Patient Portals promise convenience, efficiency, and better patient-doctor interactions. Find out who’s offering them, and why others aren’t—yet.
By Sara G. Stephens
It’s time to reconsider renewing some of those magazine subscriptions you’ve let slide over the years; chances are, you won’t be reading them in your doctor’s office. The magazines will be there, but it’s possible that you will not. Instead, you just might be visiting your doctor via a patient portal. These Johnny-come-lately web applications let patients access personal medical records, update ongoing health information, and even interact directly with their healthcare providers via “e-visits.”
The notion of portals is nothing new. The financial industry has harnessed the power of the Internet to equip customers with their personal financial data since the 1990s. But the medical industry has been slow to embrace the concept, as providers fret about strict HIPAA regulations and have been otherwise unmotivated to challenge the status quo.
But that’s all changing, thanks, in part, to the American Recovery and Reinvestment Act of 2009 (ARRA). Within the ARRA, the HITECH Act sets aside around $19 billion for health information technology, eliminating one barrier to portal entry: the hefty price tag attached to electronic medical systems. The federal economic stimulus package states that healthcare providers who demonstrate “meaningful use” of certified electronic health records (her) systems can qualify for Medicaid and Medicare incentive payments.
Patient Portals and the New Virtual Doctor
Patient portals are being implemented at varying degrees and rates of speed across the medical industry and throughout the world. Dr. Ralph Tharp, the founder of Texas Gulf Coast Medical Group (TGCMG), believes that practice is the first in the Houston area to offer virtual doctor’s office visits over the Internet.
Patients visiting the TGCMG website (www.txgulfcoastmed.com) can log in to a secure patient portal to communicate with their doctors. Patients use this service to communicate with the practice securely and efficiently, view their Personal Health Records (PHRs), review their lab results and statements, request appointments, see dates and times of upcoming appointments, request a prescription refill from pre-populated list of currently refillable prescriptions, and manage their personal information.
The “eMD” site also lets patients engage in a virtual doctor visit or use the “ask the doctor” feature to obtain medical information. Tharp primarily handles the virtual patient visits and other physicians and specialists in the practice assist when needed. Virtual patients submit their medical concerns to the eMD site, and Dr. Tharp responds to them electronically—individually and privately.
The TGCMG website reports that Tharp saw 15 patients in person on a recent morning, and says at least five or six could have been handled through a virtual visit for a price of $50, compared to an average office visit cost of $117.
The National CML (Chronic Myelogenous Leukemia) Society (www.nationalcmlsociety.org) offers another example of this new wave in healthcare. CML is a nonprofit patient support organization that provides an “Ask The Experts” portal where site visitors can interact with medical professionals who specialize in CML treatment. Dr. Jorge Cortes from MD Anderson Cancer Center in Houston serves on this group’s medical advisory board. “The portal offers an invaluable service for patients throughout the US who do not have access to hematologists/oncologists locally with expertise in this rare type of blood cancer.”
Independa (www.independa.com) provides an application called Angela, which is designed to help society’s aging population to continue living independently longer, with better health and social well-being. Using the application, home care, home health and other professionals or family members can unobtrusively keep tabs on the elderly from a distance in real time. Angela offers elderly users one-touch access to medication and calendar reminders, and will also eventually be linked to various health and safety monitoring solutions. Professional or family caregivers use a Web-based dashboard and control panel to arrange for automated reminders to the elderly, and for alerts to caregivers of potential trouble (for instance, if medications aren’t taken or a doctor appointment is missed). Independa recently announced an agreement with national home care provider LivHOME to create a new LivHOME offering called LivIndependa. LivHOME has a Houston location.
Overseas, Dr. Thom Van Every, a sexual health consultant at Chelsea and Westminster Hospital of London has founded an online-based doctor service (www.drthom.com). Dr. Van Every noticed that many of his patients were embarrassed to see a doctor about their ailments. He founded the service focusing on sexual health, then gradually added services. The website employs doctors who review online assessments filled out by patients. Services offered include contraception, cystitis treatments, medications for erectile dysfunction and hair loss, malarial drugs, travel vaccinations, and home tests for a variety of sexually transmitted infections. Five doctors work with the service consulting with patients over the internet and telephone.
Rachel Carrell, spokesperson for drthom.com, acknowledges that online medicine is not a replacement for a traditional physician relationship. Rather, she says, it’s a convenient and efficient supplement to normal visits. “We find that our patients really value the efficiency of our service, and also its discretion,” she explains. “Many of our patients live in small towns in the country, perhaps with only one doctor and one pharmacy. For sexual health matters—like erectile dysfunction or chlamydia treatment—patients in rural areas would much rather see an online doctor than have to walk into their local pharmacy and ask for their medication when who knows who’s listening in.” Other patients are simply too busy to take time off during the day and opt to use drthom.com’s mail service, Carrell adds. “Mums with careers, kids and busy lives don’t have time to sit around in a doctor’s waiting room to get their contraceptive pill. It’s really quick to fill out the patient questionnaire online, and one of our GPs calls straight back if anything is unclear or needs to be talked through,” she says.
