September 18, 2020 – When it comes to patient engagement technology, the patient portal is somewhat like an umbrella. You might not use it very often, but when it rains — or when COVID-19 comes to the United States — you’re sure glad you have it.
“It’s like you’re out on a walk and it starts to drizzle, and you realize, ‘oh wait, I’ve got an umbrella in my bag,’” said Chris Mast, MD, vice president of Clinical Informatics at Epic Systems. “You kind of knew it was there, and it was something that you’ve used before, but all of a sudden, you really need it.”
That was the case for clinicians and patients alike at the start of the pandemic. People pulled this tool from their back pockets and were able to meet an unprecedented moment in healthcare.
After all, the patient portal is something like the jack of all trades in patient engagement technology. The tool, whose adoption was mandated as part of the 2009 HITECH Act and meaningful use, allows patient data access, online appointment scheduling, secure direct messaging, and virtual prescription refill requests, among other functions.
When the novel coronavirus forced medical practices across the country to shutter their doors to non-emergency and elective care, that kind of functionality became crucial for patients who could not engage with their providers in person. It was time to open that proverbial umbrella.
What came next was a massive trend toward patient engagement technology. Telehealth, for example, became a crucial lifeline for patients who needed a medical visit with their doctors.
Remote patient monitoring, wellness apps, virtual triage and screening tools, and asynchronous options like secure direct messaging also came to the forefront at the start of the COVID-19 pandemic.
And the patient portal has been the home for all of that, proving itself to be in a particularly good position to meet this moment in healthcare.
But the irony is, the patient portal isn’t exactly new. These technologies have been a core part of most health IT transformations and were once seen as the crux of patient engagement and empowerment.
Since patient portals came packaged with the EHRs so many hospitals and providers purchased starting after HITECH’s passage, their reception in the medical world was somewhat lackluster. It wasn’t until the outbreak of the novel coronavirus that healthcare finally saw a use case for the patient portal, and now there may be no going back.
Unlike a lot of the technologies providers tapped as part of their pandemic response, the patient portal is relatively old, in health IT terms at least. The first EHRs, with which the patient portal would eventually come bundled, began development in the 1960s. Some of the first hospitals adopted EHRs in the 1970s.
The patient portal grew out of the EHR toward the end of the 1990s, leveraging EHR data to help inform patients about their own health.
And by 2009, the entire nation began to consider health IT adoption. As part of the HITECH Act, the federal government created the Medicare & Medicaid EHR Incentive Programs, or meaningful use, to provide stimulus payments to healthcare organizations that adopted the EHR and the patient portal.
Organizations that could prove they met certain use standards, like allowing patients to view, download, and transmit their own medical information, became eligible for those payments.
The logic said patients who could access their own medical information would become empowered with that information, begin to make decisions about their own healthcare, and engage more meaningfully with their medical providers.
There was only one problem: patients weren’t buying in.
“If you think about where portals have been with the initiation of the concept through meaningful use and that drive to get people access to the medical records and other transactional capabilities in the portal, you get to the fact that meaningful use patient portals didn’t live up to the expectations of engagement,” David Harse, vice president and general manager of Consumer & Patient Engagement at Cerner Corporation, told PatientEngagementHIT in an interview.
In 2019, the Office of the National Coordinator for Health IT (ONC) reported that although most hospitals offer patient portal access, very few patients were taking advantage of it. The report, which used data from between 2015 and 2017, showed that 90 percent of hospitals offered a patient portal, and 72 percent allowed view, download, and transmit capabilities.
But more than half of those hospitals said their patients aren’t taking the bait. Sixty-two percent said less than one-quarter of their patient populations have registered for the patient portal. Just around one-third of hospitals said that less than 10 percent of their patients have adopted the tool, while fewer than 10 percent of hospitals said most of their patients have adopted the patient portal.
“During meaningful use era, there was a burden on the healthcare organization to go consume and implement and measure a tremendous amount of different technologies and specificity around the types of reports that were produced,” Harse recalled.
The amount of scrutiny that was on those meaningful use attestation reports wasn’t always relevant, at least insofar as building strong patient engagement was concerned.
“The metrics and therefore, the solutions, weren’t built with the true customer in mind,” Harse added. “And by that I mean, the actual patient, the individual that is managing their health and wellbeing isn’t sure what to do, has questions. The patient portal was built for the buyer, the health system.”
