Patient portal experience personal version
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Slide deck outlining Heartland Health's experience with a patient portal
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Patient portal experience personal version
- 1. A Discussion on Patient Engagement Heartland Health’s Patient Portal Experience 1 10/15/2012
- 2. Heartland Health • Non-profitMedical Center Heartland Region • 353 beds IDS • Annually: • Tertiary care regional medical center 19,000 annual admissions • Level 2 trauma center Heartland Clinics (> 60 in region) 90,000 patient days Community Health Improvement Solutions > 500,000 annual outpatient visits • Aetna plans > 60,000 annual ED visits • Care Management 160+ employed physicians • Wellness 3400 Total FTEs • Foundation • Medicaid ASO Hospice & home health LTACH (41 beds) Serving a 22 county service area (~300,000 lives) 10/15/2012 2
- 3. Primary Service Area Population: 109,425 Market Share: 83.7% Discharges: 14,939 Secondary Service Area Population: 182,674 Market Share: 16.5% Discharges: 4,343 10/15/2012 3
- 4. The Process To Date Go Live First Pilot Innovation Most Clinics Clinic Fall 2007 Spring 2008 2012 Went through 3 iterations of the application 10/15/2012 4
- 5. Portal: Provides both PHR and EMR access Patients via Physicians via web EMR PHR EMR 10/15/2012 5
- 6. Message Analysis Monthly Messages 700 35.0% 600 30.0% 500 25.0% System Provider 400 20.0% Staff Nurse Patient Patient 300 15.0% Nurse Staff Provider System 200 10.0% 100 5.0% 0 0.0% In Out In Out 10/15/2012 6
- 7. Message examples Patient view 10/15/2012 7
- 8. Message Types Physician’s View 10/15/2012 8
- 9. Users by Age Users by Gender 700 1500 600 500 1000 400 500 300 200 0 100 Male Female 0 Under 13 18 and 19 to 25 26 to 38 39 to 49 50 to 64 65+ Under 9000 Active Inactive No longer register 8000 under 18 7000 6000 5000 26% 4000 3000 2000 1000 0 74% 7/5/12 8/2/12 8/9/12 9/6/12 6/28/12 7/12/12 7/19/12 7/26/12 8/16/12 8/23/12 8/30/12 9/13/12 9/20/12 9/27/12 10/4/12 Active Inactive 10/15/2012 9
- 10. First Lesson: Provider Dependency Usage by patients is heavily dependent on use by providers 10
- 11. Portal Usage Begins with Providers 1,800 Pts IQH Pts If the physician is not driving the 1,600 1,400 use of the portal, it won’t be used. 1,200 Early 2010 data 1,000 Single physician accounted for over 800 600 75% of the patient portal registrations 400 an usage in the pilot clinic. 200 - Team based approach? May work Phys1 Phys2 Phys3 Phys4 10/15/2012 11
- 12. Workflow Changes Possible with Direct Patient Involvement Can use new tools to optimize and eliminate many physician/patient barriers 12
- 13. Portal streamlines processes Reducing steps and handoffs Traditional messaging involves mutliple steps and puts insulating barriers between patients and physicians Direct patient participation streamlines the communication and has the potential to eliminate barriers 10/15/2012 13
- 14. Forwarding Lab Results • Labs to endorse drop into physician’s Inbox • Creates a message to the patient • Results and normals automatically appear in the body of the message – Physician can add personal interpretation – Copy any others that need to be informed – Add new prescriptions or orders 10/15/2012 14
- 15. How Much Change? » Reduced patient phone » Reduced total messages in the conversations around 75% Inbox by nearly 30% » The more barriers between » More time for nurses to do a physician and the patient other work the more messages there are in the physicians (and » Have more time for prior the nurse’s) inbox authorizations and other » Completely counter logistical activities intuitive finding 10/15/2012 15
- 16. Challenges Issues A Long Way To Go 16
- 17. The Web Itself We live in a mobile, app dominated world. Most patients are essentially healthy. Forget URL and Password when they need to connect. Are travelling and don’t have ready access to a computer. Patients want and need an App in addition to the Web. 10/15/2012 17
