Challenges Ahead for Portals

With the rush to implement electronic health record systems and meet meaningful use requirements, there have been mixed results in getting patients to use patient portals.

As the preferred approach for engaging patients and giving them access to their medical records, portals were developed as an additional technology linked to EHR systems by system vendors. However, clinicians and federal regulators are reassessing their value and utility.

"Portals have caught on with providers because they are easy to integrate into an electronic health record and they meet meaningful use requirements," says Khaled Abdel-Kader, MD, an assistant professor of medicine at Vanderbilt University. "But I think the bigger question is, what do patients want? And how do we build a tool that's responsive to those needs?"

Simply offering patients online portals does not mean they will use them. Raj Ratwani, scientific director of MedStar Health's National Center for Human Factors in Healthcare, believes portals are not as usable as they could be. "In most cases, patient portals and other health IT have not been designed to support patient needs and do not present information in a manner that is understandable and useful," he says. "Consequently, these technologies are underutilized by the public."

Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative, agrees and argues that the Centers for Medicare and Medicaid Services never designated the "view, download and transmit" requirement to be achieved through a portal, but EHR vendors, "for whatever reason, decided they were going to do that through a portal."

Portals give patients access to information, but technology can only go so far, and patient willingness to use portals is still a challenge, says Martha Thorne, senior vice president at Allscripts. "Trying to affect change in patient behavior through providers is only going to go so far," she says.

The API option

At the same time, starting in 2018, patient portals will be contending with a new approach for sharing healthcare information with patients. The final Stage 3 rule released in October by CMS fully embraces application programming interfaces (APIs) for EHRs as a way to enable patients to view, download and transmit their health information. The use of API-based approaches has the potential to replace portals for those functions.

Tripathi describes an API as a "machine to machine" interaction in which patients gain access to their information through an app that they can use. APIs thus become the means by which consumer-usable apps communicate and exchange information across systems. The apps use APIs to "call" data stored in various health system databases.

While the "current trend to use a patient portal to meet the view, download and transmit functions" is "prevalent and acceptable," the final Stage 3 rule incorporates API functionality into an objective for patient electronic access.

"The Stage 3 objective for Patient Electronic Access is not a 'patient portal' versus 'API' requirement or a requirement to support two patient portals," according to the rule. "Instead, this proposed objective is supporting four basic actions that a patient should be able to take: view their health information; download their health information; transmit their health information to a third party; and access their health information through an API."

Nonetheless, at the same time, the rule comments that "APIs may be enabled by a provider or provider organization to provide the patient with access to their health information through a third-party application with more flexibility than is often found in many current patient portals."

It adds that "from the provider perspective, an API could complement a specific provider 'branded' patient portal or could also potentially make one unnecessary if patients were able to use software applications designed to interact with an API that could support their ability to view, download, and transmit their health information to a third party."

The Stage 3 requirements are optional in 2017 but all providers will be required to comply with the regulations beginning in 2018-including providing patient electronic access to their health information through an API-using EHR technology certified to the final rule for 2015 Edition Health IT Certification Criteria that was also released in October by the Office of the National Coordinator for HIT.

API issues

Lee Barrett says he favors giving patients the ability to access their information with an API. "The only concern that I have for the proliferation of APIs is that they are secure," says Barrett, executive director of the Electronic Healthcare Network Accreditation Commission, a voluntary, self-governing standards development organization created to develop standard criteria and accredit organizations that electronically exchange health data. That's a concern shared by CMS and ONC.

"The 2015 Edition final rule provides more expectations about system security, which should be a top priority for developers," who "will now be able to begin development of improved transitions of care and innovative API functionality," states a fact sheet released with the final Stage 3 rule. In addition, the final rule emphasizes that providers "may not prohibit patients from using any application, including third-party applications, which meet the technical specifications of the API, including the security requirements of the API."

APIs could be the answer for the shortcomings of patient portals, argues Abdel-Kader. However, Tripathi says he is "a little bit dismayed" that CMS has required deployment of an API in Stage 3. "My concern is that it may just be a little premature," he says.

Similarly, John Halamka, MD, CIO of Beth Israel Deaconess Medical Center, calls the API requirement among the most controversial aspects of the final Stage 3 rule.