Although the number and scope of patient portals is growing, the concept is still in its infancy, and is crawling through a number of “childhood ailments” before it can take full stride to maturity.
Dr. Deonne Brown Benedict, DNP, ARNP, is a nurse practitioner with a doctorate and specialty in family practice. She has an independent practice and owns her own clinic, which meets the needs of the insured, uninsured, and low-income clients of all ages. Benedict has implemented a secure portal for exchange of medical information at her practice. “Patients love receiving their test results and explanations, and they can ask medical questions via the portal,” she says. “The downside is that there isn’t a way to bill insurance companies for the consultations that occur in this manner.”
And there’s the first issue of the matter: some companies pay for e-visits, but many do not. Erin M. Gilmer, JD, is a Patient Navigator & Health Policy Attorney (www.healthasahumanright.wordpress.com) whose efforts are focused on helping the world to realize that “the real innovation in healthcare won’t just be technology, but will be in developing a culture that values and works to realize health as a human right. She says that much of the work doctors do—such as coordinating care with other physicians, spending time with patients to discuss issues like their socio-economic status or mental health state—is not compensated.“If providers were compensated for these services and e-visits, we’d see a huge improvement in care, because we’d truly have patient-centered care,” Gilmer says.
And she’s uncertain about the likelihood of change. As Gilmer explains, insurance companies are already complaining about minimum loss ratios and elimination of pre-existing condition exclusions. She doubts these companies will be open to paying for yet another service. “If [insurance companies] see the benefit of e-visits as resulting in improved health outcomes, which can be seen as fewer hospitalizations, fewer prescriptions, and other measurements like blood glucose or blood pressure, they will be more likely to [consider paying for these services],” Gilmer says.
Adding to the challenge is the fact that patient portals in Electronic Health Records (EHRs) are limited and don’t often let patients enter information that can be easily tracked. Personal Health Records like Microsoft Health Vault are not accessed by healthcare providers. “Until we have a user-friendly, comprehensive, secure system, adoption of e-visits will be slow, meaning proof of effectiveness will be slow, ultimately resulting in the likelihood providers will not be reimbursed for this time,” Gilmer explains.
Fred Trotter is a Houston-based author of the book Meaningful Use and Beyond: A Guide for IT Staff in Health Care. His analysis of the insurance issue is equally grim. “Frequently, health insurance companies do not cover e-visits, and therefore, doctors do not use the e-visit capacity or the messaging capacity in the patient portal, even if they have it, because they have a strong incentive to bring the patient in, for which they get paid,” he says.
In Trotter’s opinion, this lack of use was what caused Google Health to fail. Not enough people made use of the system to make it worthwhile for Google.
“So the ‘value’ of a patient portal ends up being an economical issue and not really a technical one at all,” Trotter surmises.
Trotter does see the situation changing with the introduction of capitated care models, like the most aggressive ACO (Accountable Care Organization) models. Wikipedia defines capitation as follows:
“…a method of paying health care service providers (e.g., physicians or nurse practitioners) a set amount for each enrolled person assigned to that physician or group of physicians, whether or not that person seeks care, per period of time. The amount of remuneration is based on the average expected health care utilization of that patient (more remuneration for patients with significant medical history). Other factors considered include age, race, sex, type of employment, and geographical location, as these factors typically influence the cost of providing care.”
Under smart capitated care models, healthcare providers will have to reduce their communication overhead, Trotter explains. “If e-mail/portal communication is as effective at getting clinical results as an office visit, the doctor gets paid more (in the end) for having a good portal,” he theorizes.
ROI for Physician
As with any profession, doctors need to make money. Yes, they are guided by an oath and code of ethics, but the bottom line is the bottom line. And some observers of the patient portal trend just don’t see enough monetary incentive for doctors to commit themselves to this new effort, despite the fact that patient portals will soon be a requirement for Meaningful Use.
“There is no return on investment (ROI) for a physician,” says John Brewer of HIPAAudit.com, a company that, among other things, consults with physicians on what makes sense for their practice from an IT and EHR perspective. According to Brewer, there is no patient portal that saves a doctor money. “A portal can help reduce input time IF the office includes the ability to update paperwork,” Brewer explains, “but there is no reduction of error, as patients can make just as many errors on paperwork as office staff.”
In Tharps’s patient portal implementation, the issue of paper-related errors is moot. No paper is involved in the TGCMG office, other than the scanning of reports from outside sources, such as consultants’ reports, into the Electronic Medical Report (EMR).
Besides the financial shortcomings, Brewer maintains that patient portals will deplete another valuable provider resource: time. “If physicians are going to answer medical questions via a patient portal, they can kiss any spare time goodbye,” he warns.
But Dr. Tharp’s experience contradicts this assessment. While he admits that volume is a variable, he insists that protocols given to the patients and used in the physicians’ responses help balance the equation. “On our end it is done in one to three minutes 95% of the time—far less than either the patient time (and cost) or physician time for an in-office visit.”
