Portal pros and problems

By Ruth Carol, Contributing Writer, November 1, 2022

Following in the footsteps of electronic health records (EHRs), patient portals are here to stay. Like EHRs, patient portals hold the promise of improving patient care and practice efficiency. The key is to effectively manage them, so they not only enhance patient communication but avoid unintended consequences.

“When doctors and patients communicate, care happens,” said Laura Houk, MD, FAAD, member of the AAD Health IT Committee who practices at MaineHealth Medical Group in Portland, Maine. With so many people communicating electronically, either via email or text, the portal can help physicians connect with their patients. “It’s another tool to help us better care for our patients,” she added.

Patients have a right to know

Adoption of patient portals can be traced back to the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act and the Medicare and Medicaid EHR Incentive Programs, now known as the Promoting Interoperability Programs. These programs were developed to encourage hospitals/health systems and physicians to implement and demonstrate meaningful use of certified EHR technology. Those who did could receive incentive payments.

In 2016, Congress passed the 21st Century Cures Act, which included provisions to promote even greater health information interoperability and prohibit information blocking. The latter is defined as preventing or interfering with the access, exchange, or use of electronic health information (EHI). At that time, the Act made no mention of patient portals, but that has since changed.

Effective January 2019, CMS introduced a new program for physicians and clinicians eligible to participate in, called the Merit-based Incentive Payment System (MIPS). This program, among other provisions, requires that patients are provided access to view their EHI within four business days. One year later, the Office of the National Coordinator (ONC) and CMS issued separate but parallel final rules detailing implementation of the 21st Century Cures Act’s provisions. Some of these provisions took effect in April 2021, later than expected due to the COVID-19 public health emergency. Based on the ONC’s interpretation of the Act, patients have the right to obtain their health data from physicians as quickly as possible. The ONC also clarified that the data include clinical progress notes, prescription medications, lab results (including pathology), and other diagnostic results. Additionally, the ONC expanded information blocking rules to include patients’ access to EHI beyond EHRs.

Portal use slowly rises following COVID-19 pandemic

Patient portals will likely become a critical tool in meeting this obligation. But like EHRs, it will take time for physicians and patients to fully embrace portals. In 2017, nearly 90% of physicians offered patient portals, but less than one-third of patients took them up on the offer, reported the Government Accountability Office.

Since then, patients using their portals to communicate and share EHI with their physicians is increasing, according to the ONC. In 2020, one-third of patients downloaded online medical records, nearly double the percentage in 2017, and nearly 60% exchanged secure messages with their physician, up 10% from 2017. More than half of patients viewed clinical notes written by their physician in 2020.

During the first 15 months of the COVID-19 pandemic, a 2021 study published in the Journal of the American Medical Association found a small, but sustained, increase in patient portal message volume across all specialties. Dr. Houk estimates that 80% of her patients are active portal users. Although portal usage grew during the pandemic and there was an uptick following implementation of the ONC’s latest rules, the level of interest is not being maintained, said Clarence William Brown Jr., MD, FAAD, another member of the AAD Health IT Committee. He estimates that about half of his practice’s patients are signed up on the portal, but active users hover around 10-15%.

Pros and cons of patient portals

For patients, portals increase the ownership of their health care, stated Faiza Wasif, MPH, associate director of practice management for the Academy. “They can easily and conveniently schedule appointments, request prescription refills, send/receive secure messages to/from their dermatologist, obtain health information (i.e., lab and test results, prescription history, past appointment summaries), and update/add personal information (i.e., medical, demographic, insurance). All these tasks can be accomplished without being placed on hold and may even reduce unnecessary office visits, the latter of which was critical especially in the beginning of the pandemic,” she said. Dr. Brown added, “People have become much more comfortable with texting and email. They can just as easily message into a medical practice as they can call.”

The ease of access and convenience of portals for patients can result in improved patient engagement and care as well as increased practice efficiency for dermatologists. For example, when lab or biopsy results are released, Dr. Houk typically attaches a note explaining the results and offers treatment recommendations. She can include links to the Academy’s patient websites that provide additional resources. “I know that the patient is going to google the diagnosis, but this way I am providing vetted information,” she said. “It also helps when the patient is explaining the diagnosis to a spouse or adult children.” If Dr. Houk makes a referral to another specialist such as a Mohs surgeon, she can include a link to the specialist’s practice information. Additionally, using the portal avoids a frustrating game of telephone tag. “Nobody answers their phone anymore; they use it to screen their calls and text. But people check their portal and see my note,” said Dr. Houk, who gets a notification when patients have viewed test results.