Since meaningful use has been discontinued and folded into other federal programs, the push for a truly consumer-centric patient portal has taken over. While providers compelled their patients to view, download, and transmit their data to satisfy meaningful use, other technology vendors developed the tools that truly activated the patient to engage.
Things like online appointment scheduling, chatbots, text message outreach, and other engagement tools that tackled really specific, niche workflows came to the forefront as solutions.
The patient portal has been able to adapt, Harse added. Most of these niche consumer engagement tools leverage application programming interfaces (APIs) that allow them to plug directly into the patient portal and the EHR, creating a seamless patient experience.
At Cerner specifically, the Cerner Consumer Framework serves as a digital tabletop where the vendor giant has partnered with tertiary consumer engagement firms. Cerner users can select which functions on the Consumer Framework they’d like to deploy in their unique consumer engagement efforts.
“You’ve seen this mind shift play out over the last several years, which is great and interesting,” Harse explained. “The meaningful use portal, I hate to say it, but it was a check the box activity.”
Armed with the baseline patient data access functionality, as well as the consumer-facing tools patients want and need, the patient portal was finally ready for its biggest use case ever: the COVID-19 outbreak.
Of course, meaningful use isn’t all to blame for limits in patient engagement via the patient portal. According to Paul Brient, chief product officer at athenahealth, the patient portal had a tough time matching other service industries, just like the rest of healthcare.
But in recent years, the patient portal has experienced the same tilt toward consumerism in healthcare the healthcare industry writ large has.
“Some of it’s meaningful use- and regulation-driven, but some of it’s just the way the rest of the world outside of healthcare is evolving,” Brient said in an interview with PatientEngagementHIT.
All areas of healthcare have had to catch up with other consumer-facing sectors, like the restaurant business with OpenTable or the airline industry with its virtual flight check-ins. Although slow and steady, healthcare —the patient portal included — has caught up, Brient argued.
Health IT has gone from transactional events — the patient scheduling an appointment, paying her bill, checking her lab results — to increasingly helping clinicians and patients break the mold of the traditional healthcare encounter.
“Traditional medicine began when you checked in for your appointment and it ended when you checked out,” Brient said. “More and more, we’re seeing clinicians want to engage with their patients in a more holistic, complete person way. This was driven in part by value-based care, but also because that’s just good patient retention, that’s good patient experience. Patients are wanting to engage more. The portal is that mechanism to do that and it’s perfect for many practices.”
It’s for that reason many providers leaned heavily on the patient portal during the COVID-19 pandemic. In March, when CMS and other regulatory bodies urged hospitals and clinics to close their doors to non-urgent care, the patient portal became a place clinicians could go to manage patient health.
That non-urgent care shutdown yielded a spike in patient portal use, as clinics and hospitals worked to cancel or reschedule appointments and inform patients about the temporary policy. But it also facilitated a bigger shift: healthcare was going virtual, and it was based out of the patient portal.
Secure direct messaging, prescription refill requests, integrated telehealth functionality all led the way for providers keeping contact with their patients — both their high-touch chronic care populations and the newly worried well — from afar.
“We’ve seen a big increase in adoption, in terms of both the number of patients that use MyChart, and then the depth of use by those patients,” according to Sean Bina, vice president of Patient Experience at Epic Systems. “Now, people are increasingly using it to really manage their clinical care. Everything from doing symptom checking in MyChart to being able to do a telehealth visit and also being able to do self-management of COVID symptoms.”
Remote technologies, many of which became centralized within the patient portal and EHR, served providers on two fronts. For the worried well and chronic care populations, the patient portal offered patients an avenue to obtain information. Telehealth visits helped address less urgent care management, while symptom checkers and the secure direct message functions gave the worried well assurances about the fluctuating public health crisis.
These tools were also essential for organizations looking to manage COVID-19 patients outside the hospital. After all, hospitals needed to keep their volumes low in anticipation of severe COVID-19 cases, and most patients were able to convalesce at home. The patient portal was a touchpoint for those patients and their providers, plugging in remote monitoring devices to flag symptom irregularities and giving a pathway to telehealth check-ins
“One of the biggest shifts is to telehealth, to video visits, specifically,” Mast, the clinical informatics lead at Epic, said.
