Patient Portal Benefits Patient Care and Provider Workflow

PHMG is an independent medical group with 11 clinics in southwest Idaho, provides both appointment‐based and urgent care. PHMG has 46 health care providers (including 12 mid‐level providers) and averages 200,000 patient visits per year. About half of PHMG’s patients are appointment‐based and half are urgent care. The practice specializes in:

• Family practice
• Pediatrics
• Obstetrics/gynecology
• Dermatology
• Otolaryngology or ENT (Ear, Nose, and Throat)
• Occupational medicine
• Sports medicine

Working with Qualis Health , the Washington & Idaho Regional Extension Center

PHMG worked closely with Qualis Health, the Washington & Idaho Regional Extension Center when they first implemented eClinicalWorks. In 2007, Qualis worked with them to map workflows and train providers and other staff in the use of eClinicalWorks. Qualis has also been an important resource for information about the meaningful use rules.

"We felt strongly that from a quality standpoint we could not succeed without going to electronic health records. I felt very strongly we had to invest in it because it would positively affect every patient that we encounter." –Dr. David Peterman

In 2007 PHMG implemented an EHR system, eClinicalWorks, as part of a strategy to improve quality of care and facilitate coordination of care across its multiple clinic locations. In preparing for implementation, PHMG proceeded with:

• Establishing several teams, including provider, administrator, and clinical content teams to map out workflows
• Developing and conducting training curricula for providers and for front- and back-office staff, including reception staff and customer service representatives
• Providing leadership from a physician champion, who played a critical role in supporting and guiding colleagues during the transition

The EHR system was implemented in phases, with one clinic going live every two weeks and a pause after the first three clinics went live to assess the process and make adjustments. In 2011, PHMG implemented eClinicalWorks V. 9 (certified version). To prepare for the update, a team of providers, clinical managers, and staff reviewed how the new version would impact clinic processes, identified training needs, and led implementation of the update.

"There needs to be a physician champion. He really learned to use the portal first. Then he could go out to the other physicians and tell them about it from the physician standpoint." –Tracy Morris

PHMG launched the patient portal in early 2010. As a first step, the physician champion piloted the portal for about 6 months before it was implemented in one clinic at a time. According to the physician champion, implementation was “easier than expected because everyone was already comfortable with eClinicalWorks, so it was just adding another step.”

A team comprising of the physician and an administrator champion traveled from clinic to clinic to demonstrate the portal and train providers and staff. Based on initial pilot testing, they were able to assess patient portal benefits and address questions and concerns, such as the common provider concern that they would be “bombarded with e‐mails,” based on their own practical experience.

"As doctors gained experience with the portal, they realized it was a very efficient way to communicate with patients. Phone encounters can be long because patients get talkative and ask a lot of questions. Using messaging, their questions are more pointed." –Dr. James Weiss

PHMG had a strategy of ensuring that patients hear about the portal from multiple sources during each clinical visit. To execute this strategy, PHMG used several methods of communication, including:

• Distributing fliers
• Posting materials about the portal in their clinics
• Providing talking points for front-office staff to encourage patient registration and use

• Do you use e-mail? The portal is just a secure e-mail system that we can use to communicate.
• You can send me a message and it goes right into your chart, so I have all of your information at hand when I read it and respond.
• If you use it and don’t like it, you don’t have to continue to use it. Just let us know.
• It’s really very easy to use. If you use the Internet, you’ll most likely find the portal helpful and easy to navigate.

They found that it is particularly persuasive when providers encourage patients to use the portal because patients trust providers and value their opinions. One provider says he reinforces a patient’s use of the portal by closing all messages with “Thanks for using the portal.”

Some patients were concerned that PHMG would send them spam. When providers and staff tell patients about the portal, they assure them that the portal will only be used to respond to the patient’s message and to share important health information such as the clinical summaries. They also explain how to prevent messages from going into the spam folder.

“Patients love them,” says Dr. James Weiss, a family practice physician, talking about clinical summaries. “I print it out and hand it to them because I want them to leave with something in their hand every time.”

Depending on the workflow in the clinic and providers’ availability to respond in a timely manner, each clinic set up systems for routing and responding to messages.

• For family practice, messages generally go right to the provider.
• For specialists, who tend to be out of the office more often, messages go to the nurses or other staff for triage.

To facilitate communication, PHMG developed a template for common messages, such as delivery of lab results. Messaging is monitored periodically to ensure that communication with patients is succinct and user-friendly.