Another portal benefit is documenting and preserving patient communication in the patient’s records, Dr. Brown said. He finds that patients are more succinct and clearer in emails compared with telephone messages. Dr. Brown has used the portal, on occasion, to engage with patients who travel shortly after a procedure to discuss any complications or determine how the post-op course is playing out.

On the efficiency side, many administrative tasks that used to be handled by a person are now handled using the portal, freeing up physician and staff time to do other tasks, noted Khang Nguyen, MD, FAAD, chair of the AAD Health IT Committee. Most messages received through the patient portal are viewed and triaged by nursing staff, Dr. Houk said. Appointment requests are sent to the administrative team. Billing issues go straight to the billing department, leaving her to receive the medical advice requests from patients. A nurse or medical assistant may triage patients by asking a series of routine questions and requesting a picture. Receiving images through the portal is enormously helpful when trying to triage how quickly a patient needs to be seen or whether they need to be seen at all, Dr. Houk said. After consulting with the nurse, either Dr. Houk responds to the patient or has the patient schedule an appointment. “It can be a very efficient process, which can be to everyone’s advantage,” she said. Sending a note to a patient about a biopsied lesion that is benign takes 30 seconds.

“People have become much more comfortable with texting and email. They can just as easily message into a medical practice as they can call.”

Like many businesses across the country, Dr. Houk’s practice is faced with staffing shortages intensified by the COVID-19 pandemic coupled with a more than 250-day wait time to schedule a new appointment, limiting her ability to see all her patients in the office. “The portal is another way for me to meet the needs of my patients and community,” she said.

Technology is the No. 1 drawback to using patient portals. In general, people struggle with technology; trying to upload photos and documents can be frustrating, Dr. Brown noted. This is especially true for the smaller EHR platforms that dermatologists tend to use because they aren’t always compatible with other EHR platforms, limiting efforts to share clinical progress notes and send medical records, he said.

Some patients expect to hear from the physician almost immediately after sending a portal message and get frustrated when they don’t, Dr. Brown said. Portal usage doesn’t necessarily speed up the response because staff may not be empowered to make a decision without the physician’s approval, Dr. Nguyen added. In fact, the portal can artificially delay scheduling appointments because patients are sending messages back and forth with the dermatologist when they should schedule an appointment, he said. Dr. Houk suggests that patients make an appointment if they exchange several emails, ask her to comment on a previously undiagnosed lesion, or she can’t determine what it is from the photo. “I tell them I may need to use the dermatoscope on it,” Dr. Houk said, adding, “I always thank them for sending a photo, even if it’s a terrible one.”

For dermatologists, a major disadvantage is that time spent on the portal is uncompensated, Dr. Nguyen said. “There’s a lot of effort that goes into implementing a patient portal,” Dr. Brown said. “If the health system expects physicians to put time and energy into patient portals, there should be some means of compensation.” Among the disadvantages Wasif cited were spending additional money to set up the portal, losing productivity early on learning the system and training staff, updating the workflow to encourage portal usage, and dealing with system glitches that may disrupt the workflow.

Obtaining patient buy-in can be daunting, she added. Overall, patient feedback has been extremely positive, Dr. Houk said, but it’s not for everybody. One patient, who has breast cancer, does not want to stumble into new medical information she is not prepared to hear on her own. “There is a note in her chart that says she does not use the portal and don’t ask her about it,” Dr. Houk said. “We respect that.”

Unintended consequences

Thanks to the information blocking rules, patients sometimes see their test results on the portal before their dermatologist does. “I’ve had experiences in which patients found out they had a serious health problem, even melanoma, before I’ve had an opportunity to review the lab report and reach out to them,” Dr. Brown said. The patients, who are sometimes upset, call the office asking why nobody has called them about the results. “I’ve been in a room with patients all day,” he said. “I don’t see the pathology reports the moment they arrive.” One of Dr. Houk’s patients had a panic attack and called the office in tears. The nurse was able to calm the patient until Dr. Houk had a chance to talk her through the results. “It’s never good to have a patient in tears and not be able to speak to them immediately because I’m in clinic,” Dr. Houk noted.

When patients are unable to fully understand or process the results without physician guidance, follow-up conversations can be more difficult and time consuming as dermatologists may first have to ease the patient’s anxiety and then carefully discuss the results, Wasif said. “All results are not the same. There are many other factors on the pathology report that impact the severity of, for example, a melanoma diagnosis and prognosis,” Dr. Brown said. “When a patient receives a life-altering diagnosis, we would like the opportunity to delay the communication until we have a chance to review the report, interpret the results, and reach out to the patient.” Another unintended consequence is when more than one family member uses the same email account for the portal, allowing others to view sensitive and personal medical information that’s not intended for them, Dr. Brown added.

