The Vision and the Challenges Patient Portals: The Vision and the Challenges Michelle Glatt, MPH, PA-C Katie Verd, CPHIT michelleg@qualishealth.org Katiev@qualishealth.org Qualis Health March 13th 2013

Qualis Health is one of the nation’s leading healthcare consulting organizations, partnering with our clients across the country to improve care for millions of Americans every day Serving as the Medicare Quality Improvement Organization (QIO) for Idaho and Washington QIOs: the largest federal network dedicated to improving health quality at the community level

Objectives What is a portal? The vision and the challenges of the patient portal What does the research say? Overcoming challenges with strong implementations A little about incentives & recognition programs Conclusions

What is a Portal? What does Google say? It's commonly believed to be an entry/exit site from this world to another, more than likely another dimension or parallel universe. A door, gate, or entrance, especially one of imposing appearance, as to a palace.

What is a Patient Portal? A patient portal is an online health application that allows patients a “window” into their personal health information. Depending on the EHR vendor, features available may include: Interactive online health information forms Access to medical visit notes and after visit summaries Prescription renewal requests Laboratory and other test results Secure messaging with the care team On-line payment options Office visit scheduling Patient education materials Preventive care reminders Chronic care reminders

The patient portal vision Patient -Centered Patients access and use their health information Patients are more engaged with their care team Patients have more convenient methods of scheduling appointments and receiving results Efficient & Cost Effective Fewer phone calls & letters More informed patients Meaningful Use Incentives and NCQA recognition Better Quality Chronic disease management reminders Preventive care reminders Interactive health improvement tools

The patient portal challenges Not Patient- Centered Do patients read the language offered? Are patients technically able to access the portal? Are FQHC patients more or less likely use a portal? In-Efficient & Expensive What about lost passwords? Won’t the provider take on extra work? Can we count on incentives or payment reform? Worse Quality Lost prescription renewal requests The “911” secure message sitting in an inbox Cross coverage issues

But how real is the vision and how much of a barrier are the challenges?

What Does The Literature Tell Us?

What kind of patients use a portal? The patients stating they benefit from a portal*: Lower income individuals Chronic diseases High school education with no college degree English as a first language At Kaiser Permanente portal users are more likely**: To be older than the average patient, female, and have diabetes To be without a college degree To make less than $75,000 annually per household *California Health Care Foundation : “Consumers and Health Information Technology: A National Survey” 2009 http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/C/PDF%20ConsumersHealthInfoTechnologyNationalSurvey.pdf **Zhou et al, 2007 “Patient Access to and Electornic Health Record with Secure Messaging: Impact on Primary Care Utilization.” American Journal of Managed Care 13(7).

Efficiency and Cost Reducing Telephone Calls Telephone calls are very important, but using this method for delivering simple messages is inefficient. Telephone tag results in excess charting & poor patient satisfaction Using an RN for simple phone messaging is not “working at the top of your license” Secure Messaging reduces telephone call volume by18%* *Liederman, E.M, et al 2005. “Patient-Physician Web Messaging: The impact on Message Volume and Satisfaction.” Journal of General Internal medicine (20)

Efficiency and Cost Return on Investment and Productivity Portals have been shown to save money by reducing snail mail appointment reminders, lab result deliveries, and phone call expenses.*** $2.69 per lab result, $0.62 per appointment reminder, $1.75 per phone call In one study, physicians using secure messaging were able to see ~2 more patients per day than those without secure messaging** **Liederman, E.M et all 2005. “ the impact of patient –physician Web Messaging on Provider Productivity” Journal of Healthcare Information Management (19). ***Gardner, E. “Will Patient Portals Open the Door to Better Care?” Health Data Management Magazine, 2010.

Better Quality of Care At Kaiser, investigators determined that use of secure messaging was associated with improved HEDIS measures in patients with hypertension and diabetes. (improvement of 4- 11%)* *Zhou, Y.Y et al. 2010 “improved Quality at Kaiser Permanente through e-mail between Physicians and Patients.” Heath Affairs 29(7). Emont, S., The California Health Care Foundation. 2011 “Measuring the Impact of Patient Portals: What the Literature Tells Us”

What Clinics in WA & ID Are Saying: Most cited barriers to successful patient portal implementation were all beliefs held by clinical staff prior to implementation: Portals increase workload and chaos for the clinic Portals will overwhelm providers with administrative work The patients can’t or won’t use a portal (language, technology) Portals do not add anything to the quality of clinical care These barriers were also mentioned: Internet access Patient portals are not always user friendly IS skill sets for a ‘healthcare’ price

What Clinics in WA & ID Are Saying: Features that improved patient care & clinic efficiency: Laboratory Result Delivery Electronic After Visit Summary Future directions: Pre-visit online health information forms

Portal Implementation

Portal Implementation: Step 1: Building Support - Staff Expectations and Attitudes Providers Clinic/Front Desk Staff Patients Administration & Leadership Information technology Consider forming a “portal committee” Have the committee develop a project plan Any of these groups have the power to limit the success of your portal. Gathering opinions and attitudes early will help identify challenges and build critical buy in.

Portal Implementation: Step 1: Building Support - Staff Develop a Communication Plan for Staff Project plan and timelines Training plan Work distribution plan and new workflows Expectations of staff and patients Benefits of a patient portal Introduce the project team

Portal Implementation: Step 1: Building Support - Patients Develop key messages – how will the portal benefit patients? What will be available? Deliver key messages early, often and via multiple different methods: Posters After Visit Summary Clinic Staff Telephone hold messaging Buttons on white coats Start gathering emails even before implementation.