Providers experienced:

• Patients use the secure messaging appropriately, asking clear and pointed questions, with very few exceptions, and e‐mail volume was not problematic
• Found themselves wishing more patients would use the portal for things such as medication refill requests
• It takes providers and staff less time to respond to e-mails than to process incoming calls and route them
• Appreciation of efficient communication and reduction of “phone tag” that often results in delays and miscommunication
• Messages are in patients’ own words and not subject to others interpretation, biases, or attention to detail
• Advise that it is important to set expectations with patients, explaining what kind of questions are appropriate and how and when providers will use the messaging; for example, “I’ll be sending your test results on the portal in 2-3 days”

Patients experienced:

• They appreciate the direct communication with providers
• They appreciate the ability to ask questions in-between visits and convenience of requesting medication and referrals online
• Some patients have told them they selected PHMG (and “fired” their other providers) in part because of the availability of the portal

PHMG established a team specifically focused on achieving meaningful use. The team identified process changes that would be required to achieve meaningful use and led the implementation of these changes. A total of 21 PHMG physicians were eligible for meaningful use and all were successfully attested by October 2011. The practice has applied for Medicare incentive payments and received the first payment in November 2011.

• Share Patient-Specific Education Resources.  
  PHMG is currently working with Healthwise® — a nonprofit organization based in Boise, Idaho, that develops health content and patient education solutions—to beta test the integration of Healthwise patient education materials into the eClinicalWorks EHR system. Providers find that the tools available on the EHR system to track health data can be powerful for patient education. For example, one pediatrician shows patients and/or parents the online growth chart to discuss growth and any health concerns, such as a trend toward overweight. He finds that “patients really get it and it has a big impact.”

• Provide Clinical Summaries. 
  Physicians are now able to use the clinical summary available through eClinicalWorks by either printing it out to give to patients at the end of a visit or making it available on the portal. However, providers noted that they would like the summaries to be more user‐friendly and robust; for example, including or linking to patient‐specific education resources. This will be part of the beta testing with Healthwise® resources. A learning point for providers is that the quality of the clinical summary depends on how they enter information in the EHR system. For example, avoiding the use of abbreviations and difficult medical terminology is important to produce a summary that patients can readily understand.

• Offer Electronic Access to Health Information. 
  Patient portal benefits include patients’ ability to access their clinical summaries online. Providers can also send lab results to patients via secure messaging accompanied by a brief message explaining the results (for example, “Your results are normal”) and any needed follow‐up instructions (for example, “Come back in 3 months for a recheck”). If lab results are critical, providers rely on the telephone to communicate with the patient. Providers encourage patients to review their medical information and report inaccuracies.

"When we first roll it out to the doctor they’re like, ‘I’m not going to have time; this is going to be a burden.’ Then they realize it actually cuts down on the phone calls and the back and forth." –Tracy Morris

Patient registration for the portal and the number of Web messages received and sent continues to increase. As of August 2011, approximately 9,000 patients were registered.

• Providers and staff appreciate that call volume has gone down as patients use the portal
• In one of the clinics, using secure messaging to provide lab results has saved the assistant from making five to 10 telephone calls per day
• With the patient portal implementation, call volume and work load is down and the assistant no longer needs to work overtime
• The response for Web encounters is much better compared with telephone encounters

One major challenge with the portal is the multiple step registration process. Patients provide their e‐mail address at the front desk and are given a password to register from home. Some patients fail to complete the registration process after leaving the clinic. Remembering and managing passwords and managing family accounts are also challenging for patients. For example, a parent may log in for one child and then ask questions about a second child. For providers and staff, a challenge is that there is no way to know whether a Web‐enabled patient actually uses the portal and there are no read receipts to confirm that patients have read a message.

"We’ve realized as we implement evidence‐based medicine we have to use national guidelines. The days of pulling out a handout and using it year after year are gone." –Dr. David Peterman

• Implement New Efforts One Step at a Time. Historically, PHMG’s philosophy has been patient‐centered and they began incorporating electronic patient engagement efforts into their workflow more than two years after implementing their EHR system. Fully embracing technology is an ongoing process and PHMG advises that it has worked well to implement new efforts one step at a time. Specifically, introducing the portal was relatively easy because providers were already comfortable with the EHR system.
• Don’t Let Assumptions Stop You. Preconceptions work both ways. Providers were concerned that they would receive a lot of inappropriate and unnecessary e‐mails from patients. Interestingly, patients had similar concerns, thinking that they would receive spam if they shared their e‐mail address with PHMG.
• Identify and Empower “Champions” for Change. Providers want to hear from other providers about new technologies. Physician champions can share practical how‐to information and address their colleagues’ questions and concerns from the physician perspective. Teaming physician and administrative champions can be an effective approach to introducing new technologies and processes.

• Increase Portal Registration. PHMG plans for another patient portal registration push in 2012, with a goal of increasing adoption to 50 percent.
• Expand Portal Access. PHMG also plans to expand portal access to urgent care patients who do not have a regular provider.
• Educate. Providers and staff will continue to educate patients about patient portal benefits and how to use the portal correctly.
• Implement New Portal Features. PHMG is not currently using all of the available portal features and will review which additional options to activate, such as publishing lab results on the portal rather than via messaging. PHMG will also consider, focusing on developing a more robust clinical summary that is linked with patient-specific education resources.

"Our EHR system has increased access for patients and improved our ability to evaluate patient care. Patients can access their health records from their living rooms—even send and receive e‐mails from their doctor if they have questions. The opportunities being presented to patients to take control of their health are quite remarkable." –Dr. David Peterman