Are Patient Portals Loss Leaders for Practices?
Using the internetThe number of U.S. consumers using the internet to shop or bank has increased steadily over the last decade. Despite security concerns, two-thirds of online Americans bought something online in 2007, up from 46 percent in 2000, and 53 percent of online Americans used the internet for banking in 2007, up from 18 percent in 2000, according to a 2008 Pew Internet and American Life Project report.
Also on the rise is the number of Americans using the internet for healthcare reasons, such as refilling prescriptions and scheduling transactions. However, more and more Americans expect to be able to communicate with their healthcare team via email. In 2009, nearly 40 percent of patients communicated with a physician office via a secure email messaging system, up from 31 percent in 2007 and 25 percent in 2006, according to a survey by Manhattan Research.
In many cases, practices are not paid for online consults and patients’ increased use of the internet for healthcare has often resulted in a decrease in office visits. Are patient portals, therefore, loss leaders for practices and hospitals? Not necessarily.
A study by Chen et al at Kaiser Permanente of its implementation of a patient portal in 2004 in Hawaii found that three years after go-live, office visits had dropped by 26 percent, while scheduled phone visits and email messaging had increased significantly (Health Affairs 2009;28(2):323–333). Researchers suggest that the reduction in office visits indicates a greater efficiency of care with an integrated EHR. “With complete patient data available, unnecessary and marginally productive office visits are reduced or replaced with telephone visits and secure e-mail messaging supported by easy access to patients’ medical records. For example, doctors reported that the EHR enabled them to resolve patients’ health issues in the first contact or with fewer contacts,” they wrote.
In 2008, CMS added CPT codes for phone contacts that are intended to supplant office visits and for online management. But Medicare has listed both services as non-covered. Reimbursement by private payors for phone and online healthcare transactions is limited. (However, in April, Virginia passed a law requiring insurers to cover and reimburse for healthcare services provided through telemedicine.) In contrast to fee-for-service systems, physicians at Kaiser receive a fixed salary regardless of the number of services rendered. But the return on investment for patient portals has to be measured by other yardsticks, say Chen et al.
The researchers noted that it’s important to align nonfinancial incentives when dealing with patient connectivity to the practice. In Kaiser’s case, 85 percent of users said the ability to communicate electronically with their physicians enabled them to better manage their health. Yet, the National Committee for Quality Assurance relies on office visits as the predominant indicator of quality-related activity, according to Chen et al. This may have to change as many patients, and an increasing number of physicians, are willing to conduct virtual office visits because they are perceived as a good value by both parties.
Heart to heartMost patient portals offer similar options, including the ability to send non-urgent email messages, access lab results, schedule appointments, refill prescriptions and view portions of the EMR. The Heart & Vascular Center of Arizona (HVCA) in Phoenix went live in late March with its patient portal and so far, “it has been very successful,” reports Barbara Watkins, administrator for HVCA, two weeks after go-live.
Thus far, patients at HVCA are utilizing the portal to view lab results, ask questions about medication titration and discuss topics such as cholesterol or blood pressure. “In the past, all this communication would have come to our front office, either in person or via the phone. The new portal has established an incredibly efficient process,” she says.
The practice does not bill for phone or online consults. “We really do not provide ‘medical consults’ online or by phone,” Watkins clarifies. They utilize their staff—physicians, nurse practitioners, physician assistants and triage nurses—to contact patients by phone or email to determine if more information is needed regarding their question or to request more information. “We do an immense amount of patient education by phone contact, and now utilize our online resources for that purpose. If the provider feels that the patient requires personal communication, we request the patient schedule an appointment.”
HVCA is located in a “very managed care” environment, Watkins says. Reimbursement for phone or email communication has not been an option for the practice. “I know there are several insurance carriers that state they are now reimbursing for phone and email consultations, but with such a large Medicare population, we have not ventured into that arena,” she says.
Bronx cheerMarketing one’s patient portal is crucial. Kaiser and HVCA utilized posters, brochures and index card-type handouts. Kaiser also included promotional material in welcome packets and on its web site. Montefiore Medical Center in Bronx, N.Y., which initiated its pilot portal in 2007, informs patients of the option during visits or phone calls. If patients agree, the practice sends an invitation via email and patients would then sign up, explains Stephen Rosenthal, president and COO for the Care Management Company of Montefiore.
“We initiated this portal because we needed to have as many ways as possible to communicate with patients,” Rosenthal says. “We needed to improve our handling of the ever-increasing patient volumes in the office practice setting, particularly at the front desk.”
One of the challenges for facilities is to recruit a physician champion who can help ease fears that the change will result in more work. Early believers at Montefiore experienced a dramatic reduction in the time it took to answer patient inquiries. “One physician, for example, typically needed 30 to 45 minutes to return half a dozen phone calls in the morning. Using email, this task took no longer than 15 minutes, and it leaves an electronic audit trail,” Rosenthal says.
To ease similar concerns, Kaiser allowed its physicians to choose to inform patients selectively, so they could control the pace of email inquiries. Interestingly, physicians at the VA Loma Linda Healthcare System in Loma Linda, Calif., chose on their own to selectively introduce the email option to patients, “which may have limited patient adoption” (J Am Med Inform Assoc 2009;16:267-270).
As more practices adopt EMRs, initiating patient portals should be easier as the two electronic systems complement each other. When HVCA installed its EMR, it wanted to immediately implement the patient portal, but decided to wait until it understood and fully utilized all the EMR functions. The practice customized templates and physicians and staff got comfortable with the EMR. A year later when the patient portal went live, it wasn’t a culture shock. The preparation period also gives practices time to market the portal to patients.