Currently, there are no national guidelines indicating how test result notifications should be released. Some institutions have chosen to release all results to patients immediately to avoid any perception of information blocking.

The ONC has identified eight exceptions to the information blocking rule. For example, physicians can withhold information from patients based on their professional judgment if the information will cause harm to the patient, Wasif explained. “However, the majority of cases would most likely not fall into this category,” she said. According to the American Medical Association (AMA), “Physicians should strike a balance between strict regulatory compliance and exercising his/her independent professional judgment — guided by personal and professional beliefs — as to what is in the best interests of patients, the profession, and the community.”

The Academy — both on its own and with the AMA — has been working with the ONC to simplify the information blocking regulations, including adopting a broader and more flexible definition of patient harm. At the 2021 Special Meeting of the AMA House of Delegates, the Dermatology Section Council introduced a resolution in support of revising the definition of harm to include mental and emotional distress. The AAD is urging the ONC to recognize dermatologists’ concerns and consider real-world dermatology examples in revising the exceptions.

Dermatologists who are part of a larger multi-specialty practice or institution should consider talking with the risk management or legal team about deadlines for the release of lab results, Wasif said. Make them aware of sensitive situations in which more time is needed to release results to patients and provide supportive written documentation.

The onus is on the organization to determine good rationale for not immediately releasing lab results, Dr. Houk said. “They can choose to hold those results back, but the chief medical officer or physician will need to justify why the information was not released immediately,” she added.

Tips for managing patient portals

Creating a default notification can help set patient expectations, Dr. Nguyen said. The notification should explain that the patient may get the results before the physician has had time to review them, but that the physician will be in touch. Dr. Brown encourages dermatologists to train front desk staff and medical assistants to deliver a consistent message about the federal regulations mandating the immediate release of this information.

Dr. Houk sets expectations at the time of the biopsy, which she explains is being done because of the concern that the lesion could be skin cancer. The follow-up care summary includes an explanation of the 21st Century Cures Act. She emphasizes that the Act enables patients to check the results before speaking with the doctor, “but sometimes you may wish you hadn’t,” she said. “My advice is to wait for me to call you. I will always call you to talk about the results.”

In five years, patients will have sorted themselves into two camps: those who want to know the results immediately even if they don’t fully understand them, and those who prefer waiting to speak with the doctor, Dr. Houk said. Unfortunately, some patients may have a bad experience before they figure out which camp they are in.

“We’re really in version 1.0 of patient portals. As the technology develops and evolves, it can become even more helpful to physicians and patients.”

In the meantime, good protocols/workflows can go a long way for effectively managing the patient portal. Protocols should address who is responsible for managing the portal and determine which messages the clinical staff should review, and which ones can be delegated to others, such as the scheduling or billing department, Dr. Nguyen said. Depending on the practice, the front desk staff or a non-physician clinician could review the portal requests first. “It really depends on what works best for your practice,” he said. Cross-training staff on how to use the portal will help ensure that there are multiple touch points throughout the day, Dr. Brown added.

Developing a communication and promotion strategy will help encourage patients to use the portal, Wasif said. Establishing guidelines for portal engagement using consistent communication is key, Dr. Brown said. Consider creating a one-page handout for patients explaining how to use the portal. As an example, don’t use the portal for emergencies or urgent questions, know that the portal is not checked after business hours or during the weekend, and allow at least one to two business days for a response.

The ONC found that physicians are particularly persuasive when encouraging patients to use the portal because patients trust physicians and value their opinions, Wasif said. Seventy-one percent of individuals encouraged by their physician accessed their portal compared with 48% who were not, according to ONC 2020 data (see sidebar).

Make it as easy as possible to sign up for the portal, Dr. Nguyen suggested. Encourage patients to sign up during visits or offer automatic sign up. There are signs posted in the exam rooms, waiting area, and even bathrooms listing the benefits of using the portal at Dr. Brown’s practice.

Once the portal is implemented, don’t just leave it, and forget it. “Periodically evaluate the uptake of portal use, how it is impacting the practice, and what improvements can be made,” Wasif said. “We’re really in version 1.0 of patient portals,” Dr. Brown said. “As the technology develops and evolves, it can become even more helpful to physicians and patients.”

Additional DermWorld Resources