“That’s been something that’s been simmering at a low level in a lot of organizations who were experimenting with it. All of a sudden, the switch went on when people could no longer show up face-to-face, and that has been something that really has just changed overnight. Patient’s relationship to the patient portal, and doctor’s use of their EHR system. It’s just a much tighter way to connect in these challenging times.”
The COVID-19 pandemic also inspired patient portal use outside the traditional clinic or hospital setting. As more testing sites began to stand up across the country, attracting large crowds of people potentially infected with the virus, the patient portal stood as a key tool for connecting patients to care and disseminating results.
“When you think about the need for a test and the ability to easily find a testing time and location that works for you, organizations are using their portals and the relationships they have with people through direct messaging,” Harse said.
In other words, the patient portal not only served as a care management platform, but as a directive for COVID-19 testing access. And once at test sites, providers said they would primarily rely on the patient portal to report results.
This was a natural move, especially from an efficiency standpoint, and it introduced a whole new population of people to patient portal technology, but Mast said that wasn’t always easy.
“Some of the challenges have to do not with the technology, but with some of the patient groups who might not have had access to technology or didn’t have it set up,” he explained. “So, organizations have been really innovative with helping to connect that subset of patients.”
A lot of EHR vendors created new mechanisms to get patients enrolled on the patient portal quickly and efficiently. If a patient accessing a COVID-19 test was not yet set on a certain vendor’s patient portal, test message and email links made it easier for them to register and receive their results.
“And with that, patients are getting their results and starting to engage with what’s the next best treatment option,” Harse said. “We have clients that are leveraging self-monitoring care plans that were within the portal. Or once confirmed positive for COVID-19, organizations tap the portal to say what the quarantine process should look like.”
It’s not just getting a test result, Harse said. The patient portal is helping patients answer, “what do I do next?”
But the patient portal has also come with some hiccups. It’s not enough for just the patient to get her COVID-19 test results; her primary care provider also needs that information, and that’s long been a sticky area for health technology.
At the heart of it, this is an interoperability question. If a patient gets a test at one site using one patient portal vendor, and wants her results compatible with her primary care provider using another portal vendor, there needs to be certain technology levers at play.
At Epic Systems, leadership has leaned on its famed Epic-to-Epic interoperability, and for a good reason. CVS Pharmacies are one of the biggest COVID-19 testing chains, and its partnership with the Epic MyChart has been in place since before the pandemic.
“The good news is that a lot of the testing facilities are connected up with Epic sites so that the results will just come automatically, directly from the testing site into the Epic EHR,” Bina said.
“Patients can actually upload their own results,” he continued. “If I’ve had a COVID test, I can send a message to my physician saying that I’ve had this test, and I can attach the results from the site directly to that.”
Things like Carequality, Apple Health Records, and other API-enabled technologies can also help patients overcome data sharing challenges, the vendor has pointed out.
But still, the question of unhindered and seamless health data exchange, from one testing site, through the patient portal, and into another vendor’s EHR has remained somewhat elusive, although healthcare is further along in this area than it was even a year or two ago.
Part of the solution is going to come from the 21st Century Cures Act, Harse suggested, because it puts the data right into the hands of the patient. Data should be able to flow from the testing site and into the patient portal for the patient to access. From there, the patient should be able to transmit that data to any provider she would like.
“And so, part of the answer is with 21st Century Cures and opening up that data,” Harse said. “But it’s also putting the initiation and action to go get that data into the hands of the consumer, where you can know that you had gone through a lab and that data was isolated in its own environment. If you want it in your EMR, your source of truth, you have the ability to go access that information.”
But in a lot of cases, these new innovations that help patient data travel from provider to provider haven’t been seen everywhere. According to Brient, the COVID-19 testing push was still largely punctuated by fax.
“This is an unfortunate fact of health care today which is the most universal way of exchanging data is the fax machine,” he admitted. “It’s kind of like wiring the country for internet, right? ‘Yup we have internet, we have high speed internet in all the cities but we’re not touching everywhere.’ Over time, we’ll get these patient portals connected and we’re still processing, but yet it’s about 700 million faxes sent a year, which is crazy.”
In fact, the prevalence of faxes sending and receiving COVID-19 results became exceptionally overwhelming to agencies that may not be used to it, like the public health organizations that kept track of COVID-19 outbreaks in a given region, Brient noted.
