The Patient Portal: Window on the Health Record

Implementing a patient portal requires a large commitment of time and resources.

PAUL KREMER, MD • TRISH KOLB, COA

The Centers for Medicare and Medicaid Services states that the goals of using electronic health records are to provide higher-quality care, improve the patient office visit experience, increase efficiency, and reduce unwanted or unneeded tests.¹

CMS also seeks to foster integration of the patient as a part of the healthcare team in a model known as patient-centered care.¹ CMS publications have reported that EHR will save the healthcare system money, save doctors and hospitals time, and save lives.¹

Implementing systems to meet the CMS requirements requires a large investment of both time and money. One of the mandates of Meaningful Use Stage 2 (MU2) is that EHR include a patient portal. A portal is not required to meet the Meaningful Use Stage 1 (MU1) criteria.

We focus here on the process of adopting a patient portal and discuss the metrics CMS uses to determine whether it is utilized appropriately.

PATIENT PORTAL

A patient portal is an online interface with a practice’s EHR that allows patients to view and transmit healthcare information in a secure fashion. CMS required it for two of the 17 Core Measures in Stage 2 of the Meaningful Use Incentive Program.¹

Implementation

Some EHR systems come with an integrated patient portal; otherwise, a cottage industry of portal suppliers may help. The security and MU requirements for a portal make it impractical for practices to develop their own systems.

Installation of the portal and integration with the EHR typically require an on-site IT specialist and close cooperation between the EHR and portal vendors.²

Office Training

A portal makes a practice’s medical record visible to the patient and anyone with whom they share their online access.³ Because patients might not appreciate the frank language sometimes used in medical records, staff and doctors must choose their words carefully in light of the added exposure and visibility.

Notations such as “complained she waited too long” or “did not take his medications as instructed” may reinforce dissatisfaction or be viewed as inappropriate once the patient returns home.

Tactful language can spare you embarrassment and wasted time coping with dismayed patients.³ “Patient expressed concern about wait time” or “Reports medication dosing omissions” may be more appropriate.

Practices must develop protocols for addressing portal-generated patient queries and requests for medical record corrections. Portal instructions for patients generally include warnings that questions may not be addressed for several days and that urgent matters should be called in to the office.

Requests for medication refills, scheduling changes, and general questions may be routed, much as phone requests, through appropriate e-mails. A technician may respond to patient portal messages on behalf of the physician by phone, with progress note documentation in the EHR.

Only physicians are allowed to respond via secure e-mail. MU2 guidelines, however, do not require physicians to respond to portal queries. In our office, technicians answer them over the phone.

No requirement exists to simplify or “dumb down” the medical terminology transmitted to the portal into nonmedical nomenclature. Most nonophthalmic physicians admit an inability to understand and interpret ophthalmologists’ examinations.

Patients who review their records on the portal may find much of the information confusing or unintelligible, and offices should prepare for clarification requests.⁴

Costs

Portal implementation entails a setup fee and ongoing maintenance fees. In most cases, the fees are “per doctor” and run in the thousands of dollars for setup and hundreds of dollars for annual maintenance.

Depending on your software vendor, a transaction fee may apply for each patient’s access to the portal. Portals may offer levels of services ranging from bare bones (the minimum necessary to achieve MU2 requirements) to “Cadillac,” which could include appointment scheduling, visit reminders, and bill paying.

These costs do not take into account the substantial additional time required of technicians and doctors to train for and use the portal.

MEETING THE MEANINGFUL USE STAGE 2 REQUIREMENTS

Medicare and Medicaid provide financial incentives for the MU of EHR to encourage physicians to adopt EHR in their practices. To receive incentive payments, physicians must meet specific requirements; MU Stage 2 requires the use of a patient portal.

This requirement can only be excluded in areas of “low broadband availability.”⁵ Two MU Core Measures require the use of a portal, and another indirectly requires it.⁶

Portal MU Core Measures

Core Measure 7: Patient Electronic Access (two parts). Part 1 requires physicians to provide online access to health information within four days of the visit to at least 50% of unique patients seen within the reporting period.

Part 2 requires that at least 5% of unique patients view, download, or transmit their health information to a third party.

Part 1 can be accomplished by collecting patient e-mails at check-in and entering them into the EHR. Those patients who have e-mails will be granted “access” to the portal after their visits. The patients will then receive an e-mail message with an invitation to access their health information through the portal.⁷

Our goal has been to educate our patients about the portal while they are in the office, assuring them that their records will be secure and that no solicitations or advertisements will be sent. Consequently, we have collected e-mails from more than 50% of our patients.

Achieving Part 2 is more difficult. Physicians have no means to ensure that 5% of patients go through the process of signing up online, establishing a password, and viewing their health information. At the time of an office visit, we provide patients instructions for establishing accounts on the portal.

Core Measure 17: Use Secure Electronic Messaging. This measure requires that 5% of unique patients send an electronic secure message to the physician. The only means to achieve this objective is via the patient portal. As with Measure 7, no way exists for a practice to force patients to send messages.

Our portal handout includes instructions for sending doctors a secure message. We also send these instructions to patients who have portal accounts, encouraging them to send doctors a message.

Core measure 12 requires physicians to use clinically relevant information to identify patients who should receive reminders for preventative/follow up care “via the patient’s preference of the methods available.” If a patient indicates e-mail as a preferred communication technique, this must be transmitted via a portal. The requirement mandates that 10% of patients with two or more visits in the preceding 24 months receive notifications.

In our practice, we identified patients with conditions such as AMD and transmitted health information to their portal site.

PATIENT FEEDBACK

The patient response to our portal has been mixed. Many patients prefer not to provide us with their e-mails. Some confront the doctor in the exam lane, fearing that their medical information will be shared with the government or that they will receive solicitations. Many call the office for clarifications regarding information on the portal that they do not understand or question.

A few patients have used it as a platform to complain about wait times and the office waiting room running low on free coffee and cookies. Others have used it as an outlet to blog about their entire medical history. Some find the clinical information on the portal interesting and thank us for the service.

In our office, the most useful function of the portal has been facilitation of medication refills. It has reduced phone volume for those requests. This function is not required by MU2.

CONCLUSION

Patient portals in ophthalmic practices require considerable investments of time and money.⁸ They allow patients to review their ophthalmic records and send secure messages to the office and doctor.

Challenges remain in assisting patients in interpreting ophthalmic nomenclature and encouraging them to utilize portal technology, as mandated by Meaningful Use Stage 2. RP

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