Engaging patients through the use of health information technology has been a growing challenge for healthcare organizations, and it's one that's expected to loom even larger in years to come.

Patient portals, as the acknowledged leading patient engagement tool, so far have been disappointing in satisfying the needs of both patients and providers. While portals typically enable patients and families to view health and billing information and perform simple requests, such as schedule appointments, consumer uptake has been minimal.

That's a worry for providers, which are on the hook for consumer use of engagement technology. Objectives for Stage 2 of the federal meaningful use program were the first to set out a requirement for consumer connection to clinical information. While that level of engagement was set low, many healthcare organizations reported problems in getting consumers to participate.

Proposed rules for Stage 3 have set a much higher target for consumer engagement, and the industry is worrying about how providers will improve numbers from Stage 2.

"Patient engagement is one of the hardest pieces of Stage 2, because you're no longer just relying on your physicians and staff to help you meet meaningful use," says Jenna Barsky, a project manager in the healthcare consulting group of WeiserMazars, an accounting firm with expertise in meaningful use. "You're now relying on your patient [to meet meaningful use objectives]. It's definitely an area of frustration for a lot of physicians, in particular, because they need to depend on their patients in order to meet this all-or-nothing program."

Creating 'customers'

Stage 2 meaningful use objectives established by the Centers for Medicare & Medicaid Services require that patients have the capability to view, download and transmit their data from a provider's EHR via a patient portal. The objectives stipulate that 5 percent of patients actually use this functionality and send a secure electronic message to their provider.

The proposed Stage 3 rule, released by CMS in March, would increase the "view, download, and transmit" requirement to 25 percent of patients. The silver lining for providers is that the proposed Stage 3 rule would give providers the option of providing patients access to their information through an API rather than a portal.

And patient engagement is expected to be an important component of new reimbursement models, such as value-based payment models. These approaches will give providers additional incentive to get patients more engaged in their healthcare in efforts to keep them healthier and out of expensive care settings.

While provider systems offer such capabilities, the real challenge for providers has been to pique consumer interest in using the technology. Some 64 percent of Americans do not currently use online patient portals, according to results of Xerox's fifth annual EHR survey, released in December 2014.

However, survey results indicate that consumers potentially could become portal "customers." Some 57 percent of respondents suggested they would be much more interested and proactive in their personal healthcare if they had online access to their medical records. Of respondents who said they didn't use patient portals, 35 percent did not know a portal was available, and 31 percent said their physician had never spoken to them about portals.

Portal technology is still in its early stages. The inability to provide customized experiences for patients is one factor that's limiting acceptance, says Donald Voltz, MD, an anesthesiologist and medical director of the main operating room at Aultman Hospital in Canton, Ohio.

Voltz says he is not able to customize and individualize portals for his patients to provide them with preoperative instructions. "The highest end of technology available for our patients is whatever portal is available from the EHR," says Voltz, who is also assistant professor of anesthesiology at Case Western Reserve University and Northeast Ohio Medical University.

"We don't have the ability to go where I think we need to go, and that is to really individualize and customize the overall patient experience-from the time they schedule an appointment, to preparation for that appointment, and as follow-up for any issues that arise from that appointment," he says.

"It's frustrating for me, as a physician, to find the data I need on a patient in the portal, so you can imagine how frustrating it is for patients to go in there and track down the data they need," Voltz adds. "They have no idea what they're even supposed to look for. They're going into their records and trying to make sense of them, but [the information doesn't even make sense] for most of us physicians."

Physician support is key

It's not enough to have portal technology available; the right people must strongly support its use by patients, Barsky says. She believes that providers-particularly physicians-must have a thorough understanding of the patient portal.

"It really goes a long way for physicians to advocate the patient portal to their patients," she advises. "Patients are a lot more likely to log in and check out what the patient portal is if their physicians have recommended it to them. The first step is making sure all of your physicians are aware of the portal and all of the beneficial functions it performs."

The Office of the National Coordinator for Health IT says providers will have more success meeting meaningful use requirements for Stage 2 if they integrate a patient portal effectively into their operations.