“There is no need for that,” he asserted. “There are plenty of protocols and ways of being interoperable that allows electronic data to be exchanged and be exchanged in a discreet way so not only can you get that across EMRs, but the EMRs can also interpret the data.”
Leaders at athenahealth said it was working to fully leverage the systems that would eliminate a need for fax, like 21st Century Cures and making data seamlessly accessible for the patient.
Cerner expressed similar plans, while Epic Systems reported it would continue to build out the infrastructure that has enabled it to remain connected with Epic EHRs in disparate organizations.
Like most of the patient engagement technology getting heavy circulation during the COVID-19 pandemic, EHR vendors don’t think patient portal utilization is going away any time soon. Patients have grown accustomed to having this tool in their toolkits, and it would be hard to get the genie back in the bottle.
“Now that it’s possible for patients to get back to the doctor’s office if they want to, things have sort of settled into a steady state, but it’s a different steady state than it was before COVID-19,” Mast said.
“There are still a lot more video visits going on, and a lot of the organizations want that to continue. And so do patients because in a lot of cases, it’s more efficient for everybody. It’s just as good or better care. It’s taking better advantage of the resources.”
Brient has noticed a similar trend among athenahealth users and their patients. When the pandemic first broke out, the vendor saw a serious spike in the number of patient portal uses relative to the number of appointments happening. That stayed consistent especially as patients were accessing care digitally via telehealth and other remote platforms.
“Interestingly, as the world started to crawl its way back to normal, across our network we’re seeing telehealth volumes have now declined to about 10 percent or so of all visits — which is still higher than pre-COVID numbers — and the visit volume across our network is pretty comparable to where it was back in February,” Brient said.
“But the portal volume has gone back up to that spike and stayed there,” he continued. “We have a situation where we have the same number of visits, or maybe a few less than we had in February, and we still have 20 percent more portal volume on our network than we did before.”
And that is largely a testament to the entire transformation healthcare has seen in response to the novel coronavirus. People are checking into appointments in their car and filling out paperwork there, Brient said. Gone are the days where patient registration happens in a crowded waiting room, and the patient portal has played a big part of that recovery and reopening process.
Operationally, this is going to drastically change how clinics manage patients, Bina suggested.
“While our groups have offered the ability for patients to schedule appointments for a long time, they may have limited the total number of slots that were available for patients to book,” he offered as an example, noting providers will have to make more slots available via the portal.
“What we’re seeing is just like in other industries, healthcare organizations are moving to trying to provide an ideal digital experience for patients. Instead of the digital being secondary, people are creating and making it the primary way in which patients can do everything from schedule, register, and get access to all of their clinical information.”
For Harse, the ability for the patient portal to manage COVID-19 isn’t over. There’s still an entire vaccine rollout that the patient portal will be instrumental in supporting.
“When it becomes available, it’s really going to be turning to understanding your population, communicating the availability and the process for a vaccine, and scheduling to receive it,” Harse explained. “And then that registration and check in, and all those processes can be driven through a digital experience in order to get as many people vaccinated as possible.”
The patient portal and EHR will help providers understand how to issue the vaccine equitably, prioritizing high-risk individuals all the way down to low-risk ones.
“The patient portal is a great place to house that record that the patient had the vaccine,” Harse continued. “And there’s talk of it may be a two-shot vaccine. So, if it’s a two-shot vaccine, then there’s the portal capability to put on your plan that you need to go get number two.”
That kind of care management, set up to address gaps in care, has always been present in the patient portal. This is what it was designed to do, the health IT experts agreed, and it will be able to keep doing this moving beyond the pandemic. After all, this will not be the final storm that healthcare weathers.
“We’ve spent all this time as a country, as an industry, putting all of this infrastructure in place. Organizations have done the hard work of changing their clinical processes, educating their clinicians, educating agents, making sure that as many folks as possible have this in hand,” Mast concluded.
“It was actually tremendously gratifying when the pandemic hit and all of the pieces were in place. It was a much smaller lift for each individual organization to say, ‘we’re going to put in place a connection to this lab,’ or, ‘we’re going to set up a patient monitoring program for patients who have COVID symptoms who are staying home.’ They had many, if not all of those tools already in place. This was just setting the switches.”