Patient Portals: Building A Bridge For Patient Engagementscholar.harvard.edu/files/crotty/files/hsph_tech_talk.pdf · Policies For Patient Access 3. Reaching All Patients 4. Organizing

Instructor in Medicine, Harvard Medical SchoolInvestigator, Division of Clinical Informatics

Beth Israel Deaconess Medical Center

Bradley H Crotty MD MPH

Patient Portals: Building A Bridge For Patient Engagement

Applying Information Technology toSupport Patient-Centered Treatment Approaches

June 3 2014 3:30pm - 5:00 pm

@bradcrotty [email protected]

1 HSPH TECH Talk - June 15, 2015


Dave Bushe via Flickr


Patient Portals

Patient Portal


Have Multiple Components

Personal Health Record

Secure Messaging

Open Notes

Transactions


PatientSite


There is no “one size fits all”13 Key Lessons


Why Have Patient Portals?• Patient Expectations

• Meaningful Use• Stage I• Stage II+

• Data• Patient Outcomes• Efficiency of Care Delivery





>70%

Expect To Email Doc

Moyer et al. Bridging the electronic divide. Am J MC(2002) vol. 8 (5) pp. 427-33





Electronic Access To Medical Information

• Available Within 4 Business Days





Use Secure Messaging With Patients

• ≥5% of patients seen in a 90d window





•

• Does it help improve the care of our patients?

• Is there a reasonable ROI?


Portals & Patient Outcomes

Limited data exist to document a benefit to patient portal use onhealth outcomesUnclear association with healthcare utilization

© Arthur Lien

Goldzweig CL, Orshansky G, Paige NM, et al.Ann Intern Med 2013;159(10):677-87.


McMahon, G.T. et al., 2005. Diabetes Care, 28(7), pp.1624–1629.

P. 104 patients with diabetes mellitus and A1c ≥9% at VA

I. All had an education classIntervention patients used a Web-Based Care Management • Notebook computer• Monitoring devices• Care management website • Messaging with care manager

C. Usual Care

O. A1C Utilization

Portals & Diabetes


P. 11 Primary Care Practices

I. Web-Based Care Diabetes Journal

C. Other Web-Based Modules (i.e. family history module)

O. A1cdiabetes mellitus med ∆s

Portals & DiabetesGrant, R.W. et al., 2008. Archives of Internal Medicine, 168(16), pp.1776–1782.


X 2

X 3

p=0.023

p=0.01

X 5 p=0.001

Flu Vaccination

Mammography

Pap Smears

P. 11 Primary Care Practices, 2005-2007 (Cluster RCT)

I. Health Maintenance Reminders

C. Other Web-Based Modules (i.e. diabetes module, medication reconciliation)

O. Intention to Treat AnalysisAdherence to guideline-based care recommendations

Process of Care Quality MeasuresWright, A. et al., 2012. Journal of General Internal Medicine, 27(1), pp.85–92.


Visits

20052002

Telephone Calls

20052002

↓ 6.7% Differencep<0.003

↓ 13.7% Difference

p<0.01

Zhou, Y.Y. et al., 2007. The American Journal Of Managed Care, 13(7), pp.418–424.

P. Kaiser Permanente (Northwest), Retrospective Case-Control

I. Access to Portal + Messaging

C. No Access To Portal

O. Health Service Utilization

Health Care Utilization


Palen, T.E., 2012. JAMA pp.1–8.

P. Kaiser Permanente (Colorado), Retrospective Case-Control

I. Access to Portal + Messaging

C. No Access To Portal (Propensity Matched Controls)

O. Health Service Utilization

Health Care Utilization


OpenNotes: An Initiative That Invites

Patients To Read Their ProgressNotes Through A Patient Portal


OpenNotes Invites Patients To Read Chart2010 2011 2012 2013

OpenNotes Demonstration

PCPs at BIDMC, Geisinger, Harborview (UW)

Implementation

Sur

vey

Sur

vey

Focu

s G

roup

s

Ana

lysi

s

Data Collection

Pol

icy

Dev

elop

men

t

• 84% of BIDMC patients opened at least one of their notes• 82% GHS patients opened at least one note• 47% of HMC patients opened at least one note• 20-42% of patients reported sharing notes with others


70% reported taking better care of themselves (incl. med adherence)

80% reported better understanding of their health and medical conditions

80% reported remembering the plan for their care better

84% felt more in control of their care

75% felt better prepared for visits

Delbanco, T. et al., 2012. Annals of internal medicine, 157(7), pp.461–470.