"Just making a portal available to patients will not ensure that they will use it," states ONC. "The portal must be engaging and user-friendly, and must support patient-centered outcomes. The portal also must be integrated into clinical encounters so the care team uses it to convey information, communicate with patients, and support self-care and decision-making."

However, because each provider seeking to meet meaningful use objectives has deployed a portal, it's common for patients seeing more than one provider to have health information in multiple portals. The resulting view they get of their care is fragmented.

"That's one of the weaknesses of portals today is that there are so many out there," Barsky says. For example, if a patient has a physician on one EHR system and goes to a hospital that uses another, "they have two different logins and they're getting information in multiple places. There's absolutely some patient fatigue in that area. Part of the problem is that patients don't really understand what is in each of their patient portals. There needs to be more education."

Voltz uses a retail analogy to explain why multiple portals chill consumer interest. "Imagine having to go to three or four different websites to buy one product," he says. Having a multiplicity of portals "adds additional cognitive burdens and frustration to [patients] as they need to jump through different portals to try to piece together all the information."

"I'm very much in favor of our portal," says Ryan Bosch, MD, chief medical information officer for Falls Church, Va.-based Inova Health System. However, Bosch contends, a healthcare organization's people, processes and technology must be synchronized for engagement strategies to be successful.

At Inova, a not-for-profit healthcare system that serves more than 2 million people annually, "the technology is so far ahead of our people and the process [that it has] created myriad challenges we were not ready for," Bosch says.

Inova enrolls patients for its portal whenever they come into contact with the healthcare system-when they come into an emergency department; at outpatient appointments with ambulatory clinics and primary care physicians; and as part of elective procedures performed by non-Inova surgeons at Inova's hospitals. With 100,000 patients currently using Inova's portal, the health system is adding 10,000 new portal users per month; Bosch admits the organization is struggling to keep up with the volume.

True patient engagement

When it comes to achieving true patient engagement, David Chou, chief information officer for the University of Mississippi Medical Center, contends, "We're not there yet." He believes that most providers are "just checking the box" to meet meaningful use patient portal criteria, and he says the online experience provided by the retail industry should be the goal for the healthcare industry. "That's what consumers want; we want to be able to shop for healthcare like we shop on Amazon. We want that same convenience factor."

Deanna Wise, executive vice president and chief information officer for Dignity Health, a California-based not-for-profit public benefit corporation that operates hospitals and ancillary care facilities in 17 states, believes that vendors' patient portal offerings are "so many phases behind where we need to be as consumers, and they're not hitting the mark."

Wise argues that consumers should pressure providers and vendors to improve patient portals. Collective dissatisfaction with the state of technology, and ensuing market pressure, will be the only effective tool to drive innovation and improve portal functionality and usability, she says.

Dignity Health is proactive in getting patients signed up for its portal. Wise says the firm has hired staff whose sole responsibility is to go to home-bound patients and enroll them in the portal, personally taking them through the process. "Even though we are based in San Francisco and across California, the most tech savvy area of the country, many in the community and patient population we serve don't have computers," she says.

Barsky also finds that a lack of email addresses among some patients is a barrier to getting them enrolled in portals and their receiving login credentials. However, she observes that several patient portals have found a way to get around the email address issue.

"I would absolutely recommend that healthcare organizations contact their vendors if that is an issue," Barsky says. "Some don't even realize a solution is available."

But, she adds, lack of access to a computer is not the only challenge in getting patients to provide email addresses. "They think they are going to get spam mail, and they don't understand why they need to give their address to a hospital or physician's office. People just aren't comfortable giving out their email addresses-to anyone."

Barsky also says it's important to clear up a common misconception that older patients won't use portals because they are technologically challenged and find portals difficult to use. Rather, she says, older patients often are more interested in their health records than other segments of the population.

"They understand the importance-when they go to their doctor appointments-of bringing with them all the information they can," she says. "They might not be as technically savvy as younger patients, but they are certainly interested in learning."

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