By Gilly Munavalli, MD, MHS, April 02, 2013
I admit it: I was a little nerdy in high school. I even took typing class in high school because I wanted to get faster at typing papers on my old Commodore 64. I rolled up old tube socks to use as wrist guards and even hit 35-40 words per minute on that screaming machine on occasion. I thought I was Speed Racer or maybe it was Racer X. Unfortunately, I never really got much faster at typing, and boy am I paying for it now with electronic health records. The only thing more painful than having to type in a patient’s room is watching an untrained medical assistant hunt and peck out a note while I dictate to them.
I just had a DMV flashback, so I know things can be much worse. Stillgood EHRs are designed to work around keyboard entry, and optimized to be tap and click, but even the best-designed templates are no match for the dreaded phase, “As long as you are here”
What if I told you we could cut our data entry in half and still be able to bill at the same rates 90 percent of the time? In this month’s article, we will delve into patient portals that theoretically can do just that. [pagebreak]
Patient portals are nothing but secure Web pages containing forms, typically integrated on the front end with the practice website and on the back end with the practice’s EHR database. These allow patients to use almost any Web browser to securely authenticate their identity and then enter data, such as past medical history, medications, and elements of their history of present illness. Advanced portals allow patients to view other items in their records, such as visit history and billing information. I personally think they are a great add-on to any integrated PM/EHR package.
I have one big reason why you will be learning more about portals in the near future: our old friend “meaningful use.” In the stage 2 requirements for meaningful use (which will apply in 2014 and 2015), we will be required to make online access available to more than 50 percent of unique patients seen during the reporting period, and give them the ability to view, download, or transmit their data within four business days of their appointments. Comically, we will need to also ensure that more than 5 percent of these patients actually utilize these features. Exactly how we are supposed to make them do this isn’t yet spelled out. I really hope that certain fields in the patient EHR chart can be designated as private and not transmitted so that we can make personal observations of the visit for our future reference that aren’t part of the viewable record. Additionally, the stage 2 criteria also make allowances for having patients input their own vitals, including height, weight, etc. In stage 2, it is suggested that patient-specific educational materials on their conditions can also be distributed via the portal, if not given out by hand. Lastly, stage 2 will require communication with more than 5 percent of unique patients over this portal via some type of secure message or chat feature, although there is absolutely no mention of compensation for time spent doing this. [pagebreak]
Hurdles to adoption
Luckily, we still have time before this is implemented, but rest assured, the EHR companies are feverishly working these features into existing portals in order to be compliant.
What about right now? What can patients do in a portal? Do they really want to even use a portal? A 2008 study in the Journal of General Internal Medicine (Zickmund SL, Hess R, et al) analyzed the results of 10 focus group discussions of 40 patients and found that those who were most interested in using a patient portal were patients who were:
- Dissatisfied with their physician.
- Dissatisfied with their physician’s communication abilities.
- Dissatisfied with their ability to get medical information from their physician.
Those patients least likely to be interested in using a patient portal offered by their physician were patients who were:
- Satisfied with their physician.
- Satisfied with their physician’s communication abilities.
- Experiencing difficulty in using the portal. [pagebreak]
As noted by Stephen Wilkins, MPH, in his blog commentary on this study, patients who reported good relationships with their doctors were afraid that the patient portal would potentially undermine the strength of that relationship. In other words, patients were afraid that e-visits would replace face-to-face visits. Researchers were surprised that not one patient in the study identified encrypted email communication with their doctor as an advantage of patient portals. More recently, a survey done by Chilmark Research in March 2011 pegged consumer adoption and patient usage of available portals at 6 percent.
Making it work
So, back to the original question: Should patients be entering data themselves? My opinion is absolutely. We have all filled out and updated past medical history forms at the doctor’s office. There is no reason these cannot be filled out in advance online. Once this information becomes part of the medical chart, accuracy of data entry must be verified by the provider and/or provider’s assistants prior to the encounter. This is the key to avoiding liability issues, just like paper intake forms. For example, if a patient even mistakenly checks that they are HIV-positive, we are responsible for catching that and verifying whether it is accurate or not.
Having patients enumerate/input their complaints online (into what eventually becomes the HPI), can help them to prioritize what really bothers them the most. Complaint fields can be limited to only a few on the portal. Of course, as complexity increases, a higher level of billing can be substantiated. Currently in our office, one of the most challenging parts of EHR data capture by staff is obtaining an accurate listing of medications. Most patients don’t remember all of the meds they are currently taking that is common knowledge. Potentially, having access to their medications at home at the time of data entry will help this problem. [pagebreak]
Currently, many EHRs don’t allow these medication fields on the portal to automatically be added to the medical record without some type of staff intervention/translation. In other words, each prescription medication that is entered on a portal needs to be validated against a drug database in the EHR before that data is put forward to the electronic chart. I think this is a good idea and hope that over-the-counter drugs will eventually be reviewable on the EHR side in this manner. I still think it saves time and, more importantly, can help avoid potential drug-drug interactions. Eventually, in a centralized system, all prescription drug information on a given patient will be ported into the patient record from a centralized source and it will be up to us to add the dermatology-specific meds for the other members of the patient’s health care team to reference.
Patient portals are here to stay. My feeling is that they will be utilized to strengthen the patient-physician relationship and early adopters of this technology can use this to distinguish themselves in the marketplace. I, for one, would like the ability to deliver specific medication information sheets and specific post-procedure/post-operative care instructions over the portal to my patients. A gentle reminder for patients on their portal page to avoid heavy lifting and strenuous activity after excision of a tumor could be a good thing. I do hope that E/M codes are somehow changed to reflect the added amount of time we will spend in electronic consultation and counseling.