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The Pros and Cons of Patient Portals: Can Integrated Electronic Health Records Help Empower Patients?

Posted By Peter Y. Fifield, Friday, February 3, 2012
Providers spend a significant amount of time with patients problem solving effective ways to manage chronic health issues. Through the use of Motivational Interviewing for example, providers focus on increasing patient self efficacy; "how do I guide this patient in owning their own health?".

With the rapid grown of Health Information Technology (HIT) I'm optimistic that HIT, specifically the use of patient portals, will provide more tools for not only improving patient satisfaction and reducing costs, but also in addressing another real issue in healthcare: Increasing patient autonomy.


Patient portals become a window of opportunity for managing our own health. Metaphorically speaking it is like maintaining our car with the use of that dusty paperback in the glove compartment: The vehicle maintenance log. We resource the maintenance log to see what work has been done in the past and as importantly, what work needs to be done in the future. To compliment this log, we use the gauges on the instrument panel. We read the tachometer, the gas gauge, and the engine lights to understand what the vehicle needs. These data complete the feedback loop so we now know how to act: Get gas, inflate tires, flush your transmission.  You get the idea.

A patient portal could act in a similar way. Medications, appointment times and blood pressures could all be accessed via the encrypted portal and assist the patient in being a better manager of his or her own body. I can hear it now "there's an app for that"...imagine remote blood sugar sent from the glucose monitor to our medical record via the patient portal. Diet and exercise routines could be managed daily, calorie counts entered at each meal; all of this managed on your own medical portal (and possibly complimentary smart phone applications). Most important, it can all be updated and facilitated in real-time by patients or their HIT devices. There is a market here just waiting to explode.

With such potential, why is it then that so many providers have an issue with the use of patient portals? I heard one physician say: "not on my watch" and a BHC say: "I'm unsure of the benefits here" regarding initiating a patient portal access initiative at a local primary care clinic. In the spirit of investigating this enigma, I have listed a few key components of patient portals below that I think provide the most fodder for the cannon in terms of eliciting arguments from both camps. Just to clarify, in this blog I am referring to patient portal access to the patients own electronic medical record (EMR) not the "never-used" Electronic Health Record (EHR) that are typically little more than a hi-tech headache.

1. Patient portals can be thought of as a gateway to patient data, health record content, and web services associated with the hosting provider. Patients get secure, encrypted access via use of a patient ID and password; a similar process that allows clients access to other very sensitive information such as online banking. Unlike with online banking, medical information is often sensitive information and keeping unwanted eyes from seeing your portal could prove difficult. As this one article shows, the views on confidentiality are mixed.

2. Providers grant patients access via their username and password and through the patient portal, the patient may be able to perform the following tasks:
  • Check their appointment schedules and requests an appointment
  • View lab results and basic patient information such as BMI, BP, and weight
  • Examine medical and billing statements
  • Request prescription refills
  • Complete new patient intake forms and registration information
  • Complete ongoing assessment forms such as PHQ 9, GAD7, DUKE 17, etc.
  • Correspond with medical personal via encrypted email services
An interesting philosophical question here is that if the medical chart really belongs to the patient, why is it the provider that is granting access? Who is really driving the bus here? This may be a reflective residue of the slowly fading paternalistic role providers have played in the past. It could be argued that until the patriarchal paradigm is shifted to give power to the patient, they simply will not have it.

3. Through reviewing provider satisfaction research, one of the most often heard complaints is that the providers do not have enough time with patients. Period! In addition, providers spend significant time discussing symptoms and providing medical advice that they do not bill for. Simply stated, there are too many things to address aside from the Chief Complaint. Through the use of the portal providers and support staff can communicate back and forth with the patients and send messages such as appointment reminders, electronic statements, and lab results.

Historically, part of the provider-patient relationship included correspondence via phone. We could consider the patient portal a very high tech, and easy to facilitate version of that same information exchange, however; it would be more informative for the patient and much easier and less time-consuming for the provider.

4. The patient can complete much of the patient visit information and yearly paperwork prior to the visit. Existing patient intake and medical forms can be uploaded onto the website for the patient facilitating the process for not only the patient and provider, but for the support/office staff as well.

5. All of the interaction on the patient portal can be set to directly integrate into the chart. Although I disagree with this on a philosophical level [see above], pragmatically the medical practice is the ultimate authority regarding how much data is conveyed to the patient. Said otherwise, the patient does not have access to all of the doctor's records at any time. Patients only see what doctors want them to see and thus the physician note remains protected.

Portals could provide more patient access to a very valuable resource: Provider knowledge

Ideally, using a high quality patient portal allows the patient to upload their records to a central repository. The continuity of care between different doctors of different specialties, in different locations, becomes a reality for the self-efficacious consumer.

