The first time Debra Loggia visited her orthopedist, the practice wouldn't allow her to make an appointment until she had signed up for, and signed into, its patient portal. She dutifully did so, and filled out a detailed questionnaire so that her specialist would have all her information in advance. When she arrived at her appointment, the front desk staff handed her an iPad and said she had to fill out all the information again.

"I said, 'No, this is silly—I spent 20 minutes doing it at home!' " says Loggia, senior manager of digital transformation for Ernst & Young. She made them look up her record in the portal. When she vented to her new orthopedist about the incident, he laughed and shook his head, sharing her frustration. While the practice nominally has 100 percent participation in its patient portal, courtesy of its appointment policy, it hasn't led to greater patient engagement.

The Cleveland Clinic
The Cleveland Clinic

To compound her problems, Loggia says she has to log into separate portals for each specialist she sees, and there's no single source for all of her information. Her primary care practice, perhaps the logical aggregator, is in no position to play that role. It was recently acquired by a large healthcare system and had to abandon its original portal for the one belonging to its new owner, which—as far as Loggia can tell—has made little effort either to train the staff or to reach out to the patients.

In short, patient portals are generally a mess, and Loggia is hardly the only industry observer who thinks so.

John Moore, managing partner of health IT analysis firm Chilmark Research, Boston, recently vented his frustration with patient portals in a scathing blog post, suggesting that they be killed en masse and replaced with something that's actually useful to the patient. "As soon as healthcare institutions hit their meaningful use numbers, they no longer promote or talk about their portals," he says.

Because the federal meaningful use program required all providers to offer patients access to their data, it spawned a multiplicity of portals that make it impossible for patients to see all of their information at once and offer them little or no context to interpret or use the information they see.

Moore calls most portals "digital filing cabinets," which have about as much impact on their users' lives as the average metal filing cabinet. Most portals waste multiple opportunities to educate patients, enhance their ability to communicate with their care team, and connect them with other patients to share knowledge and emotional support.

Patients have not embraced portals with the same enthusiasm they show for online banking or shopping. Most providers haven't raised their portal participation rate above the bare minimum of 5 percent of patients, according to a recent survey of health systems by KLAS Research, Orem, Utah. "Very few can claim more than 20 percent adoption," says Adam Cherrington, research director over patient engagement.

Experts say portals will only be used when they are useful to patients. Loggia says too many providers look at the portal as an IT project when it should be a marketing project, leveraging the marketing department's knowledge about patients and their preferences.

The meaningful use program forced adoption, which most often meant quickly implementing whatever portal was offered by the provider's EHR vendor. Under that common scenario, many providers find themselves stuck. "They say, 'I spent all this money and now you want me to redo it?' instead of looking at the portal in a way that makes sense" for increasing patient engagement, Loggia says.

Those quick-and-dirty portals are better than nothing, says Dan Garrett, U.S. health IT practice leader for PricewaterhouseCoopers, but they won't be enough in a value-based care environment.

"These front ends to existing transaction systems don't fit how the consumer wants to get healthcare delivered," he says. "You have to design functionality that attracts the types of patients you want and helps them get things done." Providers without a useful portal will lose ground to their competitors who do a better job of catering to their patient's preferences, he predicts.

Some providers have significantly more than 20 percent portal participation, and they have employed various strategies to get there.

Texas Health Resources: The bedside portal
At Texas Health Resources, headquartered in Arlington, Texas, there's no one time that's ideal for signing patients up for portal access, says Tanna Nelson, nursing informatics specialist. THR has about 165,000 active users of its MyCare portal, based on Epic's MyChart; it’s been live since 2008. That's about a third of the half-million patients that use its ambulatory services every year.

Nelson knows she's dealing with a culture shift for both patients and clinicians, and some physician groups are better than others about getting their patients signed up. Her latest innovation focuses on an environment where patients may have some time on their hands: during inpatient stays.

In a pilot that started last September on two nursing units, patients are introduced to MyChart Bedside, which enables them to see their lab results, medications and other information, and also to view patient education videos and other support material.

"We give them a tablet with the portal on it, and the signup is right there and easy," Nelson says. Patients can also use their own tablet if they have one. "It gets them in the mode of looking at their information, and then MyChart can take up where the bedside portal leaves off."

Nelson says the adoption rate has been much faster for the inpatients in the pilot than for a typical outpatient site, although some patients still refuse to sign up. Those that do, however, are enthusiastic, particularly about accessing test results and messaging with their doctors.

Metro Health: Engagement by smartphone
When David Kaelber, MD, was a clinical informatics fellow at Partners Healthcare in Boston a decade ago, his major project was a value analysis of personal health records. He projected that if PHRs were fully deployed and adopted, they could save billions. Now that he's CMIO at MetroHealth, the safety-net provider for Cleveland, he gets to figure out exactly how.

MetroHealth has had an Epic EHR installed since 2011, and uses the vendor's MyChart portal. About 40 percent of patients have portal access, and the goal is to exceed 50 percent by the end of the year.