Portal Implementation: Step 2: Understand & Test the Technology Depending on your system there may be many opportunities to customize your portal or there may be none. Work with your vendor to get a clear idea of what is possible. The following portal features are the most desirable from a patient perspective and will likely increase the number of active users: Viewing lab results Scheduling appointments Secure messaging with providers Refilling prescriptions Test all features systematically prior to go-live

Portal Implementation: Step 3: Develop Portal Policies & Workflows Patient registration and password management Protect your patients’ privacy by requiring strong passwords that need to be changed periodically Managing lost passwords requires a clear plan with clear people designated to execute the plan Develop clear policies around pediatric patients & teens (hint: understand your state laws) Develop a Portal Use Policy and have every user sign

Portal Implementation: Step 3: Develop Portal Policies & Workflows Protected health information policies Should all labs go to the portal automatically? (What about HIV tests?) What patient education materials should be available? How should you handle teens? Develop clear policies around who and how it is possible to become a “proxy” for a patient who is incapacitated.

Portal Implementation: Step 3: Develop Portal Policies & Workflows Secure Messaging How quickly do messages need to be addressed? EOD? 24 hours? How will you know the message was read? What should the character limit be? Who should the messages go to first? Shared folder with care teams? Clinical staff member gate keeper? Directly to the provider? Cross coverage plans How will the content from the messages be saved in the patient record? *More than half of patient messages require clinical decision making. One quarter of patient messages require a clinical action (appointment, lab etc) *Zhou, Y.Y et al. 2010 “improved Quality at Kaiser Permanente through e-mail between Physicians and Patients.” Heath Affairs 29(7).

Portal Implementation: Step 3: Develop Portal Policies & Workflows Prescription Renewals How quickly should medications be renewed? Set expectations for staff Set expectations for patients How does this affect eRX?

Portal Implementation: Step 3: Develop Portal Policies & Workflows Appointment Scheduling Standardize Limit appointment types Sick visits – same/next day access Well visits – longer waits Providers need to give up control of their schedule – which they will – if they believe there is a robust process in place

Portal Implementation Step 4: Training & Support Develop a go-live training plan: Providers Clinical Staff Front desk PATIENTS Quick start guides for registration Define registration support workflows

Portal Implementation Step 4: Training & Support Develop a support plan: New staff Periodic refreshers Upgrades &new features PATIENTS Manage an FAQ for your website Define helpdesk support roles and responsibilities Password Management

Portal Implementation: Step 5: Recruit Users If only a fraction of your patients are using the portal it is difficult to engage staff Set a goal X patients per day registered 10% of panel registered by X date Create a portal registration campaign Friendly team to team competition with small fun rewards Make it fun Three for Free (coffee? T-shirts? Ice-cream?) Portal Power Provide feedback often to reinforce the campaign – weekly feedback is much more effective than monthly feedback.

Portal Implementation: Step 6: Monitor & Reward Progress You may want to monitor any or all of the following: Number of users signed up per care team over time Number of “active” users (log-in’s multiple times) Measure time to open secure messages, time to act on renewal requests. Satisfaction survey for patients Satisfaction survey for clinical staff Patient characteristics most commonly associated with portal use (provider, chronic disease, age, language etc.)

Incentives and Recognition Programs

NCQA Medical Home Recognition NCQA 2011 standards are aligned with meaningful use Several of the standards specifically call out electronic exchange of information and treat secure messaging as improved access.

NCQA: Enhance Access and Continuity 1A – Access during office hours (must pass) Provide timely (as defined by practice and documented via response time report) clinical advice by secure electronic messages 1B –Access after office hours Providing timely (as defined by practice and documented via reports) clinical advice using a secure interactive electronic system when the office is not open. 1C – Provide Electronic Access Electronic access to health information (50% of patients who request a copy receive in in 3 days, 10% of patients have electronic access to health information) Two way secure electronic communication as documented by screen shots Electronic request for prescription renewals, referrals or test results as documented by screen shots

Meaningful Use Stage 1 Menu Objective: Measure: Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, medication allergies) within four business days of the information being available to the EP Measure: More than 10% of all unique patients seen by the EP are provided timely (available to the patient within four business days of being updated in the certified EHR technology) electronic access to their health information subject to the EP’s discretion to withhold certain information Starting in 2014, this measure is replaced by the expanded Stage 2 electronic access measure.

Meaningful Use Stage 2 Core Objective (replaces Stage 1 e-access measure in 2014): Provide patients the ability to view online, download and transmit their health information within four business days of the information being available to the EP. Measure 1 (must meet both measures): More than 50% of all unique patients seen by the EP during the EHR reporting period are provided timely (available to the patient within 4 business days after the information is available to the EP) online access to their health information. Measure 2: More than 5% of all unique patients seen by the EP during the EHR reporting period (or their authorized representatives) view, download, or transmit to a third party their health information.

Meaningful Use Stage 2 Core Objective (new measure): Use secure electronic messaging to communicate with patients on relevant health information. Measure: A secure message was sent using the electronic messaging function of CEHRT by more than 5 % of unique patients (or their authorized representatives) seen by the EP during the EHR reporting period. A prescription renewal request via secure messaging “counts”

Conclusions? Patient portals have the potential to provide our patients with a more patient-centered experience. They can improve clinic efficiency and even lead to some improved quality of care, but the challenges are very real, and implementation must be done with thought and care to achieve any of these benefits.

Questions? Michelle Glatt, MPH, PA-C Katie Verd, CPHIT michelleg@qualishealth.org Katiev@qualishealth.org For more information: www.QualisHealthMedicare.org/cardiac This material was prepared by Qualis Health, the Medicare Quality Improvement Organization for Idaho and Washington, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. ID/WA-C9-QH-1035-02-13 Special thanks to Trudy Bearden PA-C for very helpful conversations and research