Despite seeing a lack of incentives for physicians to implement patient portals, Trotter does not see the endeavors as entirely lacking in ROI, as Brewer depicts. “Technically, patient portals create an opportunity to communicate with patients at a lower cost,” he suggests. Still, he concedes that the current medical reimbursement arrangement gives them a strong incentive to not use that lower-cost option. “A lower-cost option that doctors will not get paid for will never replace a higher-cost communication option where they do get paid,” Trotter says.
By Tharp’s accounts, patient portals are, by design, not a high-volume endeavor. “The financial impact is minimal, but it is a very popular service, and tremendously appreciated by our patients who can take advantage of it. It is a convenience.” He adds that the service does offer a huge practice-building potential if done properly and in compliance with medical ethics and regulations. “We have assessed the issue and are preparing a plan to move forward on a larger and compliant scale,” Tharp says.
Patient portal systems are expensive, even with incentive payments. According to Gilmer, this expense is one reason ACOs present a viable option. When smaller practices can join forces with hospital systems that have a lot more capital to invest in new technologies, Gilmer believes those practices will be able to stay competitive. “But if all doctors go this route, that means the death of private practices, which I feel often provide better, more individualized care,” she cautions.
Years ago, people were reluctant to shop online because the threat of privacy issues and security breaches gravely overshadowed the conveniences offered by the Internet. Today, patient portals face the same concerns. One issue, as Gilmer points out, is authentication. How do healthcare providers determine who is accessing this information? Then, how can they make sure the information is protected? “HIPAA and HITECH are interesting in that they enforce privacy and security for covered entities and business associates and give rights to patients, but many new technologies that can be used as patient portals are not necessarily covered in the same manner,” Gilmer explains. “The problem is this isn’t just your credit card information being stolen, it’s your medical information, which unfortunately still comes with a lot of stigmatization.”
Another potential concern is that of phishing (defined by Wikipedia as “a way of attempting to acquire information—and sometimes, indirectly, money—such as usernames, passwords, and credit card details, by masquerading as a trustworthy entity in an electronic communication.”) Brewer considers phishing scams to be very realistic threats with patient portals. “Some of the trickiest scams right now pretend to be UPS/FedEx, that you missed a delivery and have you click to ‘find where your package is,’” he says. “Having one more place to log in means one more way to be tricked.”
But Trotter thinks the eager leap to fear of phishing is unwarranted, and somewhat lazy. He describes phishing as “a social engineering attack where a criminal pretends to be a legitimate site in order to get your credentials to that legitimate site.” But, he points out, getting the credentials to a “patient portal” where your health data is kept and getting your credentials to your bank account have vastly different benefits for a criminal. “The worst a ‘fake patient portal’ could do is ask for your credit card number, but the credit card companies typically have policies protecting consumers from this type of online fraud,” he distinguishes. “So, technically, this new attack vector will be made possible via patient portals, but practically, there is very little threat.”
Tharp says that these particular security issues have not been an issue in his practice to date, as TGCMG does not exchange health records via the EMR system. This is due to the fact that there are currently no standards for the different software programs used in the industry. But Tharp says his practice is working on pilot projects toward that end.
Finally, the patient portal debate bubbles with the question: who owns the patient records? In Gilmer’s opinion, a view shared by many, patients not only have a right to their health information, but also own that information. Before HIPAA and other patient bills of rights emerged, patients did not have a right to access their information in the belief that, without the doctor’s expertise, the patient could not understand it. Gilmer maintains that this perspective is still relevant today. “We Google a lot of medical information, we have direct-to-consumer marketing by pharmaceutical companies and that information alone is already often misused,” she says. “But I believe that having access to this information would empower patients and engage them and their doctors in a discussion that can result in better health outcomes.”
With all these obstacles, the idea of a day where patient portals are as ubiquitous as telephones can seem distant, if not improbable. Still, enough traction and optimism exists in the industry to spark hope for the fledgling new offering. And some people believe that e-visits and other new approaches will change the face of healthcare as we know it. “It’s incredible how little the typical patient-doctor interaction has changed in decades, while just about every other industry has undergone revolution,” Carrell remarks. “There are so many inefficiencies in the way that patients and doctors interact—and mostly this causes inconvenience for patients rather than the system itself. As e-visits become more common, patients will get used to demanding the same efficiency of their healthcare interactions that they do of other services.”
Gilmer, too, sees hope for her dream of health becoming realized as a human right, and she underscores the role that patient portals will play in this evolution. Here’s her version:
“Ideally, I would love patients to be able to track any and all information they want to in a patient portal or PHR. This information would be transmitted to all their caregivers over health information exchanges. Alerts would pop up if there is something a patient reports that needs immediate attention, perhaps through an e-visit. The next time a patient went to any doctor (primary care or specialist or even mental health providers) or went to the hospital, this information would be available. The providers will then have not just a snapshot of a person’s health, but the full picture and can then engage in a meaningful discussion with their patients, using the most of the short time these providers have for a visit. I also envision patients from every part of the globe having access to these technologies, ensuring that everyone has access to health care. If the poorest countries were able to engage in e-visits and other telemedicine capabilities, the impact would be unimaginably huge. And I think all of this is possible.”