As more and more physicians’ offices and other providers begin to take the first step in setting up a patient portal, I thought it would be interesting to tell our story about how our office implemented and uses a portal. The lessons we learned may be helpful for you as Meaningful Use Stage 2 deadlines for patient portal use approach. And we would love to connect with others who have tackled and solved similar situations.

Dr. Gilbert’s practice recognized early on that a patient portal can spur communications between doctors and patients.

Our organization – 75 providers in Orange County, Calif.-based St Joseph Heritage Medical Group and 150 providers in our sister organization, St. Jude Heritage Medical Group, have been fully implemented on Allscripts Enterprise E.H.R. since 2005. Early on, we recognized the value of a secure patient portal that could spur online communication between us and our patients. Our first two portals, allowed patients to communicate securely with providers and allowed patients to develop a personal health record. Initial obstacles to success mainly centered on provider reluctance to adopt online patient communications. Providers were terrified that, like e-mail, the volume of messages would sky rocket.

To address some of those concerns, our initial efforts were educational. We looked at published data and the personal experience of a small group of providers to dispel the notion of overuse by patients, and promote the positive aspects of online patient communication – namely the ability to respond to patients asynchronously, when it was convenient for providers.  It was easier, quicker and more complete than the telephones we were all used to using for patient communication. Providers who embraced this message actively engaged their patients and actively promoted registering for the portal. We were pleased with the adoption of the portal for this core group of providers, but sought to expand registration to include patients from all providers. We decided to incentivize registration, providing specific monetary bonuses for providers who achieved 50 and then 100 registrations in a year. The lesson learned in this initial phase was two-fold – incentives helped, but were no substitute for provider promotion of the portal to patients.

Periodically we solicited feedback from patients about our portal. In this initial phase, patients especially liked the ease of contacting providers on their time. They enjoyed the ability to author a question at night or early in the morning, when the kids were in bed, or before work. With the expectation that they would receive a response they could read later that day. In later deployments of subsequent portals, patients enjoyed the 24-hour access to important parts of their medical record, and the portability of that record. Patients expressed delight when they realized they could review, scan, print or transmit their lab results back to 2005, or confirm the date of their flu vaccine, or children’s school aged vaccines.

About a year or so after our initial roll out, the original provider of the portal sold to another company, and Allscripts, our EHR vendor, suggested changing portal vendors. We elected to change as well, since we knew that for a portal to be successful among providers it must integrate seamlessly with our EHR. We knew that providers would not and should not be expected to log on to a different product to communicate to patients. Lesson two derived from our transition. Though this was EHR- sponsored, and the transition was fairly seamless for patients, we found that transitioning portals resulted in up to 40% loss of registrants. Hard earned patient acceptance had to be regained in order to achieve the same engagement we had already worked to achieve.

This brings us to our current portal, Jardogs, Follow My Health. We felt hampered by the inability to expand our portal functionality so we wanted a tool that would go beyond just online communication. We wanted to share results, allow direct scheduling, online bill pay, and two-way updating of Problems, Medications, Allergies, Immunizations and such and Follow My Health provided us with this deeper integration. We now use Follow My Health and currently 547 physicians, nurse practitioners and physician’s assistants, medical assistants, receptionists and pharmacy technicians across our two Orange County medical groups participate in secure online clinical communication, schedule appointments, refill medications, and answer routine questions with and for patients.  The new portal automatically uploads all results within minutes of being verified by the provider and patients can directly schedule into providers schedules, ask for medication renewals and pay bills. The portal also offers a computer, iPad and iPhone application with all of the above functionality to patients. We have over 30,000 patients registered, and have achieved 10% penetration of all registered patients across both medical groups. Some providers have almost half of their patients registered.   Our physicians encourage their patients to message them via the portal.  It’s a great way for the physicians to keep track of their communication with their patients.

It is the perfect system, so what’s the issue? We have a constant 12,000 pending registrations, many of which never become active patients with the portal. This is especially important given the Meaningful Use Stage 2 requirement for 5% of your patients to message a provider. Lesson number three: It is really hard work to get patients to register and use even the best patient portal. Obstacles include the patient authentication process which requires a phone call to authenticate a patient’s identity, registration confirmation e-mails succumbing to spam filters, the use of Silverlight, and — perhaps the biggest challenge — patient ennui.  Silverlight is a plug in for graphics.  Patients weren’t able to see the graphics on the portal if they didn’t download and install Silverlight.  Our portal vendor eventually removed Silverlight after a year of frustrated feedback from patients.

We employ a process-improvement system based on Toyota Lean Methodology to problem solve difficult system issues. We put this Rapid Improvement Event process to the task of improving successful registration of patients. We tried the following – Kiosks placed in the waiting rooms, follow-up phone calls to registrants, staff promotions, including buttons, fliers, pamphlets, and waiting-room bill boards. We are considering registering all new patients through the portal, conveying referrals through the portal, adding screen savers in exam rooms and are always trying to find ways to simplify the portal-authentication process.

When all was said and done, we determined the single most important factor in obtaining high patient registration and use of a patient portal was provider engagement. Despite all marketing efforts and staff engagement initiatives, it was the provider asking the patient to register, actively communicating results, responding to patient messages, and engaging the patient in their health care through the online portal tools that was the single most important factor in motivating patients to buy into the new system.

We are happy with our results. We set a goal of 10% of our patients being registered with the portal, we have achieved this goal. We will be building out other ways to measure our success toward the portal related meaningful use measures (e.g., messaging from patient and the view, download, and transmit).

We still face challenges. We have an additional 200 providers in Northern and Southern California we are urging to embrace and implement the portal before next October when we attest for MU Stage 2.

With this said, we are embarking on phase 3 of our portal journey. Our health system bought a software development company and is actively developing a new patient portal, creating our own Health Information Exchange, and adding a physician HUB to this exchange.

I am part of a small physician group testing usability and voicing ideas to the development team. Frankly, we are both excited and worried. We are excited, because we will have ultimate control over the look, and feel of the new portal. We are worried because we know we will have to master a big hurdle: the transition of patients to the new portal. We know we cannot afford to lose current portal users. Historically, transitions result in losses of between 15 – 40 %. This portal will allow MU certification for both our hospital and our ambulatory medical groups, but we worry that mixing these very different patient experiences into one portal will confuse patients.

So, exciting and scary times.

I share these experiences in hopes they will be helpful to others seeking to implement patient portals in their practice, and to seek advice from others about how to promote a portal among patients, as well as what features a robust, dynamic and useful patient portal should contain.

Dr. Gilbert is an HIT Fellow and Orange County, Calif. Family Physician. Have a similar story to tell or want to leave a comment? You can contact Dr. Gilbert or leave a comment below.