The principal drawback to the hospital-controlled portal is the limited portability of the record, Sands acknowledges. "When patients sever ties with the institution, they can't take their information with them," he says. "We don't have EHR connections across the country to make it easier."
In the short run, that lack of portability won't affect many patients, Sands contends. "Increasingly, there's consolidation among provider groups to large systems. The portal is going to be the only thing you need. As the industry consolidates, the portal will be fine for the majority of patients-unless they move. We need to figure out how to connect our disconnected system through health information exchanges, so patients will have access to their own data through them."
As the industry moves away from fee-for-service to outcomes-based reimbursement models, the need to maintain connectivity with patients becomes even greater.
The shifting payment landscape is a big driver behind patient portals. Practices like Women's Care Florida need to run as efficiently as possible-and automating transactions via the portal is a timesaver for patient and provider alike, according to Mervis and Mangan. Using the Greenway portal, patients can fill in customized forms online prior to the visit, information which ports to the task list in the EHR.
"The staff can compare the old history with the new before accepting," Mangan says. Each year, the practice completes some 8,000 appointment requests and 2,500 prescription refills through the portal, transactions which once required phone calls and paper notes. Inevitably, during those calls, staff would small talk with patients, protracting the call needlessly, Mervis adds. "There's no more chit-chat with the staff when they call now."
Other practices are looking to combine a portal with embedded PHR capabilities to keep tabs on patients with chronic conditions. The Santa Clara (Calif.) County Independent Practice Association is a consortium of 800 physicians and treats over 100,000 patients, with many enrolled in commercial ACO plans, says Wayne Pan, M.D., the chief medical officer.
The IPA has deployed an administrative portal for its physicians, which collects and adjudicates referrals automatically with an adjoining messaging feature. The home-grown case management system, called Access Express, is supplemented by a clinical hub, from AxSys Technology, Scotland. The clinical hub includes a portal which gives patients the ability to enter in certain data into a PHR, which can be shared with providers, says Pan.
"There have been many false starts with PHRs," says Pan. "So we are taking a disease-specific approach. We are starting with the most difficult diabetic patients." With its limited initial purpose, Pan hopes the PHR will catch on with patients. "When we talk to patients, there is not an onslaught of requests to connect to commercial PHRs. But they are looking for tools to manage their disease process."
Portals also figure in meaningful use payouts. Some 140 physicians strong, Worchester, Mass.-based Reliant Medical Group (formerly the Fallon Clinic), has received nearly $2 million in incentive payments, says Larry Garber, M.D., medical director, informatics. "As part of meaningful use, we must give patients access to their record, their test results and allow them to get electronic copies," he explains. Using Reliant's portal, which is part of its Epic EHR, patients can download a Continuity of Care Document, or CCD, which summarizes key clinical measures, thus enabling Reliant to meet that meaningful use requirement.
At UPMC, patients can see their data from the ambulatory setting and inpatient alike, notes Martich, the CMIO. Its portal is housed in its ambulatory system, but any inpatient discharge summaries, ED reports, and operative reports are conveyed to the patient's individual HealthTrak account, he adds.
Enter accountable care
That kind of data sharing will be critical to the success of accountable care, says Mary Ann Holt, R.N., a partner at IMA Consulting. "The PHR is a way to provide a cohesive longitudinal record for any consumer," she says. "In the high-deductible era, there are more financial demands on patients. We have to get out of the mode that we enable consumers to not be responsible for their care. The PHR would help transition some responsibility to the consumers."
Holt understands the limitations of untethered PHRs, explaining that there will always be interface issues between a standalone record derived from an EHR-driven patient portal and a portable PHR controlled by patients. The central limitation to the portal is the inability of providers outside a given hospital network to see the data in it. And high-risk patients, the kind targeted first by accountable care, often see a multitude of specialists. A diabetic patient may have multiple specialists, Holt notes. "If they're not connected to the health system sponsoring the patient portal, giving them access to a PHR helps with coordinating care."
There are ways around the medical staff privilege limitations of a provider-controlled patient portal. At UPMC, for example, patients can grant proxy access to their HealthTrak PHR, says Martich the CMIO. "They could grant it to family members or to other physicians," he says. UPMC is also in the early stages of enabling patients to enter their own data to their PHR. Right now, patients can send data directly to their physicians via the secure messaging system and ask them to add the new data, Martich says. This coming summer, patients will be given the ability to update their charts directly, but any changes must be approved by the physician. "It is a way to insure the quality of data is at a certain medical standard," the CMIO explains.
One of the biggest gaps in the provider-controlled patient portal is its ability to capture between-visit care data, such as blood sugar scores for diabetics or weight for CHF patients. Mike Lee, M.D., director of clinical informatics at Newton, Mass.-based Atrius Health, says in the future the PHR can help with "patient stealth management," or monitoring clinical data between visits in areas such as weight loss.