6. The portal is accessed through the practice’s web site. Educational material [including pdfs, photos videos etc] and links to other websites [i.e.patientslikeme.com, sermo.com, dailystrength.org] can be posted on the web site as well to provide adjunct services and supports. Many practices post educational information such as diabetes information, exercise options, support service information, times and dates of groups being held, diet/meal planning suggestions, and medication information, etc. on their practice web site as a service to their patients.

With the HITEC Act in place, it is reasonable to say that more and more providers will continue to venture into the world of high-tech charting. Patients could have far more access to their provider's vast knowledge by complementing the face-to-face visit with portal access and thus create a more interactive relationship with their medical record.

I see this as exchange of information via patient portal as a compliment to the face-to-face appointment; an extension of the office visit, if you would. Providers are the keepers of an infinite amount of medical knowledge and currently there are 2.7 physicians per 1000 people in the US. The informational bottlenecking lies in the finite space in time providers have to transfer that information to the patient. In a 15 minute visit we all know this is impossible. The patient portal could act as an expansion of this 15 minute window and would allow for more patient access to a very valuable resource: Provider knowledge.

Patient portals are obviously no panacea for the health care crisis. Ultimately nothing replaces patient accountability when it comes to overall health outcomes. However; the patient portal could function as an integral tool in increasing patients’ motivation for healthy living by giving patients access to their own information.

Inevitably technology will continue to play a role in patient care and most likely patient portals will be more widely used.

My question is, why not now? I'd be curious to hear other opinions out there regarding the pros and cons of using patient portals. Is there anyone out there in the CFHA audience already using them? How has it worked? What are your thoughts?


Pete Fifield is the Manager of Integration and  Behavioral Health Services at Families First Health and Support Center; an FQHC in Portsmouth NH. In his off time he is the Managing Editor of CFHA Blog and makes all attempts to keep up with his wife and two sons.

The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.

Tags:  CFHA  health information technology  Integrated Health  patient portal 

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Salud 2.0 Part One: Healthcare Collaboration, e-Patients, and Social Technologies

Posted By Gonzalo Bacigalupe, Thursday, July 21, 2011
For two days in July, The University of Deusto Business School in Bilbao hosted the course Salud 2.0 Euskadi. More than 160 healthcare professionals, administrators, researchers, and business leaders, came to learn and discuss what emerging digital media offers to patients, professionals, and healthcare organizations. The Basque Institute for Healthcare Innovation (o+berry) and TEDxSol organized the conference with Luis Luque (a health informatics doctoral candidate at the University of Tromso) and Manuel Armayones, a researcher from Cataluña. Since most of the contributions to the course were in Spanish as well as the archived stream, interviews, and visuals, with this entry I share my summary of the terrific contributions and ideas for readers in the United States. I believe this is especially significant since the healthcare experts in Spain deal mostly with quality of access and patient care rather than first worrying about insurance access (health access in Spain is written in the Constitution as a citizen right).

Two American "starts” participated: e-Patient Dave deBronkart, a well-known inspiring patient advocate, and Manny Hernandez, founder and director of the Diabetes Hands Foundation. Their work is widely available on the Internet and since it is in English, following their links should be more informative than attempting to synthesize their engaging talks. Appropriately, being patients themselves, they were the ones who kicked off the conference calling for clinicians to listen, stay curious, and be transparent. Dave asked us to advocate strongly for patients to have access to their own health data. His mantra, Gimme my Damn Data, is the subject of a popular and compelling TedTalk.

The Blue Button for Health Data initiative is being promoted by the Veteran Administration and the Medicare and Medicaid Services.

Beginning with their personal histories, surviving cancer for Dave and living with diabetes for Manny, their talks transmitted a contagious resilience. Participating in patient care is the responsibility of everyone, not just those in the healthcare professions. Communities of patients telling their story and utilizing new media productively are not only possible but also sustainable and rich in possibilities. The video Do the Big Blue Test on World Diabetes Day is a great testimony to the potential that social technologies offer in fostering healthcare collaboration and reaching large segments of the population. Their call for networking across the healthcare professional, governmental, business, and citizen spectrums was refreshing and percolated through the whole course. It was also in sync with Kronikoen, the Basque Health System strategy to deal with chronic illness.

Julio Mayol, innovation director, and professor and surgeon at the Clinic Hospital of Madrid and Jorge Juan Fernandez, e-health and health 2.0 director of the Sant Joan de Déu Pediatric Hospital of Barcelona, reported on their efforts to get hospitals closer to patients’ needs. It seems like an oxymoron but often hospitals practices are not designed to collaborate with patients. In the family health systems movement we have discovered that institutions are often designed to prevent collaboration among professionals and to reinforce the expert medical role versus a passive patient one. Innovation is not easy in hospital settings despite the urgent need for reorganizing around family and patient health rather than purely around illness. Julio, citing Shahid Shah, reminded us: "People want more time with their physicians and don’t really care who manages their chart”. Good ideas, as he reported, are not valuable unless someone uses them. Shah provided many examples of how to use social media effectively for research and development in healthcare. He insisted that concerns about reputation are overrated and should not stop us from introducing change.