P. 114 Primary Care Doctors and Their 20,000 Patients

I. Patient Direct Access To Notes Through Web Portal

C. No Access To Notes

O. Survey Measures

OpenNotes


Weeks after my visit, I thought, "Wasn't I supposed to look

into something?“ I went online immediately. Good thing! It

was a precancerous skin lesion my doctor wanted removed (I

did). { }22 HSPH TECH Talk - June 15, 2015

In his notes, the doctor called me "mildly obese." This

prompted immediate enrollment in Weight Watchers and

daily exercise. I didn't think I had gained that much weight.

I’m determined to reverse that comment by my next check-

up.{ }23 HSPH TECH Talk - June 15, 2015

It really is much easier to show my family who are also my

caregivers the information in the notes than to try and

explain myself. I find the notes more accurate than my

recollections, and they allow my family to understand what is

actually going on with my health, not just what my memory

decides to store.{ }


Portals are not “one size fits all”12 Portals, like most other forms of

technology, are merely tools. Outcomes depend on how they are used.

3 Key Lessons


Challenges For Patient Portals

• CIO • Patients • Clinicians • Business Operations • Administrators • Clinical InformaticsReti, S.R., Feldman, H.J. & Safran, C., 2009. Governance for personal health records. JAMIA, 16(1), pp.14–17.

1. Ideal Governance Models

2. Policies For Patient Access

3. Reaching All Patients

4. Organizing Patient Generated Health Data

5. Aligning Patient Portals With Care & Business Processes

6. Revenue & ROI


Challenges For Patient Portals

• Info Embargo • Withholding Notes • Proxy Access

My OpenNotes Toolkit available at:http://www.myopennotes.org

1. Ideal Governance Models





6. Revenue & ROI


Challenges For Patient Portals1. Ideal Governance Models





6. Revenue & ROI

Minority Patients AreLess Likely To AdoptYamin, C.K. et al., 2011. The digital divide in adoption and use of a personal health record. JAMA Int Med, 171(6), pp.568–574.







6. Revenue & ROI







6. Revenue & ROI

• Scheduling • Population Health • Care Management • Shared Care Plans







6. Revenue & ROI

• Global Payments • E-Visits • Additional Fees • Efficiency


A Roadmap For Portals

E-Mail & Labs

OpenNotes

Patient Input

Shared Care Plans


Portals are not “one size fits all”12 Portals, like most other forms of

technology, are merely tools. Outcomes depend on how they are used.

3 Key Lessons

3 Leaders should create roadmaps for how patient portals should be used locally, tackle challenges head-on.


Contact InformationBradley H Crotty MD MPH Division of Clinical Informatics Beth Israel Deaconess Medical Center

@[email protected]

For Further Reading

• OpenNotes Toolkit Available at http://www.myopennotes.org



Reports from Patients Post intervention• 26-36% had privacy concerns

• Few patients said reading notes made them• Worried (5-8%)

• Confused (2-8%)

• Offended (1-2%)


PCPs’ Main ConcernsOpenNotes impact on patients

Pre -intervention % BIDMC / GHS / HMC

Post-intervention % BIDMC / GHS / HMC

PCPs think patients who read their notes will:

Find notes more confusing than helpfulWorry more

Feel offended

48 / 54 / 43

50 / 58 / 45

33 / 8 / 29

13 / 21 / 12

15 / 42 / 12

18 / 8 / 2


PCPs’ Main Concerns OpenNotes impact on workflow

Pre-intervention %

BIDMC / GHS / HMC

Post-intervention %

BIDMC / GHS / HMC

Visits significantly longer

More time addressing patient questions outside of visits

More time writing/editing/ dictating notes

…and the volume of electronic messages from patients did not change

23 / 32 / 21

49 / 45 / 34

46 / 36 / 34

3 / 5 / 0

8 / 0 / 0

21 / 14 / 0


Documents

Patient Portals: Building A Bridge For Patient Engagementscholar.harvard.edu/files/crotty/files/hsph_tech_talk.pdf · Policies For Patient Access 3. Reaching All Patients 4. Organizing