- 18. Visual World We live in a very vibrant and visual world. Text is a poor substitute for pictures. More and more a picture doesn’t convey the story … but a short video does. Many patients are used to posting multimedia to social networks. Potential to reduce or improve the appropriateness of office visits … especially in an ACO world. 10/15/2012 18
- 19. 10/15/2012 19
- 20. Providers, Policies, P olitics Providers (physicians) not on board yet. There still exists a very strong reluctance to have patient’s interacting in the same space as providers. Most of our policies and procedures are based on paper work flows. Current laws, policies and procedures lag behind the technology curve and the distance between them and the world is increasing, not decreasing. 10/15/2012 20
- 21. What’s Your Message? Questions 10/15/2012 21
Editor's Notes
- Heartland Health quietly turned on Cerner's patient portal in 2007 and after several years of piloting it in one clinic has now expanded it throughout it's entire network. The primary benefit has been to provide patients a secure communication directly with their providers. Patients also have access to their labs, medications, problems, physician documents and upcoming visits. This talk will go over usage, enrollment decisions and issues as well as many other outcomes.This Scottsdale Institute presentation discusses that experience for the audience
- The primary service area surrounds St. Joseph, MO with a population of a little over 100,000. Surrounding the primary service area is a secondary one scattered in a wide area in 4 states (Missouri, Kansas, Iowa and Nebraska and we are expanding southward into the greater Kansas City metropolitan area with a much larger population.
- The pilot was started in with one physician in a single of around 30 Heartland Health clinic, primarily with one physician in a clinic located in the north suburbs of Kansas City. It was originally started as a stealth project, requiring very few resource to see if there would be any traction. After nearly a year over a thousand patients were registered and many of them were interacting with good feedback. Very few problems were encountered and significant work flow improvements were documented and in 2008 the pilot expanded to the entire clinic. All 4 physicians were encouraged to enroll their patients and each of their staff were taught how to enroll and educate their patients. Attempts were made to encourage other clinics to enroll their patients but this process did not become part of Heartland Health’s core strategy until early in 2012 when the need arose as part of the Meaningful Use Stage 1 attestation process.
- Our patient portal is provided by Cerner and integrated with our Cerner Platform. Patients access the portal either through Cerner Health’s personal health record or directly via IQHealth.Patients can use the Healthe PHR to record home measurements and maintain their own medical record that is separate from Heartland’s Electronic Health Record. IQHealth is a web view of Heartland Health’s EMR and we current open most of the record to patients. They can see their problem lists, medications, appointments as well as physician derived notes including admission H&P’s, discharge summaries and clinic notes.Physicians interact with patients within Cerner’s PowerChart Messaging Center where patient originated messages show up as another item in the Message Center. They do not need to leave their critical work flow to participate electronically with patients.
- Physicians express concerns that they will be overloaded with patient originated messages and change the nature of their interaction with the electronic message center or Inbox. Our own experience is that providers during a measurement period averaged a little over 600 messages a month of which a around 13% were patient originated. This compares favorably with a little over 12% of messages originated by the physician to the patients (close to a 1:1 ratio). In other words the communication stream was not dominated by “needy” and “unnecessary” patient originated messages.Most of the messages in-bound and outbound are with nursing and other staff (>30% of all messages). Interactions with other providers and the system (alerts) comprise the remainder of messages.