Jorge Juan spoke about the "liquid” hospital—how a hospital has used information communication technologies to integrate patients as active stakeholders. The liquid hospital is just one of many initiatives that his institution has implemented for 4 years. The information revolution has been disruptive and two variables changed: time and space. What I heard was that we are moving fast towards virtual interactions demanding a change in the doctor’s role; a change not necessarily welcomed. His hospital intends to facilitate the sharing of information to open up new conversations with patients, and to publish its results in the name of accountability. To achieve these goals this private hospital has embraced most but not all the popular social media outlets to share hospital and medical news, to ease patient attention, obtain funding, market new services, and to attract human resources.

Luis Luque and I grounded this conversation in the ethical and social challenges that arise with the mainstreaming of emerging media. Luis addressed some of the ethical problems that arise as patients have access to the same technologies. He showed the example of eating disorder patients who reinforce and normalize their pathology, tobacco consumers that map bars welcoming smoking, and more generally the potential disinformation related to finding appropriate information on the Internet. A YouTube video of a patient at a hospital bed complaining about how he was mistreated by the healthcare personnel created some controversy. For Luis, the video demonstrated the negative side of patient ability to go public bashing health services. For others, me included, the video highlighted the ability of patients to make accountable unresponsive professionals and healthcare organizations. Privacy in patient communities was also mentioned, including the danger of inappropriate use of genetic information. Luis’ questions challenged healthcare professionals to think about privacy of healthcare professionals and of patients.

My presentation asked participants to reflect on issues of health access and quality and the digital divide. The potential of emerging technology is clear, initiatives like PatientsLikeMe and TextforBaby are good examples of social media platforms that can facilitate collaboration in health, and thus the alleviation of health inequity. Does the introduction of social technologies enhance the well-being of all the populations and decrease health disparities? Furthermore, could the integration of Information Communication Technologies in the healthcare setting solidify or widen the healthcare gaps? Vulnerable populations, the ones needing the most increase in access and quality of healthcare, are also those left behind in the adoption of new technologies. Health literacy and digital literacy seem to go hand in hand. Like access to healthcare does not necessarily correlate with quality; access to digital tools does not immediately mean that the user can use them effectively. Often in the implementation of e-healthcare innovations the early adopters are more privileged and typically the ones who benefit the most from the innovation. The implementation of social media initiatives in healthcare requires careful thinking of how to incorporate the less literate and the most vulnerable. In other words, we need to think not of the early adopters, but those often left behind--the most vulnerable.

Introducing e-health into the system of care should be more about health outcomes and less about the technology. This is not a novel idea, but one forgotten in social media healthcare circles. The now head of the Centers for Medicare and Medicaid Services (CMS) Donald Berwick, in article in JAMA (2003) suggested that technology should translate into improved patient outcomes. In Bilbao that morning, indeed there was consensus that technology should be at the service of health and not the other way around. In the afternoon, my workshop on ethical and social dilemmas reaffirmed both the creativity in implementing innovation on the ground and the difficulties we still have in addressing the core issues of access, cost, quality, and health outcomes. There is definitely a hunger for learning about social media, electronic medical records, and other health information communication innovations, but also a lot of fear and lack of support to experiment with them. We heard, for instance that whole health systems are experimenting with the possibilities of social networks (Facebook) to outreach and connect with patients and professionals. Paradoxically, however, the same institutions have imposed filters that prevent doctors, nurses, and administrators to use Facebook in their offices.

The comments of those in the audience with a twitter account (#Salud2eus) and the ones watching on their computers added to the richness of our face-to-face conversation. The engagement was certainly horizontal; similar to the one we lived through the conference face-to-face. The live stream and the virtual discussion that accompanied the presentations gave testimony to the possibilities, but also the challenges ahead of healthcare innovation. The design of the conference demonstrated too that the collaborative conversation with the elimination of professional silos could occur in a respectful as well as rich critical way.

Photo Link 1: http://www.flickr.com/photos/bacigalupe/5912113373

This is part one of a two part series on integration and social technologies. Read part two of Salud 2.0 next week.


Gonzalo Bacigalupe, EdD, MPH (third from right in the bottom row) is an Ikerbasque Research Professor with the Vulnerability to Stress and Resilience Research Team at the College of Psychology and Education, University of Deusto Bilbao; Associate Professor, Department of Counseling Psychology, College of Education and Human Development, University of Massachusetts Boston. Gonzalo is co-senior editor of Family, Systems, & Health. His webpage is at: www.gonzalobacigalupe.com

Tags:  health information technology  Social Media  technology 

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