patient portals: building a bridge for patient...
TRANSCRIPT
Instructor in Medicine, Harvard Medical SchoolInvestigator, Division of Clinical Informatics
Beth Israel Deaconess Medical Center
Bradley H Crotty MD MPH
Patient Portals: Building A Bridge For Patient Engagement
Applying Information Technology toSupport Patient-Centered Treatment Approaches
June 3 2014 3:30pm - 5:00 pm
@bradcrotty [email protected]
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Dave Bushe via Flickr
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Patient Portals
Patient Portal
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Have Multiple Components
Personal Health Record
Secure Messaging
Open Notes
Transactions
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PatientSite
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There is no “one size fits all”13 Key Lessons
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Why Have Patient Portals?• Patient Expectations
• Meaningful Use• Stage I• Stage II+
• Data• Patient Outcomes• Efficiency of Care Delivery
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Why Have Patient Portals?• Patient Expectations
• Meaningful Use• Stage I• Stage II+
• Data• Patient Outcomes• Efficiency of Care Delivery
>70%
Expect To Email Doc
Moyer et al. Bridging the electronic divide. Am J MC(2002) vol. 8 (5) pp. 427-33
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Why Have Patient Portals?• Patient Expectations
• Meaningful Use• Stage I• Stage II+
• Data• Patient Outcomes• Efficiency of Care Delivery
Electronic Access To Medical Information
• Available Within 4 Business Days
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Why Have Patient Portals?• Patient Expectations
• Meaningful Use• Stage I• Stage II+
• Data• Patient Outcomes• Efficiency of Care Delivery
Use Secure Messaging With Patients
• ≥5% of patients seen in a 90d window
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Why Have Patient Portals?• Patient Expectations
• Meaningful Use• Stage I• Stage II+
• Data• Patient Outcomes• Efficiency of Care Delivery
•
• Does it help improve the care of our patients?
• Is there a reasonable ROI?
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Portals & Patient Outcomes
Limited data exist to document a benefit to patient portal use onhealth outcomesUnclear association with healthcare utilization
© Arthur Lien
Goldzweig CL, Orshansky G, Paige NM, et al.Ann Intern Med 2013;159(10):677-87.
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McMahon, G.T. et al., 2005. Diabetes Care, 28(7), pp.1624–1629.
P. 104 patients with diabetes mellitus and A1c ≥9% at VA
I. All had an education classIntervention patients used a Web-Based Care Management • Notebook computer• Monitoring devices• Care management website • Messaging with care manager
C. Usual Care
O. A1C Utilization
Portals & Diabetes
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P. 11 Primary Care Practices
I. Web-Based Care Diabetes Journal
C. Other Web-Based Modules (i.e. family history module)
O. A1cdiabetes mellitus med ∆s
Portals & DiabetesGrant, R.W. et al., 2008. Archives of Internal Medicine, 168(16), pp.1776–1782.
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X 2
X 3
p=0.023
p=0.01
X 5 p=0.001
Flu Vaccination
Mammography
Pap Smears
P. 11 Primary Care Practices, 2005-2007 (Cluster RCT)
I. Health Maintenance Reminders
C. Other Web-Based Modules (i.e. diabetes module, medication reconciliation)
O. Intention to Treat AnalysisAdherence to guideline-based care recommendations
Process of Care Quality MeasuresWright, A. et al., 2012. Journal of General Internal Medicine, 27(1), pp.85–92.
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Visits
20052002
Telephone Calls
20052002
↓ 6.7% Differencep<0.003
↓ 13.7% Difference
p<0.01
Zhou, Y.Y. et al., 2007. The American Journal Of Managed Care, 13(7), pp.418–424.
P. Kaiser Permanente (Northwest), Retrospective Case-Control
I. Access to Portal + Messaging
C. No Access To Portal
O. Health Service Utilization
Health Care Utilization
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Palen, T.E., 2012. JAMA pp.1–8.
P. Kaiser Permanente (Colorado), Retrospective Case-Control
I. Access to Portal + Messaging
C. No Access To Portal (Propensity Matched Controls)
O. Health Service Utilization
Health Care Utilization
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OpenNotes: An Initiative That Invites
Patients To Read Their ProgressNotes Through A Patient Portal
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OpenNotes Invites Patients To Read Chart2010 2011 2012 2013
OpenNotes Demonstration
PCPs at BIDMC, Geisinger, Harborview (UW)
Implementation
Sur
vey
Sur
vey
Focu
s G
roup
s
Ana
lysi
s
Data Collection
Pol
icy
Dev
elop
men
t
• 84% of BIDMC patients opened at least one of their notes• 82% GHS patients opened at least one note• 47% of HMC patients opened at least one note• 20-42% of patients reported sharing notes with others
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70% reported taking better care of themselves (incl. med adherence)
80% reported better understanding of their health and medical conditions
80% reported remembering the plan for their care better
84% felt more in control of their care
75% felt better prepared for visits
Delbanco, T. et al., 2012. Annals of internal medicine, 157(7), pp.461–470.
