications, whether it's providing lab results, handling refill requests, or monitoring a patient with a chronic condition. Tiffany Nelson says the portal has increased patient, physician, and staff satisfaction.

Still, despite these and other advantages, some evidence suggests that the majority of doctors with EHRs haven't yet adopted patient portals. A representative from eClinicalWorks (ECW), a leading EHR vendor, says that only 20 percent to 25 percent of its customers bought ECW's patient portal when it was a standalone product (it recently became part of ECW's standard package). And a recent KLAS report found that more than two-thirds of ambulatory-care providers who had purchased an EHR were not sharing records electronically with patients. A portal is not the only way to do this to show meaningful use, as we'll see, but it's the easiest way to do it.

Consultants advise practices to start using portals for several reasons.

"The cost of running a practice can be reduced by using a portal," says Rosemarie Nelson, an MGMA consultant based in Syracuse, N.Y. "If we get patients off the phone, we get staff off the phone. If staff aren't on the phone, they're doing something else or we need less staff."

Moreover, she points out, physicians can use portals to increase the number of patients who receive recommended preventive and chronic care. That not only benefits patients, but can also boost doctors' earnings from pay-for-performance and medical home programs.

Michelle Mann, a principal in the IT Strategy Group of consulting firm CSC, agrees. As healthcare reform moves more of the financial responsibility for care to providers, she notes, portals could help doctors keep their patients healthier and out of the hospital and the ER. In addition, she says, portals may become a requirement to obtain government financial incentives in the future.

Given all of these reasons to use patient portals, it's not surprising that they're becoming increasingly popular with doctors. Here's what you need to know if you're considering adding a portal to your EHR.

The meaningful use factor

In Stage 1 of the meaningful use criteria, there are two core measures and one optional measure related to sharing records with patients. The first core requirement is to provide a clinical summary of each visit to at least 50 percent of your patients within three business days. The second criterion specifies that, upon request, you must provide half of your patients with electronic copies of their health information (including lab results, problem lists, medication lists, and allergies).

The leading EHRs can generate a standardized clinical summary known as the Continuity of Care Document (CCD). Consultants and vendors say that the CCD can satisfy the two core requirements of meaningful use. The CCD doesn't have to be sent to a patient portal, but it does have to be provided to patients in electronic form. A summary downloaded to a thumb drive or a CD would suffice.

The main problem with the latter approach is that it requires a lot of staff work. In contrast, moving a CCD to a patient portal - especially if your EHR automatically triggers the transmission - doesn't take up staff time.

Seth Eaton, a med-peds specialist in Laurel, Md., cites another reason why it might be hard for a practice to show meaningful use without using a portal. "The criteria say that 50 percent of patients have to get a summary of their visit notes within three days of visit. How do you do that if you're a busy primary-care doctor and your note is not necessarily finished when the patient leaves the office?"

There's also a possibility that more patient data-sharing requirements may be added in Stages 2 and 3 of meaningful use, notes Mann. For instance, one measure in the Stage 1 optional menu requires doctors to show that "more than 10 percent of patients are provided patient-specific education resources" electronically. This would have to be done on a patient portal or a practice website - and it could well become a core requirement in Stage 2, Mann says.

How patient portals work

Today, there are more- and less-robust portals available. The most elaborate ones have as many as two dozen features. These portals may allow practices to:

• Post lab results
• Post clinical summaries
• Send general health reminders, such as the need for flu shots
• Send alerts to specific subpopulations of patients (e.g., women over 40 who are overdue for mammograms)
• Receive and route prescription refill requests
• Receive and route appointment requests
• Have patients send messages to doctors, nurses, and/or administrative staff
• Let patients see statements and pay bills
• Let patients fill out medical histories
• Provide patient education materials
• Register new patients
• Create personal health records for patients

Generally, practices can turn on or off any of these portal features and use only the ones they want. But in some cases, it's impossible to inactivate particular components without hobbling others. For example, Jogi turned off the secure messaging feature of his portal because he's not getting paid for e-mailing with patients. But he can't send reminders to patients on the portal without the online messaging feature, so his staff has to phone patients or use regular e-mail to remind them to come in.

Eaton, whose seven-doctor practice has been using the eClinicalWorks portal with its EHR since 2006, says the group recently began letting patients make same-day or next-day urgent appointments on the portal. (They could always request appointments online.) Patients can also fill out a family history that populates the EHR directly, and they may soon be able to complete medical histories online. Also, patients can send messages to their doctor describing their symptoms after a visit or asking questions about their healthcare. All the physicians in the practice respond to these messages, which have become part of their workflow, says Eaton.

The ability of a practice to use a patient portal for clinical reminders may depend as much on the group as on the product, Rosemarie Nelson points out. Practices must understand how to run reports in their EHRs so they can identify subgroups of patients who need reminders about particular preventive screenings or types of chronic disease care, she says.

