The Effect of Patient Portals on Healthcare Utilization

(I wrote this article on Patient Portals for my Masters in Health Informatics Program, and am posting here as others may find it useful.)

Introduction

The passage of Health Information Technology for Economic and Clinical Health (HITECH) Act as part of American Recovery and Reinvestment Act (ARRA) has led to a dramatic increase in the usage of Electronic Health Records (EHR’s). “Meaningful Use” guidelines proposed as part of the HITECH Act require providers to adopt EHR’s with features that will improve quality of healthcare delivered and reduce costs at the same time. Meaningful Use Stage 2 requires Eligible Hospitals and Eligible Providers to implement a Patient Portal, and to release pertinent information to this portal.

Since the passage of the HITECH Act, adoption the usage of EHR’s has been growing steadily.[1] Many hospitals have already implemented Patient Portals, as part of their EHR strategy.

Personal Health Records and the Patient Portal

Traditionally patients would seek out healthcare information either from healthcare professionals or their friends and family.[2] Increasingly, patients are receiving information about their healthcare from the Internet. Much of this information obtained from the Internet may be incorrect or misleading. Patient Portals allow hospitals and healthcare providers to provide high quality information personalized to their patients.

The Markle foundation in 2003 defined the Personal Health Record as “An electronic application through which individuals can access, manage and share their health information, and that of others for whom they are authorized, in a private, secure, and confidential environment.” [3]

The definitions of Personal Health Record and Patient Portal, however, are broad and evolving. The author defines a Personal Health Record as a “repository of an individual’s health information controlled by the individual or by a designated proxy”. The Patient Portal is defined as “a Personal Health Record that is part of their providers Electronic Health Record”. The terminologies Personal Health Record and Patient Portal are commonly applied to online web based repositories due to their evolution on the web platform, but these repositories may also be offline, stored on personal devices such as computers, smartphones and even paper. The definitions proposed by the author remove constraints from earlier definitions that define the purpose and use of these repositories, thereby allowing the proposed definitions to incorporate new use cases and technological developments.

The National Learning Consortium (NLC), a body of the Office of the National Coordinator (ONC) believes that Patient Portals will improve healthcare by: 1) Improved patient activation, 2) More efficient and effective communication, 3) Better and more timely self care among patients, 4) Ability to focus better on high priority patients, and 5) Improved patient satisfaction.[4]

Assuming that Patient Portals do have the ability to affect all the intended changes, we still do not know if these changes will increase, decrease or have no effect on healthcare utilization. To understand these effects, we need to understand the capabilities and functionality of Patient Portals, and how they are being used.

Capabilities and Functionality Offered by Patient Portals

Patient facing information and services can be grouped into categories; 1) information and transactions, 2) expert care, and 3) self care and community.[2]

Information and Transaction

This category is represents the low hanging fruit and provides basic functionality that is already established in other industries. Examples of such functionality include managing appointments with caregivers, medication refill requests, managing financial information and co-pays, and requesting health information.

Expert Care

This category includes services that allow patients to connect with their healthcare provider using online technology, such as secure messaging/email and video conferencing. Secure messaging and video conferencing have been slow to start and have been hampered by the fact that either they are non-reimbursable services, or the reimbursement is lower that office visits. Many states have now started reimbursing providers under the fee for service model.

Some institutions have attempted to utilize Internet and Patient Portals for targeted interventions such as medication[5] and disease management for common diseases such as diabetes[6] and mental health.[7]

Self-care and Community

This category of services is very different from traditional medicine. Traditional methods of delivering care are provider initiated, whereas this category of care is patient initiated.

Healthcare systems offer a few basic services via the patient portal in this category, such as health library allowing patients to find relevant health information, and “just in time” information (e.g. linking a medication in the patients medication list to information about that drug).

However, this category is very rapidly advancing outside the traditional walls of healthcare. A number of health parameters monitoring devices have been released in the market in the last few years and are being used by consumers. These devices can measure activity levels, calories intake and burnt, sleep hygiene, oxygen saturation, heart rate, respiration and other health parameters. EHR vendors are starting to incorporate data from these devices by allowing patients to upload it to the EHR via the patient portal. With the advent of smart phones with always on internet capability, these monitoring devices have the potential to always be connected to the providers EHR, enabling providers with access to real-time (or near real time) information on patients health indices.

Online health oriented social networks like “Patients Like Me” allow patients to share their health and treatment experiences with others. These social health portals allow patients to compare treatments, and bring this information back to their providers. Patient Portals have yet to capitalize on this opportunity.

Utilization of Patient Portals

Use of Patient Portals is still increasing in the United States. Patients who use the Internet Portals are generally younger, more affluent, lived in urban areas, and were more educated and healthier than the average patient.[8][9] The most commonly used functionality included, requesting medication refills, viewing laboratory results, sharing information with other healthcare providers.[10]

Kaiser Permanante, U.S. Department of Veteran Affairs (VA) and Geisenger Health System were some of the early health networks to implement a patient portal. KP HealthConnect Online, Kaiser Permanante’s Portal was implemented in 2002 for its members in the Northwest region. Kaiser reported a 6% registration rate by 2005 and 25% by 2009. The tripling of registrants was attributed to improved functionality. MyHealtheVet had over 976,000 registered members as of March 2010.[11]

Patient Portals offering secure messaging functionality with their providers saw a decrease in the number of telephone calls and increase in patient satisfaction,[2][12] but may lead to an increase in the total number of patient contacts (i.e. office visits, telephone calls, emails). [13] This decrease in call volume may lead to increased provider productivity and allow staff members to take care of patients with more urgent needs. [14][15]

As mentioned earlier, Internet based portals are increasingly being utilized to target disease intervention programs such as diabetes and mental health. These programs have had mostly encouraging results, especially when these portals are used in conjunction with case managers or patient care coordinators. Such programs will become more popular due to the changing healthcare landscape, with the formation of Accountable Care Organizations (ACO’s) and attention of population management. These programs generally target gaps in care and screening for diseases. Both these activities, by their very nature, increase health care utilization in the short term, but have the potential to decrease utilization in the future, as patients remain healthier.

