Many of us look forward to a time when the experience of interacting with our health care providers will be as consumer-friendly and technology-enabled as, for example, using an ATM or Uber. The vision is health care at the touch of a finger — lab results, prescription refills, and communication with providers made easier and more convenient through technology. Not only do consumer expectations push the delivery system in that direction, but so too do federal requirements.
As part of the federal Electronic Health Records (EHR) Incentive Program meaningful use requirements are updated to improve patients’ ability to view online, download, and transmit their health information via a patient portal. Physicians must also enable secure email exchange with patients.
Unfortunately, the second half of 2015 brought disappointing news regarding patient portal and secure email. An August study in Health Affairs found that only 10.4 percent of U.S. hospitals met the current meaningful use objective of providing patients with online access to view, download, and transmit information about an admission. A few months later, a Nielsen Company survey of consumers found that only 15 percent say they have access to email with their physician, and just over 20 percent have access to online appointment scheduling.
It isn’t just consumers who have concerns. At the start of 2016, physicians continue to be frustrated by the progressing requirements of the five-year old meaningful use program. In a recent Health Affairs Blog, representatives of the American College of Physicians say that “CMS should completely re-conceptualize the program.” As they explain, under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Congress combined meaningful use, the Physician Quality Reporting System, and the Value-Based Payment Modifier into a single program, the Merit-Based Incentive Payment System (MIPS). Regulators have yet to begin rule-making under MIPS, so it remains to be seen how clinicians will involve themselves with new technology and workflows.
As meaningful use continues to evolve, and as consumer expectations for user-friendly technology increase, the next few years will be critical for patient portals. It remains to be seen whether stakeholders’ demand and steadfast belief in their benefits can overcome the considerable barriers to implementation. At this time of intensified debate about expectations for health information technology, we offer real-world lessons from over a decade of work with Kaiser Permanente’s patient portal — the largest private-sector patient portal in the U.S.
Early Implementation And Growth Of Patient Portals
In the late 1990s and early 2000s, the earliest adopters of patient portals began offering electronic tools for patient-centered communication, often “tethered” to their integrated electronic health record system. In addition to Kaiser Permanente, other early portal adopters include the Veterans Affairs Administration, Geisinger Clinic, Beth Israel Deaconess Medical Center, Palo Alto Medical Foundation, and Children’s Hospital Boston, among others.
Although Kaiser Permanente had maintained an informational patient website since the 1990s, the site did not become interactive until 2003, when the Northwest region piloted a new functionality—called “MyChart”—for secure members’ access to parts of their electronic health record. Today, the portal—now called My Health Manager—is available throughout all of Kaiser Permanente’s regions and can be accessed through the Kaiser Permanente website. Access is free, but registration/authentication is required.
As of the third quarter of 2015, more than 5.2 million, or 70 percent of eligible Kaiser Permanente adult members, had registered to use My Health Manager. (It is worth noting that this online user rate rivals the banking industry; 51 percent of U.S. adults banked online in 2013.) In 2003 at Kaiser Permanente, there were essentially 0 percent secure physician-patient emails; in the first half of 2015, secure emails represented 33 percent of all primary care physician-patient encounters (see Exhibit 1). There were a total of 23 million secure emails between patients and all levels of providers in 2015.
Exhibit 1: Transforming Primary Care Encounters
From more than a decade of experience engaging patients online, we offer four key lessons.
1. Secure email supports improved outcomes and patient-centered care
We found that use of patient-physician email is associated with a 2 to 6.5 percent improvement in Healthcare Effectiveness Data and Information Set (HEDIS) performance measures, such as glycemic (HbA1c), cholesterol, and blood-pressure screening and control measures. While the specific mechanisms underlying this association are unclear, contributing factors may include increased continuity of care, greater patient-physician connectedness, and better support for patient self-management.
According to a 2011 internal Kaiser Permanente study, nine out of 10 patients with chronic conditions agreed that My Health Manager enabled them to manage their conditions more effectively. Patients also reported that the portal helps them make informed decisions about their health and makes it more convenient for them to interact with their care teams. Kaiser Permanente research also suggests that patients who use the patient portal for prescription refills experienced greater medication adherence and improved outcomes.
2. Patient portal use positively impacts patient loyalty to the health plan and member satisfaction
My Health Manager users are 2.6 times more likely to remain Kaiser Permanente members than nonusers, and the impact is more substantial among newer members. Unpublished operations research reveals that our members who emailed their primary care providers reported a high degree of satisfaction with their email encounters: 85 percent rated email encounters an eight or a nine on a one-to-nine point scale.
3. Evidence of a relationship between secure email and other kinds of utilization is mixed
Four observational studies using different methodologies and patient populations from Kaiser Permanente shape our understanding of secure email’s impact on utilization. The findings of the studies were inconsistent.
- Early on, Zhou and colleagues found that patient access to secure email was associated with decreased rates of primary care office visits and telephone contacts.
- The opposite was documented in a 2012 study in which Palen and colleagues found the use of the patient portal was associated with increased use of clinical services, including office visits, phone calls, urgent care visits, emergency department visits, and hospital stays.
- Meng and colleagues (2015) conducted a study with improved methodologies and found no statistically significant differences in utilization between secure email users and non-users after controlling for multiple factors.
- Most recently, Reed and colleagues found that patients with higher out-of-pocket cost sharing for visits were significantly more likely to report secure email as their first method of contact with a health concern and more than one in three patients who sent an email to providers reported that it reduced their phone contacts or office visits.
Despite the mixed evidence, we know in absolute terms that face-to-face visits per member per year are slightly decreasing within our system, while secure email visits per member have substantially increased. This experience suggests that primary care access has improved because technology allows more contact with patients.
4. Even with the best intentions, e-health disparities can emerge
We now understand that the benefits of My Health Manager may disproportionately accrue to individuals with both access to these technologies and the resources and skills needed to use them.
- Some feared that My Health Manager would disproportionately attract the young. In fact, the opposite might be true. Members with the highest rate of registration and use of the portal are between 60 and 69 years old.
- Members who are registered to access My Health Manager are more likely to be white (non-Hispanic) than those who are not registered.
- Asian Americans, Latino Americans, and African Americans were 23 percent, 55 percent, and 62 percent less likely to register for personal health record access, respectively, compared to non-Hispanic whites, even after adjusting for age, gender, income, and other factors.
- Likewise, members with a postgraduate education more frequently registered for access than adults with a high school education or less.
Kaiser Permanente is working to better understand and to overcome e-health disparities. Non-users risk being left behind in terms of consumer empowerment, lack access to online tools for managing health and wellness, and can miss out on health care quality improvements realized through the patient portal.
Within 10 years, Kaiser Permanente’s patient portal has become a cornerstone of how we deliver care. According to our research, patients using the portal reported feeling:
- more in control over their medical condition;
- they had access to information and access to the people they needed to consult; and,
- more confident, less intimidated, and closer to their physician.
We believe that patient empowerment tools help our health care system improve outcomes and manage resources. We hope that our experiences can inform the policy conversation about health information technology requirements. Finally, as Charles Safran of Harvard Medical School said, “the patient is the most under-utilized resource in health care.”
By empowering and enabling patients with their own clinical information and abilities to refill prescriptions, make appointments, learn about their health conditions, and email their care team members we not only improve the care experience and quality, but support better value in delivery of care. Patient portals help us achieve the Triple Aim.