- Patients can create and use 3 message types:General Messages that resemble traditional e-mail Medication Refills in which a list of their current medications are presented and they can select ones or request a new one by completing a form that captures all the elements a provider needs to respond to the patientSpecific messages focused on a particular visit … helps the provider pull up the right visit to review before answering
- These messages show up in the Consumer Messages tab of the Message Center’s Inbox right next to other messages. Answering these messages is no different than answering messages from nurses and other providers. We’ve found that a large number of messages result in the physician needing to create a prescription or an order. To facilitate this interaction a button that brings up the Ordering tool is built into each of these messages and their replies. All selected prescription(s) or order(s) are textually rendered when the physician returns to the message and included in the body of the message.Many times the physician will also copy the nurse or another provider in the reply to the patient and having the textual rendition of the order dramatically speeds up any handoffs and eliminates any need for redundant processing or potential for errors since all those who need to be in the loop are part of the reply to the original message and the entire message thread is included.
- In late 2011 Cerner, the provider of the patient portal, migrated their platform to a new system and enrollment process. Every user was sent several messages with an invitation to re-enroll. Initially very few responded to this enrollment request and the number of enrolled users plummeted from a little over 8,000 to well under 1,000. This illustrated that while it was very easy to enroll over nearly 90% of all patients during their visits, the overwhelming majority of them had no reason to actually log in and use the system as they were for the most part healthy. Those who did log in did so primarily to review lab results and maybe ask a follow-up questions. Apart from the chronically ill and those on controlled substances that needed frequent attention most patient’s next need of the system occurred many months if not over a year later. By that time most had completely forgotten the URL let alone their username and password to the system. In addition many patients change physicians annually and often jobs and they may have used work-related e-mails for their primary contact. This active migration requiring re-enrollment essentially dictated that we start all over again with our patients and we began re-enrolling them.The new platform required that every patient have a unique e-mail. This led to the discovery that many families shared a single e-mail account and had built communication strategies around a single e-mail not unlike most homes had only one telephone number. The requirement that every portal user have a unique e-mail was surprisingly uncomfortable for many families as usually a single user (most often the wife) logged in and managed the IQHealth accounts of each of the family members. On the positive side this re-enrollment process did illustrate that while it is easy to enroll a large majority of patients the overwhelming majority of enrollees have no need to use the patient portal. The re-enrollment process enabled us to winnow out those inactive accounts and have a system where a greater percentage of enrollees are active users. It must be said, however, we have no effective way of validating this explanation of why so few of the original enrollees re-enrolled.Only in the last month have we seen a change in the curve from the relatively stable 2,000 or so enrollees that logged in and claimed their accounts.We also removed all of the pediatric patients under the age of 18 from the list as Missouri laws requires a complicated set of age-related abilities to redact information from others that are very difficult to deliver. We are waiting for more clarification and or improvement in the ability of the system to meet these rules before re-enrolling children under 18. Other clients enroll children but un-enroll them between 12 and 13 until the age of 18 for compliant reasons.
- The first lesson we learned was that the patient portal use is highly dependent on the willingness of the physician or provider to engage patients directly. Those providers where relied on their nurses to register and enroll patients, never promoted it during the face-to-face encounters and had their nurses be the primary responders to patient queries (in essence duplicating their phone messaging workflow) saw little use or value in the patient portal.On the other hand the physicians who actively promoted this and responded directly to patient questions, bypassing the nursing triage, saw immediate benefits.
- These graphs illustrate the importance of physician involvement in the use of the portal. We are experimenting around with team based approach utilizing the call center but up to now it appears patients want one-to-one connections with their providers and respond accordingly.
- Those physicians who leveraged the asynchronous communications with patients experienced changes in workflows that benefitted the working unit (physician-nurse-scheduler) as illustrated in the following slide.
- Traditional phone messaging necessarily insulated the physician as direct patient-physician phone interactions are very time consuming. These phone conversations can easily average 5 minutes or more. Unlike synchronous mediums, asynchronous communications are much less time consuming and often a physician can read and respond to a patient message in a minute or less. This is one of the reasons e-mail has dominated business communication for over a decade.Those physicians who leveraged the patient portal were able to streamline their patient communications process by eliminated several handoffs and at least 2 processes. Quantitatively we were able to document up to 8 hours of patient-provider (nurse/physician) phone time per week per care delivery unit (patient-nurse-scheduler).
