According to a report released by the Office of the National Coordinator for Health Information Technology (ONCHIT) in April, only 52% of patients in a large survey said they were offered online access to their medical records as of 2017. Of those, approximately half said they viewed their records in the past year, totaling about 28% of people nationwide. At the same time, roughly one-third of respondents were using an electronic health device and 40% had a wellness app on their phone or tablet. In addition, according to the Pew Research Foundation, 96% of Americans own a cell phone and three-quarters own a computer.
These findings suggest a gap in the way health care providers and patients use technology generally and how they incorporate it into their health care. Should doctors should care? If so, how can they increase portal usage among patients?
Who is using them?
In 2015, researchers at athenahealth, a company based in Watertown, Massachusetts that provides network-enabled services for health care and point-of-care mobile apps, investigated portal use and adoption and found a few interesting statistics, some of which debunked popular portal myths.
First, small practices implement portals at about the same rate as larger groups. Next, 30-somethings’ use is highest, but people in their 60s are about as likely to use them as those in their 40s. Portal adoption does not trail off steeply until patients are in their 70s. And older patients sign in and use portals more frequently than younger ones. In 2018, almost 40% of athenahealth’s portal users are aged 55 years or older.
Income levels may have a slight impact on whether or not people are using portals. David Miller, MD, MS, Associate Director of the Clinical and Translational Science Institute at Wake Forest School of Medicine in Winston-Salem, North Carolina, said portal usage has grown at the clinic where he works, which has a high number of low-income patients, but remains somewhat low.
A 2016 article in the Journal of Medical Internet Research penned by Dr Miller and colleagues reported on a study of low-income primary care practices in North Carolina. After interviewing clinical personnel at the practices, they found most implemented portals because they were mandated. The providers also had low expectations for portal use. In addition, they expressed concerns portals would create more work, confuse patients, and alienate those not using them.
Should you push it?
Though she is generally a fan of portals, Dawn Paulson, director of informatics at the American Health Information Management Association, said they are not necessarily for everyone. A healthy person who only sees a doctor when they have a cold has little need for it. People with chronic conditions, however, will be the “heavy hitters” on the portals.
“People who have chronic illnesses are very in tune to their health care,” she said. “Even before portals, they would come in the office with three-ring binders with their health records in them.”
Portals generally are thought to be beneficial for both patients and providers. Emily Lord, product marketing manager at athenahealth, said portals empower patients to be more active in their health care; improve patient/provider communication; and save patients time and hassle by letting them pay bills and view health information online.
It can also be an advantage for providers working in a consumer-driven market. “Providing patients with the convenience they have come to expect in their interactions with other industries—banking, retail, etc.—will increasingly become a competitive advantage when it comes to attracting and retaining patients,” she said.
Dr Miller said people have looked at whether portals improve outcomes, and the data are “messy.” Many portal users are already engaged patients with greater resources. Overall, though, he said they are beneficial and can be an important tool for managing care.
If portals can improve patient care, but uptake is low, what can providers do to increase usage? Dr Miller suggests taking the effort to build portal usage out of the hands of physicians. “If they put it on the doctors it generally doesn’t work,” he said. “Clinics that have higher uptake are ones that empower the front desk and nurses to explain it to the patients.”
A multi-pronged approach appears to be the most effective in encouraging usage. This includes making it part of a routine patient visit by discussing it during check in or intake. Paulson said providers have a higher success rate with sign up and usage if they have a nurse sit down and show a patient how to use the portal.
“It helps get over that initial step of uncertainty,” she said. “Patients aren’t sure what to expect – especially with people who aren’t tech savvy – it can be very intimidating.”
Different portals come with a range of features, but nearly all of them should allow patients the basics: viewing lab and test results, requesting prescription refills, and scheduling appointments. The ONCHIT report found about 85% of patients used the portal for lab results, 62% either refilled a prescription or made an appointment, and nearly half sent a message to their provider.
Another feature many physicians have been hesitant to put in place is the ability to email or send messages through the portal. Many worry, as Dr Miller did, about “opening the floodgates and ending up with hundreds of emails a day.”
But this capacity has ended up saving him time. He can respond to electronic notes much more quickly than having to pick up a phone or relay a message to a nurse, who then must call a patient, he said.
“For me, it saves a little bit of time and, at worst, is time neutral,” he said.
The more tools a portal has, the more likely patients are to use it, Paulson said. She recommends using OpenNotes, which allows patients to see a provider’s notes placed in the health record.
“That’s what people want to see,” she said. “It gives a more complete record and gives a bigger, better picture of what the patient’s condition is. We will see patient engagement skyrocket as more information is made available to them.”
Dr Miller said opening his notes to patients did give him pause initially, but it has not changed the way he writes notes. Notes are particularly helpful for patients with complex medical histories and who may rely heavily on family members or caregivers.