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Stage 2 and Patient Portals: No Time to Pause

June 3, 2013
by Carl Dolezal, Senior Manager, Aspen Advisors
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Nine steps to take now to engage and empower users

Did you finish the last year attesting for meaningful use Stage 1? If you did, congratulations! You may be thinking you just made it, you’re aware that Stage 2 is waiting for you, and you’re thankful to have preparation time. Before you rest too much, remember that the Stage 2 clock is ticking. It requires that a patient portal be in place and establishes an active role for patients to meet required thresholds.

If you don’t have a patient portal in place, now is the time to develop your patient portal implementation strategy. If you do have a portal in place, now is the time to review your organization’s patient portal strategy and how your patients are using the portal to ensure that you’re on the right path to meeting Stage 2 requirements.

This article describes the need for a patient portal and patient engagement and outlines the top considerations for developing and deploying a successful strategy to engage active users, meet meaningful use requirements, and create value for the organization and patients.

Meaningful Use Patient Access and Engagement Requirements
MU Stage Meaningful Use Program Description
Stage 1 Eligible Professional Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and medication allergies) upon request.
The EP who transitions his or her patient to another setting of care or provider of care or refers the patient to another provider of care should provide a summary of care record for each transition of care or referral.
Eligible Hospital Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies, discharge summary, procedures) upon request.
Provide patients with an electronic copy of their discharge instructions at the time of discharge, upon request.
New for Stage 2 Eligible Professional Provide patients with the ability to view online, download and transmit their health information within four business days of the information being available to the EP.
Use secure electronic messaging, to communicate with patients on relevant health information.
Eligible Hospital Provide patients with the ability to view online, download, and transmit information about a hospital admission.
The eligible hospital or CAH that transitions its patient to another setting of care or provider of care or refers the patient to another provider of care supplies a summary of care record for each transition of care or referral.


Getting Ready for Stage 2: The Need for a Patient Portal and Patient Engagement

There are multiple meaningful use Stage 1 objectives that either directly require a patient portal or, at the very least, make it challenging to meet requirements without one. For example, a Stage 1 core objective specifies that patients have the ability to request an electronic copy of their health information. While meeting this objective can be done without a patient portal, having one makes it easier for both patients and clinic staff. Another Stage 1 menu objective requires that patients have electronic access to their health information (including lab results, problem lists, medication lists, and allergies). 

Electronic access for patients is further emphasized in Stage 2. One core objective specifies that patients seen by an eligible provider must have the ability to view online, download, and transmit their health information. Perhaps the most challenging of the patient portal-related Stage 2 objectives is a core objective that over five percent of patients seen during the reporting period send a secure message to communicate relevant health information through the use of electronic messaging.

Since the Stage 2 objectives rely on patient activity, patients are a critical component for meeting the objectives. For this reason, Stage 2 not only requires the implementation of a patient portal but also requires an active and engaged patient population.

Key Elements for Patient Portal Enrollment and Engagement Strategies

There are a number of important first steps toward engaging an active patient portal user population. They include the following:

1. Know the Population Characteristics and Usage. Consider patients’ needs and what would draw them to use the portal. For example, if the patient population is largely managing chronic conditions, there is a high potential for patients interested in accessing a portal to view routine lab results and regularly schedule appointments. This population would benefit from tools that would help them manage their health like the ability to track blood pressure, blood glucose levels, and weight. Conversely, if the patient population tends to be healthy and chooses to only seek appointments once or twice a year for a checkup or treatment of an episodic illness, their potential for frequently engaging with their healthcare team online will be lower. However, they may be interested in receiving health tips, completing health surveys and health risk assessments, or using tools to help manage their diets or exercise.

A successful patient portal strategy depends on responding to the needs and wants of the unique patient population. Although a secure messaging threshold of just over five percent may not at first appear to be a significant challenge, consider how many patients are currently enrolled in the portal compared to the entire patient population. Also investigate the level of active use. Several patient portals at large academic medical centers have showed average patient secure messaging activity to be 1.4 messages per patient per year. Look at your portal activity to determine how often patients log in and how much messaging they are doing.

2. Create Value for Enrollment and Use. There are multiple approaches for increasing patient enrollment in portals. Strategies commonly used include holding enrollment drives and competitions among affiliated practice sites, placing tablets or kiosks in waiting rooms to improve accessibility, sending enrollment materials through regular mail, including patient enrollment as part of the registration process, and many others. While these strategies may initially be effective in increasing overall patient enrollment, they often fall short in growing actual active use of the portal.

Patients need to receive value for enrollment and active use of a patient portal. Portals that primarily support administrative features like scheduling and online bill payment may not be as appealing or engaging as ones with features like the ability to review lab results, renew prescriptions, or even the ability to track health issues.

3. Focus on Provider Encouragement. While features available through a patient portal are certainly a contributing factor to increasing enrollment and active use, one of the most effective strategies is encouragement from providers and staff. Introducing a patient portal as a viable means to access health information, manage health issues, and communicate with care providers can be a culture change for patients, providers, and staff.