- A very good example of simplified communication stream is illustrated in how patients are now notified of their results.The most common physician originated messages to patients are lab results. As labs are processed and resulted they are returned as a message to the physician to endorse. If the patient has been registered and activated their invitation to the portal the physician is able to generate a message to the patient and the results along with normals are automatically inserted into the body of the message to the patient. The physician is able to add a personal interpretation, instructions, alter existing or create new prescriptions and write any new orders that might be needed. Like the lab results, new prescriptions and orders are automatically rendered into text and included in the message.In the process of replying to the patient the physician can also CC nurses, physicians or other providers.This process has dramatically shortened the time between a specimen’s drawing and the patients notification of these results. Most patients have messages in their inboxes with interpretations before the end of the day or at most a day after they are drawn.
- When physicians interact asynchronously with patients this interaction replaced phone conversations. As mentioned before phone conversations are much more time consuming than asynchronous communication. In care delivery pods that effectively leveraged the patient portal we witnessed around 75% fewer patient phone conversations.It is very counter intuitive but those physicians who chose to configure their portal so patient messages bypassed the nurse and went directly to them answered on average 30% fewer messages throughout the day. This surprised us but as we examined the messages requiring a typical response we found that a single patient message being intercepted by the nurse almost always required the physician to either answer the nurses question and/or to co-sign an order. In short, every patient originated message that went first to the nurse resulted in more than one message to requiring a physician response. It was not atypical to find the physician and the nurse exchanging up to 3 or 4 inbox messages before the nurse was able to compete the patient’s request. By contrast if the request went directly to the physician, bypassing the nurse, the message to response ratio was almost 1 instead of 1:2.3 over the period studied. The physician very often looked at the message, moving it to one side of the screen, opened up and reviewed parts of the chart on the other half of the screen and responded not only with a change in medication dosage, the addition of another medication or placing several downstream orders that all were textually rendered and then returned to the patient along with copying the nurse and other physicians … all in a single transaction.In short we discovered that unlike the phone world, the more barriers physicians created between themselves, the more work they had to do. The fewer barriers the less work.
- There remain significant challenges.
- The first is turning out to be the web itself; or more accurately put, the dependency of the portal on the need for computer accessing a URL in order to effectively use the portal. Over the last few years the world has moved away from computers to mobile phones. The current patient portal is not designed for mobile computing. Most patients still cannot remember a URL or their user name and password in the time between the need for logins. Only those who are chronically ill or have need for frequent interactions are not experiencing this problem. In short, the patient portal needs to be an app in which the average relatively health patient can configure once and then use infrequently without having to re-identify themselves.
- Just looking around we see the importance of images in news print, web sites and social media. The same is true in the clinical world. A significant number of patient originated messages involve minor injuries or rashes and the primary question is whether they should be seen. Images are essential to many of these. While it’s relatively straightforward to transmit photos increasingly videos are being recorded.
- This anecdoteiIlustrates the importance of photos and videos. This elderly patient has been having spells that were thought to be TIA’s or strokes that had resulted in several ED visits and subsequent short term hospital stays. One day the daughter took several pictures of this even in the home but had difficulty loading them into the patient portal (the portal did not have the ability for patients to upload photos at the time). Notice the Facebook solution for me to get the videos.A few days later she was able to capture another whole sequence with the her daughter’s camera. Once again she had difficulty getting the image to me. This time she used YouTube to view as well as brought me a CD to view.Patient portals do need to have the same multimedia sharing available in social media applications as the patients are used to them and expect this type of activity.
- Finally there’s a widening gap between where patients are as a group and the providers. Neither appreciate how far the other has come. It get’s worse when it comes to our documented policies and procedures that, for the most part are based on paper work flows. Many organizations still prohibit their own employees from opening up their electronic charts, for example. And then the political world continues to lag even farther behind as the time to legislative action is very lengthy.