When patients check in for their first appointment, staff ask them if they speak English and if they use email. If they answer "yes" to both questions, they receive background information on the portal to read while they wait, and assistance signing up after they're in an exam room. "MyChart signup needs to be a team sport," Kaelber says.

Kaelber estimates the organization has saved at least a "couple of million" dollars in mailing costs alone by delivering test results, reminders and immunization records through the portal, and "tens of thousands" by decreasing no-show rates for appointments. "Those savings are hard to find in our bottom line, but they're absolutely there," he says. MetroHealth has also seen a 30 to 40 percent increase in women getting recommended mammograms, by automatically entering orders, sending e-mail reminders and enabling patients to self-schedule through the portal.

Kaelber labors against the stereotype that safety-net hospitals can't get portal participation because their patients don't have access to computers. While that's true to an extent, Kaelber says, the advent of the smartphone has made the lack of desktop computing irrelevant—as long as the portal's mobile app is up to snuff.

"Epic has been prioritizing desktop development over the smartphone, but we tell them it should be the opposite," Kaelber says. "If you have a desktop computer, you probably also have a smartphone, but a lot of our patients just have a smartphone."

Cleveland Clinic: Access to everything
The best portals give patients multiple reasons to visit, says Lori Posk, MD, medical director for the Cleveland Clinic's MyChart portal. She advises organizations not to be afraid to load up all available information, after consulting with their clinicians, of course.

The portal opened in 2012, and there wasn't much there at first beyond the basics, but over time, the clinic began releasing all lab results, then X-rays, then other types of images, then pathology and procedure reports, and finally all the providers' office notes. Some pieces of information, such as pathology reports, are delayed as long as four weeks at the request of physicians, who want the chance to discuss results that may not be clear at first blush, or might cause trauma. "My surgery and oncology colleagues say they want to deliver that news in person," Posk says.

She's received many more compliments than complaints from patients about the abundance of information. About 180,000 patients log in to the portal each month, and 675,000 have accounts. Posk says it's hard to estimate what percentage of the clinic's patients they represent because much of its population uses the clinic only temporarily, for highly specialized care.

Both clinicians and patients are happier now that they can send one another messages through the portal. "A lot of simple issues can be taken care of with messaging," Posk says. "I message with my patients all the time."

Patients can also use the portal for e-visits for minor health issues, like back pain and urinary tract infections. Posk hopes to expand that function, as well as to integrate home monitoring devices and use the portal as a tool for population health management.

Cancer centers: Serving the engaged patient
The future of patient engagement is happening now: at cancer centers. Cancer patients tend to be highly engaged to begin with, because of their intense but often fairly brief involvement with the center where they receive their treatment. Many of them travel hundreds or thousands of miles, and make the center and its environs their temporary home. A portal, done right, offers multiple ways to help them connect with their providers, their personal health information and their surroundings.

"We asked our patients, who so generously donate us their time, tissue and blood samples, what we could give back to them, and they overwhelmingly said, 'Access to our data,'" says Jenn Camps, director of clinical systems at Moffitt Cancer Center in Tampa; she has a degree in marketing but works within Moffitt's IT department.

MyMoffitt is developed largely in house, based on the portal software provided by Cerner Corp., Moffitt's EHR vendor. Patients can schedule appointments, fill out exhaustively detailed questionnaires in advance (rather than arriving 90 minutes before their appointment to do paperwork), and view test results before they see their doctors instead of being overwhelmed by bad news during an office visit and having to formulate their questions on the fly.

The portal also includes a curated search engine that enables patients to find cancer information from sources that the Moffitt medical staff deems reliable, rather than having patients swim through oceans of misinformation on the entire Internet.

Camps says all new Moffitt patients log in to the portal before their first visit, armed with their medical record number and other log-in information supplied by the appointment staff. Completing basic clinical intake forms is usually their first activity, and at the same time, they answer questions related to research being carried on at the center.

Camps has provided multiple reminders about information available through the portal, using strategies such as e-mail, refrigerator magnets and table tent cards in the cafeteria. "I've done everything short of wrapping my car" in portal advertising, she says. It's paid off: the 81,000 patients registered for the portal visited it 1.3 million times in the past year.

M.D. Anderson Cancer Center in Houston has enhanced its basic patient portal with many special features, including Yelp-like local information tailored for its unique audience. Two-thirds of the center's patients come from out of town, split between U.S. and international patients.

Developed internally and integrated into Epic's MyChart, MyMDAnderson's "patient concierge" generates customized suggestions of things to see, do, and eat, based on a profile filled out by the patient. "Patients were always asking our staff what to do in the area," says Jeffrey Frey, director of innovation communities. Patients on special diets receive suggestions for appropriate restaurants. Driving directions are included. Also available through the portal: connections to remote translators for a variety of languages, in case one of Anderson's staff translators isn't immediately available.

The center is working on adding step-by-step walking directions through its vast facilities, where pedestrians frequently have to navigate around construction, and ways to wrap in information from social media to further personalize the patient concierge's recommendations.

Four out of five MD Anderson patients use the portal, Frey says. "Our patients are a different breed," he says. "They know if their levels should be 11 or 14, so when results come back, they're right there checking."

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