P. 114 Primary Care Doctors and Their 20,000 Patients
I. Patient Direct Access To Notes Through Web Portal
C. No Access To Notes
O. Survey Measures
OpenNotes
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Weeks after my visit, I thought, "Wasn't I supposed to look
into something?“ I went online immediately. Good thing! It
was a precancerous skin lesion my doctor wanted removed (I
did). { }22 HSPH TECH Talk - June 15, 2015
In his notes, the doctor called me "mildly obese." This
prompted immediate enrollment in Weight Watchers and
daily exercise. I didn't think I had gained that much weight.
I’m determined to reverse that comment by my next check-
up.{ }23 HSPH TECH Talk - June 15, 2015
It really is much easier to show my family who are also my
caregivers the information in the notes than to try and
explain myself. I find the notes more accurate than my
recollections, and they allow my family to understand what is
actually going on with my health, not just what my memory
decides to store.{ }
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Portals are not “one size fits all”12 Portals, like most other forms of
technology, are merely tools. Outcomes depend on how they are used.
3 Key Lessons
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Challenges For Patient Portals
• CIO • Patients • Clinicians • Business Operations • Administrators • Clinical InformaticsReti, S.R., Feldman, H.J. & Safran, C., 2009. Governance for personal health records. JAMIA, 16(1), pp.14–17.
1. Ideal Governance Models
2. Policies For Patient Access
3. Reaching All Patients
4. Organizing Patient Generated Health Data
5. Aligning Patient Portals With Care & Business Processes
6. Revenue & ROI
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Challenges For Patient Portals
• Info Embargo • Withholding Notes • Proxy Access
My OpenNotes Toolkit available at:http://www.myopennotes.org
1. Ideal Governance Models
2. Policies For Patient Access
3. Reaching All Patients
4. Organizing Patient Generated Health Data
5. Aligning Patient Portals With Care & Business Processes
6. Revenue & ROI
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Challenges For Patient Portals1. Ideal Governance Models
2. Policies For Patient Access
3. Reaching All Patients
4. Organizing Patient Generated Health Data
5. Aligning Patient Portals With Care & Business Processes
6. Revenue & ROI
Minority Patients AreLess Likely To AdoptYamin, C.K. et al., 2011. The digital divide in adoption and use of a personal health record. JAMA Int Med, 171(6), pp.568–574.
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Challenges For Patient Portals1. Ideal Governance Models
2. Policies For Patient Access
3. Reaching All Patients
4. Organizing Patient Generated Health Data
5. Aligning Patient Portals With Care & Business Processes
6. Revenue & ROI
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Challenges For Patient Portals1. Ideal Governance Models
2. Policies For Patient Access
3. Reaching All Patients
4. Organizing Patient Generated Health Data
5. Aligning Patient Portals With Care & Business Processes
6. Revenue & ROI
• Scheduling • Population Health • Care Management • Shared Care Plans
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Challenges For Patient Portals1. Ideal Governance Models
2. Policies For Patient Access
3. Reaching All Patients
4. Organizing Patient Generated Health Data
5. Aligning Patient Portals With Care & Business Processes
6. Revenue & ROI
• Global Payments • E-Visits • Additional Fees • Efficiency
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A Roadmap For Portals
E-Mail & Labs
OpenNotes
Patient Input
Shared Care Plans
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Portals are not “one size fits all”12 Portals, like most other forms of
technology, are merely tools. Outcomes depend on how they are used.
3 Key Lessons
3 Leaders should create roadmaps for how patient portals should be used locally, tackle challenges head-on.
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Contact InformationBradley H Crotty MD MPH Division of Clinical Informatics Beth Israel Deaconess Medical Center
For Further Reading
• OpenNotes Toolkit Available at http://www.myopennotes.org
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Reports from Patients Post intervention• 26-36% had privacy concerns
• Few patients said reading notes made them• Worried (5-8%)
• Confused (2-8%)
• Offended (1-2%)
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PCPs’ Main ConcernsOpenNotes impact on patients
Pre -intervention % BIDMC / GHS / HMC
Post-intervention % BIDMC / GHS / HMC
PCPs think patients who read their notes will:
Find notes more confusing than helpfulWorry more
Feel offended
48 / 54 / 43
50 / 58 / 45
33 / 8 / 29
13 / 21 / 12
15 / 42 / 12
18 / 8 / 2
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PCPs’ Main Concerns OpenNotes impact on workflow
Pre-intervention %
BIDMC / GHS / HMC
Post-intervention %
BIDMC / GHS / HMC
Visits significantly longer
More time addressing patient questions outside of visits
More time writing/editing/ dictating notes
…and the volume of electronic messages from patients did not change
23 / 32 / 21
49 / 45 / 34
46 / 36 / 34
3 / 5 / 0
8 / 0 / 0
21 / 14 / 0
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