Different types of portals

Basically, there are three different kinds of patient portals. A few EHR vendors, including Epic, NextGen, and eClinicalWorks, have created their own portals, which are integrated with their EHRs. Other vendors have interfaced third-party portals with their EHRs: For example, GE Centricity's portal comes from Kryptiq, and Allscripts uses the Intuit Health portal. Other independent portal vendors have interfaces with particular EHRs. Some of these companies contract directly with physician practices; others, like Axolotl and Medicity, are available only through healthcare systems. Some third-party portals offer unique features: PatientPoint, for instance, uses claims data from certain payers to help practices alert portal visitors about their coverage gaps.

If you have a non-interfaced third-party portal, your staff may have to enter information from the portal in your EHR, creating additional work. Interfaced portals sold by EHR vendors may pose a similar problem or may allow only documents to be sent to EHRs, instead of populating them with discrete data. Some of these portals seem to fit well into the work flow of the practices we looked at. But only portals designed for EHRs provide true integration.

Rosemarie Nelson says a good portal will let you interact online with your patients and will be connected to your EHR. "The key components would be interactive forms and functionality that gets the patients and the staff off the phone. If the patients have to call in to get their prescriptions refilled, let's let them do it on the portal; ditto for appointments."

Tiffany Nelson explains how NextMD, the integrated NextGen portal, handles refill requests. "The portal has a text box for messages and one for refills. We have the doctors do the refills, so you'll see a request within your NextMD message box, and you can respond to the patient and say you're sending the prescription to the pharmacy, and then refill the medication. In an office where the medical assistant gets the refill request first, you can route it to the MAs."

Brett Smith, administrator of a seven-doctor internal-medicine group in Sandy Springs, Ga., near Atlanta, also cites refills as an example of the work flow integration between the practice's Allscripts EHR and its Allscripts-branded Intuit Health portal. When a patient asks for a refill on the portal, he says, the patient sees a list of her current medications and can request one of them. The message pops up on the doctor's website, and when he clicks on the refill request, the patient's chart opens up. The physician sees the medication and dosage requested and clicks on "refill," and the prescription goes online to the patient's pharmacy of record.

How much portals cost

Most EHR vendors charge separately for their portals, says Mann. Some of them charge an upfront license and implementation fee as well as a monthly subscription fee that depends on the amount of usage. Sometimes the latter is scaled to the number of patients using the portal (Epic) or the number of cumulative hits on the site (Allscripts), Mann says.

eClinicalWorks recently bundled its portal with its EHR for a monthly-based subscription price, per provider per month, including new mobile and "interoperability" features, says ECW CEO Girish Navani. Tiffany Nelson says that the efficiencies gained through the use of NextMD have saved more money than the portal costs her practice. But Smith says that hasn't been true for his practice's Allscripts portal. "If you're looking at the portal as a purely money-saving venture, that's going to be a tough sell," he says. "It's a very expensive feature to have."

Even if a patient portal isn't a moneymaker, it can help your practice show meaningful use and prepare you for the value-based reimbursement approach that's widely expected to take over. So a patient portal is a wise investment in your future.

Getting patients to use your portal

Obviously, a patient portal isn't going to have much impact if only 10 percent of your patients enroll in it. But some practices have been able to persuade a majority of their patients to get aboard. This requires effort and an effective strategy.

Rosemarie Nelson recalls, for instance, that one primary-care group was frustrated because few patients provided their e-mail addresses when receptionists requested them at the front desk without explaining why. The solution was to ask patients for their e-mail addresses at checkout after telling them that they could get their lab results and communicate with the practice online.

Tiffany Nelson and her colleagues take a different approach. When a medical assistant rooms a patient, she talks about the portal's benefits. If the patient is interested, the medical assistant collects his e-mail address and starts the enrollment by giving the patient a portal security "token." The nurse lets the doctor know the patient has begun the process, and the doctor tells the patient that if he finishes enrolling, he'll be able to get his lab results, a visit summary, and/or educational materials on the portal.

This approach has worked well: 3,500 of the practice's 9,000 patients and 50 percent to 60 percent of those seen in the office have enrolled on the portal, Tiffany Nelson says.

Smith's internal medicine practice uses another method to induce patients to go on the portal. When new patients register with the practice, they're asked for their e-mail address, and they receive a "welcome to the practice" e-mail that urges them to set up a user account on the portal, says Smith. Over the past year, he says, nearly all of the practice's new patients enrolled on the portal. One reason, he adds, is that he provides his own name and e-mail address in case they have any problem setting up the user interface.

In Summary

Patient portals can help practices in many ways that go beyond meaningful use. But they need a portal that can interact with patients and connect with their EHR. Here are the main points to remember:

• Use portal features, such as refill and appointment requests, which reduce the volume of phone calls.
• Look for a portal that provides interactive forms and fits well into your practice's workflow.
• Sending a clinical summary to your portal can meet key requirements of meaningful use.
• Portals can help physicians send patients alerts about needed preventive and chronic care.

Ken Terry is a New Jersey-based freelance writer and the author of the book "Rx for Health Care Reform." He can be reached at editor@physicianspractice.com.

This article originally appeared in the July/August 2011 issue of Physicians Practice.