While Halamka is a strong supporter of the use of APIs as a means to enhance interoperability, he argues that currently there are few patient-facing apps that use APIs and questions whether regulation is the best approach to accelerate the move to consumer-facing mobile apps and APIs for downloading of EHR data and uploading of patient-generated data.

"Meaningful Use Stage 2 attempted to use regulation to accelerate patient downloading/transmission of data," Halamka observes. "There were few places to transmit consumer data and few compelling reasons for consumers to do it, so few tried."

As a result, Stage 2 was modified to move the 5 percent view, download, transmit requirement to just one patient. "Regulation alone cannot change consumer behavior, since APIs are not so much a technology but a market ecosystem to support the technology," Halamka asserts.

The patient piece

Halamka makes the case that patient access to their medical records is one of the most difficult aspects of meaningful use for providers to achieve. In meaningful use Stage 3, the bar will be raised to require 10 percent of patients to access their information, he notes.

Nonetheless, ONC recently reported a sixfold increase in the percentage of hospitals giving consumers the ability to view, download and transmit their health information online, going from 10 percent in 2013 to 64 percent in 2014, enabling hospitals to meet Meaningful Use requirements. The percentage of Americans offered online access to their medical records rose from 28 percent in 2013 to 38 percent in 2014.

"It demonstrates progress, but we still have a lot of work to do," said National Coordinator for HIT Karen DeSalvo, MD, at ONC's recent Consumer Health IT Summit. "This has got to continue to rise."

More than half of the individuals who were offered online access to their medical records in 2014 viewed their record at least once, DeSalvo said. In addition, last year almost half of individuals nationwide either sent or received a text message or an email from their provider, used a smartphone health app or looked at their test results online.

Portal disparities

While portal adoption does appear to be increasing, Abdel-Kader says greater attention is needed to understand why vulnerable populations in particular do not access portals at the same levels as other sociodemographic groups, says Abdel-Kader, a nephrologist.

He points out that one of the goals of the HITECH Act was to "bridge and mitigate" some of the disparities among underserved populations through the use of health IT. Nonetheless, according to the results of Abdel-Kader's study of more than 2,800 patients with chronic kidney disease, African-Americans, older patients, those with lower neighborhood median household incomes and patients covered by Medicare or Medicaid are all less likely to use patient portals.

At the same time, one of the findings of the study was that portal use was associated with blood pressure control in patients with a diagnosis of hypertension-an important step in managing chronic kidney disease. In addition, patient portal use promoted several important actions: 87 percent of users reviewed their laboratory results, 85 percent reviewed their medical information, 85 percent reviewed or altered their appointments, 77 percent reviewed their medications, 65 percent requested medication refills, and 31 percent requested medical advice from their renal provider.

"Value-based care is forcing patient portals to evolve from being merely tools for reactive regulatory compliance to becoming valuable instruments that allow patients to proactively engage in their own care," says Coray Tate, vice president of clinical research at KLAS Enterprises-an evolution that will continue with the healthcare industry's delivery system reform.

Consequently, Tripathi sees APIs and patient portals "living in parallel" for the foreseeable future.

Time for a pause?

However, Halamka advocates removing the API requirement from Stage 3 and moving it to the Merit-based Incentive Payment System (MIPS), envisioned to replace the Sustainable Growth Rate formula for reimbursing physicians. That would create a new way for the marketplace to develop innovative technologies after there is increased consumer and provider demand.

"Pause Stage 3-even ideally eliminate Stage 3-and instead use merit-based pay to offer, in effect, a reward for innovation and outcomes achieved," he suggests.

Nonetheless, Stage 3 requires that providers meet the "Coordination of Care through Patient Engagement" measure by: viewing, downloading or transmitting to a third party their health information; or accessing their health information through the use of an API that can be used by applications chosen by the patient and configured to the API in the provider's certified EHR technology; or a combination of both.

"To put it in regulation that there needs to be this API available to patient apps-in fact, any patient app-is just too early," Halamka says. "I would have waited until we actually have experienced products and services and an ecosystem for which the API would actually be useful."

Under the current Stage 3 schedule, EHR vendors would have only one year to make software changes and get certified under the 2015 Edition Health IT Certification Criteria that was released by ONC.

"In effect, this criteria says 'you must drive a car but we haven't built any roads.' So it's kind of hard to drive," Halamka says. "I love the idea of patient and family engagement, but to believe at this point in history that we're going to have patients being the stewards of their own just too early."

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