Patient Portals – What Do Patients Really Think About Them?

There seems to be an inverse relationship between the amount of spin one hears about “the next big thing”…and reality.    First it was EMRs and virtual e-visits, then social media, and now patient portals seem poised to be next big thing.   The drumbeat of vendors and pundits is unmistakable….physician that don’t adapt will be toast.   It can all sound pretty convincing until you ask to see the evidence.  What do patients think?

Take the physician patient portal.   If you read between the lines, patient portals are frequently being positioned as the new “front door” to physician practices.   By signing on to a secure website patients will have real time access to the electronic health record and will be able to communicate with their physicians by e-mail.   Additional patient features include being able to schedule an appointment with their doctor, reading their test results and refilling prescriptions.  But despite these features, according to John Moore at Chilmark Research, “nationwide use of patient portals remains at a paltry 6%.”

Ok… so now we know what vendors and pundits think about patient portals. What about patients – what do they think?

They would love it right?  I mean who at this very moment isn’t at home trying to e-mail their doctor.  Yeah right.

If a qualitative study of primary care patients in Journal of Internal Medicine is any indication, those most interested in using a patient portal were patients who were:

• Dissatisfied with their physician
• Dissatisfied with their physicians communications ability
• Dissatisfied with their ability to get medical information from their physician

Those patients least likely interested in using a patient portal offered by their physician are patients who are:

• Satisfied with their physician
• Satisfied with their physician’s communication abilities
• Difficulty in using the portal

Of significant note, patients who reported good relationships with their doctors were afraid that the patient portal would potentially undermine that strength of that relationship.    In other words, patients were afraid that e-visits would replace face to face visits.  Researchers were surprised that not one patient in the study identified encrypted e-mail communication with their doctor as an advantage of patient portals.

While the findings from this study are not generalizable, the study does highlight a potentially significant unintended consequence of encouraging patients to use a new patient portal.   Patients may interpret the move as a signal from their physician that they will have less face-to-face time with their doctor…which in their mind is not a good thing.

To be sure, there are notable exceptions to the cautionary tale described here.  MYGroupHealth , the patient portal developed by patients and providers at Group Health Cooperative in Seattle, is perhaps the best example.

Take Aways

1. Patient Portals are not going to go away.  Having a patient portal is expected to be a requirement in the final  Stage 2 Meaningful Use (MU) Requirements (June 2012) and is listed as a condition for advanced Patient Centered Medical Home (PCMH) accreditation by NCQA
2. Ask patients what they think about a patient portal – what services should it offer, would they use it, how should it be promoted and so on.  After all, it is supposed to be patient-centered.
3. The real value of the patient portal lies in physicians providing  patient-centered, clinical support to patients rather than promoting products and services.
4. Integrate the patient portal into the primary care physician’s work flow and practice.  If you collect patient data on the portal then make use the physician actually uses the information during the patient visit.

That’s what I think.  What’s your opinion?

Sources:

Zickmund SL, Hess R, Bryce CL, et al. Interest in the use of computerized patient portals: role of the provider-patient relationship. Journal of General Internal Medicine. 2008;23.

Lack Of Time And Reimbursement – Is That Why Physicians Don’t Do a Better Job Communicating With Patients?

“I don’t have the time…I don’t get reimbursed for that.”  This is an all too common refrain from primary care physicians and practice managers when ever the subject of improving physician-patient communications comes up.

I get it.   Primary care physicians in particular are under tremendous pressure to produce.   Just imagine…physicians in small primary care practices spend about 3.5 hours/week just on dealing with insurance-related paperwork.  Then there’s keeping up with recommended treatment guidelines, journals, and IT issues and routine staffing issues…not to mention routine patient care, much of which they in fact don not get paid for.  Physicians do have it rough right now.

But Doctors Can Sometimes Be Their Own Worst Enemies

Currently, in just about every State, there are health-plan sponsored pay-for-performance (P4P) and medical home initiatives that reimburse primary care physicians 20% to 30% more for engaging in activities (often of the physicians choosing) aimed at improving quality and patient outcomes.   Some of these initiatives provide additional reimbursement for meeting certain prevention and treatment targets, like making sure that X% of type 2 diabetics have their A1C checked X times a year and the so on.  The evidence shows that small steps like these can collectively have big payoffs in terms of improved quality and outcomes.