Some vendors such as Epic Systems Corporation have started offering video conferencing and virtual visit capability in their patient portal. The quantified-self movement is gaining traction and people are using multiple devices to track their health parameters as mentioned earlier. Some vendors such as Epic Systems allow patients to upload data collected by these devices to the EHR. However, this technology is very new and does not follow any standards or protocols for collecting and communicating data. Apple Inc. recently announced HealthKit for their iOS platform, [16] which aims to bring the data captured by these various devices under one umbrella, and effortlessly share it with their provider. [17] This avalanche of data being captured by patients and shared with providers will need to be interpreted and acted upon, thereby increasing utilization of resources in the near term.

Conclusion

The use and functionality of Patient Portals is still evolving. These portals have the potential to decrease healthcare utilization for traditionally reimbursable services rendered by providers. However, as these portals gain more features, especially features that enable patient to initiated care, healthcare utilization will increase. However, this utilization will require different types of healthcare resources, such as patient care coordinators, case managers, educators etc., and most of these services are non-reimbursable under the current fee for service system.


  1. Hsiao, C.-J., & Hing, E. (2012). Use and Characteristics of Electronic Health Record Systems Among Office-based Physician Practices, United States, 2001–2012. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics.  ↩

  2. Ahern, D. K., Woods, S. S., Lightowler, M. C., Finley, S. W., & Houston, T. K. (2011). Promise of and potential for patient-facing technologies to enable meaningful use. Am J Prev Med, 40(5 Suppl 2), S162-S172. doi:10.1016/j.amepre.2011.01.005  ↩

  3. Tang, P. C., Ash, J. S., Bates, D. W., Overhage, J. M., & Sands, D. Z. (2006). Personal health records: definitions, benefits, and strategies for overcoming barriers to adoption. Journal of the American Medical Informatics Association, 13(2), 121–126.  ↩

  4. HealthIT.gov. (2013). How to Optimize Patient Portals for Patient Engagement and Meet Meaningful Use Requirements.  ↩

  5. Osborn, C. Y., Mayberry, L. S., Wallston, K. A., Johnson, K. B., & Elasy, T. A. (2013). Understanding patient portal use: implications for medication management. J Med Internet Res, 15(7), e133. doi:10.2196/jmir.2589  ↩

  6. Osborn, C. Y., Mayberry, L. S., Mulvaney, S. A., & Hess, R. (2010). Patient web portals to improve diabetes outcomes: a systematic review. Curr Diab Rep, 10(6), 422–435. doi:10.1007/s11892–010–0151–1  ↩

  7. Druss, B. G., Ji, X., Glick, G., & von Esenwein, S. A. (2014). Randomized trial of an electronic personal health record for patients with serious mental illnesses. Am J Psychiatry, 171(3), 360–368. doi:10.1176/appi.ajp.2013.13070913  ↩

  8. McInnes, D. K., Gifford, A. L., Kazis, L. E., & Wagner, T. H. (2010). Disparities in health-related internet use by US veterans: results from a national survey. Inform Prim Care, 18(1), 59–68.  ↩

  9. Weingart, S. N., Rind, D., Tofias, Z., & Sands, D. Z. (2006). Who uses the patient internet portal? The PatientSite experience. J Am Med Inform Assoc, 13(1), 91–95. doi:10.1197/jamia.M1833  ↩

  10. Turvey, C., Klein, D., Fix, G., Hogan, T. P., Woods, S., Simon, S. R., … Nazi, K. (2014). Blue Button use by patients to access and share health record information using the Department of Veterans Affairs’ online patient portal. J Am Med Inform Assoc. doi:10.1136/amiajnl–2014–002723  ↩

  11. Emont, S. (2011). Measuring the impact of patient portals.  ↩

  12. Goldzweig, C. L., Orshansky, G., Paige, N. M., Towfigh, A. A., Haggstrom, D. A., Miake-Lye, I., … Shekelle, P. G. (2013). Electronic patient portals: evidence on health outcomes, satisfaction, efficiency, and attitudes: a systematic review. Ann Intern Med, 159(10), 677–687. doi:10.7326/0003–4819–159–10–201311190–00006  ↩

  13. Chen, C., Garrido, T., Chock, D., Okawa, G., & Liang, L. (2009). The Kaiser Permanente Electronic Health Record: transforming and streamlining modalities of care. Health Affairs, 28(2), 323–333.  ↩

  14. Stone, J. H. (2007). Communication between physicians and patients in the era of E-medicine. N Engl J Med, 356(24), 2451–2454. doi:10.1056/NEJMp068198  ↩

  15. Liederman, E. M., Lee, J. C., Baquero, V. H., & Seites, P. G. (2005). Patient-physician web messaging. The impact on message volume and satisfaction. J Gen Intern Med, 20(1), 52–57. doi:10.1111/j.1525–1497.2005.40009.x  ↩

  16. Apple. HealthKit  ↩

  17. Munro, D. (2014). Apple Gives Epic And Mayo Bear Hug With HealthKit. Forbes.  ↩