In early 2000, Seattle-based Group Health Cooperative executives held a series of strategic planning meetings on the imminent rollout of their patient portal. The integrated health system's leaders told each other that if they were successful in extending the business model online, other healthcare organizations would surely catch up.
Nine years later, the MyGroupHealth portal connects more than 40 percent of Group Health's members to their clinical data and physicians through secure messaging.
But the number of health systems with similar online features remains small.
“We have been stunned that people aren't following us,” says Ernie Hood, Group Health's CIO. “Consumerism is eventually going to change that, but for now we still have a competitive advantage. We have patients who go to the clinic for lab tests, and the results are posted online for them to review before they even get home.”
Portals have the potential to increase patient involvement in their own care, and can be especially helpful for people with chronic conditions, such as diabetes.
“Organizations can more easily alert patients to clinical gaps in care and be more proactive in sending messages that they should schedule exams,” says Lynne Dunbrack, program director for market research and advisory firm Health Industry Insights (Framingham, Mass.). Then compliance should increase, and that will help with pay-for-performance initiatives, she says.
Portals also can alleviate administrative problems such as excessive call volumes. For instance, at Duke University Health System (Durham, N.C.), the impetus to create its full-featured HealthView patient portal came not from clinicians, but from the patient revenue management organization, says Boyd Carlson, associate CIO for application development and revenue management systems. “We saw that if we could decompress the number of billing question calls to the call center, there was a solid ROI case to make,” he says. “We have created a five-year business plan with ROI goals and expectations attached, most relating to administrative efficiencies.”
It's also clear that the portal concept is popular with consumers. In New York-based consulting firm Deloitte's 2008 Survey of Health Care Consumers (an online poll of more than 3,000 Americans), 60 percent say they want physicians to provide online appointment scheduling and access to medical records and test results, and one in four says they would pay more for the service.
While it's difficult to connect health outcome data to portal usage, Group Health's leadership finds its survey results compelling. In a recent survey of 761 members, 54 percent say they find the portal extremely valuable, and 34 percent, very valuable. Only 1.8 percent say the online features were not important to them. Among those who use the Web regularly, 91 percent say the portal was very important. “It builds loyalty,” Hood says. “That makes a difference to executives.”
Yet perhaps because introducing a portal involves a commitment to organizational change, industry-wide adoption has been slow, even among organizations that have fully launched electronic health records and some level of integration between hospitals and physician practices.
A 2008 survey by Web software and consulting firm Geonetric asked 209 people who run e-health initiatives in hospitals and health systems about their Internet projects. Only 27 people filled in the section of the survey about patient portals. “The inference is that the vast majority is not there yet, and their online communications are still generic,” says Ben Dillon, vice president and eHealth evangelist for Geonetric (Cedar Rapids, Iowa). Most respondents cited a lack of staff and funding and the inability to demonstrate return on investment to senior executives as barriers to improving their Web presence.
So why have so few organizations developed sophisticated portals? Are they a drain on IT resources and a complicated integration task with limited ROI?
Dunbrack says CIOs give a number of reasons for going slow. Many are still working through EHR implementation and are still concerned about the privacy of patient data.
“It may be important to healthcare organizations whether or not their vendor offers a portal option,” she says. “Epic has MyChart and places like Cleveland Clinic and Kaiser Permanente are using it. But if they have to integrate their EHR with a third-party portal, that just adds another technical hurdle.”
Hood says he believes funding shouldn't be a roadblock. “I think the costs are overestimated,” he says, adding that for a large integrated health system like Group Health, which has 592,000 members, it might cost $500,000 per year for software; $2 million for staffing; and up to $500,000 for hardware, for a total of approximately $3 million per year.
He also says technological complexity shouldn't be a barrier. “That's more of an excuse than a reason,” Hood stresses. “The real challenge is the impact on workflows and changing the institutional mindset to what's best for the patient. That's why too many organizations are timid about it.”
Getting to ROI
Hospitals and health systems can realize great advantages from portal development, says Kathleen LePar, vice president of professional services for healthcare consultancy Beacon Partners (Weymouth, Mass.), who adds that it is not all that difficult to define a return on investment.
“Start with the end result in mind,” she says. Are you constantly struggling with getting people to answer questions about billing? Is a lot of the phone traffic concerning prescription refills? If going online might reduce call volume, first find out what it costs for a nurse to find a chart, speak to a doctor, and get back to the patient. “Or if you want it to increase revenue collection,” she adds, identify what your costs are and what it might save you.
That's exactly what Duke's Carlson did. “We documented that during tax season we get around 5,000 calls from people itemizing their taxes and asking what they spent at Duke last year.” His project team argued that converting those calls to self-service online lookups would help pay for the portal's development, which also includes patient information from the clinical data repository.
The three-hospital Duke system is rolling out a feature that will not just let patients make a request of an appointment time, but actually look at open slots and make an appointment online. It also has added e-mail reminders of appointments, which is cutting down on no-show rates.
“We are doing express check-in, so patients can do demographic and insurance and Medicare updates online beforehand, and avoid that in the office,” Carlson says. “The killer apps so far,” he adds, “are seeing appointments and lab results online.”
Although Duke hasn't started marketing the portal heavily yet, it gets 45,000 logins per month. “We proceeded slowly in introducing it because we had to reach critical functionality. We wanted it to do several things well before most people tried it, so that they would have a positive experience and come back.”
Beyond portals, healthcare companies are looking at how other Web technologies — such as blogs, Wikis and social networking sites — can play a role in patient interactions.
“The interest is very significant in figuring out how these new Web 2.0 tools can cross collaboration gaps between patients and providers,” says David Kibbe, M.D., a senior advisor to the American Academy of Family Physicians (Leawood, Kan.).
Some of the companies have disruptively innovative technologies and business plans, he says, such as American Well, which has created a platform for interactive health videoconferencing online. Another called PatientsLikeMe creates online communities for patients with specific serious conditions and their clinicians.
Web-savvy healthcare organizations are studying ways to adopt technology to interact with patients to self-manage, and to interact with one another in social networking situations, Kibbe says. “This is about being inclusive, and allowing people and providers to collaborate in new ways.”
Leading-Edge Portal Adds Devices
The Cleveland Clinic Health System is in the midst of a 90-day pilot to extend its MyChart patient portal by adding data from in-home medical devices. The Clinic — which has nine owned and three affiliate hospitals and 13 clinics — has partnered with Redmond, Wash.-based Microsoft HealthVault to gather more continuous data about patients with certain chronic conditions. Approximately 400 patients with diabetes, congestive heart failure and hypertension are taking regular readings at home with digital devices such as blood pressure monitors, glucometers, and weight scales linked to the HealthVault platform. The data is then fed into the patient's MyChart record at the Clinic.
“We are designing a process change by getting this data in front of the care provider on a regular basis, rather than just once every 120 days when the patient comes in for an office visit,” says C. Martin Harris, M.D., Cleveland Clinic's CIO.
If the values on a patient's chart are inside an acceptable range, the physician reviews them once a week. If they are outside the range, the physician sees them right away, he says. Another goal is to improve the quality of office visits by having clinicians spend less time taking readings and more time communicating with patients.
Harris adds, “We hope that over a longer period than this 90-day pilot to be able to see improvements in measurements of clinical outcomes.”
Creating a portal means changing the relationship between physicians and patients, so the change management process must be slow and inclusive.
Portal offerings from EHR vendors may be convenient, but they could also limit your ability to add features or get data from other systems.
Although the ROI on the clinical side is likely to be more qualitative that quantitative, administrative efficiencies should be easier to demonstrate.
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Healthcare Informatics 2009 February;25(14):45-49
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