Take patient education and chronic care.  Up to 90% of care management for diabetes is provided by the patient and their family.  The quality of self-care among diabetics is a key determinant of patient outcomes.  Patients that engage in high quality self-care have fewer ER visits, fewer re-hospitalizations, have lower risk of complications and a better quality of life.  There is probably evidence out there somewhere which shows that better self-care results in fewer office visits as well.  Yet studies show that primary care physicians spend less than 60 seconds per visit engaging in any form of patient education, including self-care management often because they “don’t have the time.”

Think about it for a second.  Physicians can (and in many cases are) actually make more money and freeing up more time in their practice (be more productive) by doing the very things they “don’t have the time” and “are not paid to do.”

The “lack of time and poor reimbursement” mantra hopefully will soon run its course if for no other reason than increasingly it is no longer as accurate as it once was.   But there is another important reason it should go away.  When patients read in blogs like this and KevinMD, that doctors appear to be withholding care for lack of time or money,  they begin to lose trust in the doctors.  They legitimately wonder what needed health services their doctor is withholding from them.  What is my doctor not doing for me that he/she is not telling me?  If you doubt me, just check out the non-physician,  e.g. patient, comments.

And when patients no longer trust their doctors where will that leave us?

That’s what I think.  What’s your opinion?

Source:

Heisler, M. “Actively Engaging Patients in Treatment Decision Making and Monitoring as a Strategy to Improve Hypertension Outcomes in Diabetes Mellitus.” Circulation. 2008:117; 1355–1357.

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Poor Physician-Patient Communication – Is “Lack of Time” Really the Problem?

Maybe We Need A National “Change Your Doctor Day”?

Come  on people…you know what I am talking about.  Sure you are comfortable with your current doctor…after all you are still alive and kicking.  Besides it has taken you years to figure out what you can safely tell your doctor and when it’s ok to speak up.  Yes the fact that your doctor is often late and never seems to listen to you bothers you just a little.  But you aren’t displeased enough to stop giving your doctor high satisfaction scores.  After all who wants to upset their doctor?   But admit it; you have wondered if there isn’t a doctor out there that would be a better fit with you.   I know I have.

Doctors probably feel the same way about many of their patients.   It can’t be easy everyday trying to help patients that don’t seem to want to help themselves…or who want a quick fix from a bottle of pills.   Not to mention patients who habitually miss their appointments and are generally non-compliant.

How Would Changing Doctor’s Help?

The problem with established doctor-patient relationships is that each side makes too many assumptions about the other, presumably based upon their history together.   As the graphic above suggests, this “familiarity” carries with it significant, potential risk.

It is widely reported for example that anywhere from 40%-70% of patients that use non-traditional sources of care do not tell their physician.  Why?  Because they assume that their doctor will chastise them for doing so.  Two-thirds of patients never tell their doctor that they can’t afford their medications and split their pills to make them last longer.  Why?  Because they presume their doctor doesn’t care since they never ask…or that there is no way their doctor can help since they have never volunteered help in the past.  Up to 50% of patients walk out of their doctor’s office without knowing what their doctor told them to do.   Why?  In part, because they assume their doctor is too busy for them to interrupt and ask for clarification.  I think you get the idea.

Physicians are often just as guilty of making assumptions about their patients.  Physicians assume that every patient these days is “empowered” and wants (and knows how) to take more control of their health.  Why?  Because that what they read in the industry press.  Forget the fact that for the previous 100 years doctors have been the experts and have controlled the medical interview process.  Physicians often acknowledge giving up on counseling patients against obesity.  Why?  Because physicians assume that patients should know better.   In fact studies have shown that my obese patients have never been told they have a weight problem by their doctor.   If as a patient you grew up believing that the doctor would tell you whatever you needed to know…you could see how there could be a possible disconnect here.

By changing physicians, patients would be forced to questions the assumptions they had made about their old doctor.  The same is true of the physician.   At a minimum, patients would hopefully have learned what they wanted in a physician relationship…and how to get their needs met.   Doctors would learn that it is easier and less time consuming to keep an existing, “known” patient healthy and satisfied than it is to start over with a new patient.

My Point?

Physicians and patients, like most human beings, make a lot of assumptions that color how they talk with and relate to one another…sometimes to the detriment of both parties.  Dissatisfied patients are more likely to just leave your practice than complain on a satisfaction survey.   Isn’t it easier and ultimately better for all involved if patients and physicians routinely check their assumptions at the door?

That’s what I think.  What do you think?