Patients need to feel that portals are an appropriate way to reach out to their healthcare team. When providers and staff encourage patients to use the portal and are responsive to submitted messages and requests, patients will view the portal as a viable way to communicate and manage their health. For example, patients can be instructed during a visit to log into the patient portal in three days to send feedback on how they are feeling. Provider encouragement will lead to the more active patient population required to meet Stage 2 requirements.

4. Promote Across the Communication Spectrum. While provider encouragement is integral to increasing use, think through the continuum of communication points with patients and identify opportunities to promote the portal. For example, on-hold messages reminding patients of the services they can access online without waiting can be helpful. Sending appointment reminders and notifications when lab results are available can engage patients to become active users. Notes on after-visit summaries reminding patients that lab results will be available from the patient portal or suggesting available health education resources specific to their needs will also encourage patient portal use.

5. Educate and Encourage Staff to Incorporate into Daily Operations, Saving Them Time. Addressing staff concerns is also a critical part of an effective patient portal strategy. Providers and support staff are often concerned about becoming overwhelmed by patient messages. One approach to consider when discussing the introduction of a patient portal with clinic staff is to compare messaging activity to telephone call activity. Patients will message when they have a clinical reason, and secure messaging actually offers significant advantages. Since patients are actually entering their questions online, they are completing a significant portion of documentation that would otherwise be entered by clinical staff following a phone call. Additionally, the use of a telephone requires that both the patient and the staff member be available at the same time, often leading to missed or repeat calls. Secure messaging is asynchronous; messages can be addressed as time allows (within a reasonable response time) and without the requirement to coordinate schedules. Depending on the features available in the patient portal, messaging will often follow a workflow similar to telephone calls. Messages may first be read by support staff and then either responded to or triaged to the appropriate recipient at the clinic site. This workflow significantly reduces the amount of messaging activity required by providers.

The full value of a patient portal will only be achieved if it becomes a fundamental part of the way care delivery staff interact with it as a means to support their patient’s needs. The continual encouragement of patient participation is a critical part of building an active patient population in preparation for being effective in achieving these requirements under Stage 2.

6. Set Patient Expectations to Keep Them Engaged. It is also important to manage patient expectations. Messaging response times, often stated in responses of one or two business days, can be detailed and controlled through instructions placed on a web page. Similarly, responses for renewing prescriptions or lab release can also be detailed on an appropriate page.

7. Create Enthusiasm by Involving Clinicians and Engaging Champions Upfront. Active engagement of clinical staff during the planning and implementation stages is a good way to address concerns and encourage communication about the patient portal. Including providers and other clinic staff in the design, implementation, and development of enrollment and engagement strategies will make it easier to obtain clinical acceptance and adoption of the portal. 

Additionally, it’s essential to engage champions early. The right structure and leadership governance for a patient portal implementation project is a critical factor for success, and strong clinical and operational executive-level participation in the project is key. Ideally, executive sponsors (project champions) should be entrepreneurial and have an ability to influence the organization’s culture. They should also have some excitement for the project and enjoy driving change. Executive sponsors should also come from clinical and operational areas as opposed to solely Information Technology to ensure that the project meets the operational and clinical needs of the organization and its customers and keeps design closer to those who will support the workflow or ultimately use the portal.

8. Offer Portal Access within the Facility. Some organizations provide patients with the ability to activate patient portal accounts during their visit. When patients leave the visit with an active account, there is additional emphasis for the portal being a valid way to interact with their healthcare team, and they may be more likely to use it.

There are multiple options available to provide on-site patient account activation. Patient kiosks placed in waiting rooms are commonly used; however, some organizations have found that patients are not motivated to use kiosks because of privacy and security concerns. Alternatively, with some EHRs the provider or nurse can create the account during the patient visit by allowing the patient to enter a user name and password through the workstation. Tablet devices can also be used to support on-site account activation and could be provided while the patient is in the waiting room or after they have been placed in an exam room and are waiting to be seen by their provider.

9. Measure Results and Evolve. Measuring and monitoring your portal performance is a critical step to ensuring success. There are numerous metrics to consider. While overall enrollment is a common measurement, there are many portal-related measures that should be monitored. Metrics like message response times and dropped messages (messages without a response) provide insight to the user experience and how responsive staff is to patients. Frequency of user access and use of distinct features also helps to gain an understanding for the value patients receive.

Some organizations routinely survey their users to assess how well the portal is performing and to identify additional features that they may find useful. Continual processes of assessment and implementation of new functionality will help to ensure a match between user needs and portal functionality and ultimately contribute additional value to the organization.

In order to meet the Stage 2 requirements that a patient portal be in place and demonstrate that patients have an active role in meeting established thresholds, it’s important to take action now.  By incorporating these 9 key steps to engage active users, you’ll ultimately create value for the organization and patients, while meeting the meaningful use requirements.

Carl Dolezal is a senior manager with Aspen Advisors. With 14-plus years of experience in planning, implementing, and managing IS systems, he has led multiple patient portal and MU initiatives. 

As Director of Clinical IS at the University of Texas medical Branch before joining Aspen, he led the implementation of a patient portal and the IT effort to achieve meaningful use Stage 1. Before that, as Project Director for eHealth at the University of Pittsburgh Medical Center, he designed and implemented a patient portal strategy with functionality, eventually scaling to eVisits.

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