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'I No Longer Have to Go to See the Doctor': How the Patient Portal is Changing Medical Practice

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Not long ago, the only options my patients had for communicating with me were to come in to the office or relay a message through the office staff. The result is a cumbersome system that most patients avoid using unless there is a major problem or crisis to address.

But since recently introducing the patient portal in our electronic medical record, my practice has changed substantially. My patients tell me it's for the better. Admittedly, there is the additional daily burden of responding to lab results, refill requests and patient questions. But each of these is also a major improvement in efficiency and effectiveness of information flow, which is fundamental for any patient who aspires to be "participatory."

Patients can now expect to see their lab and imaging results as soon as they are released by the lab, along with an interpretative comment from me. They can request a refill for their medications. They can use the system to request an appointment. And they can send a question to me about their health care, medications, test results or anything else.

This online dialogue is much more efficient, timely and effective than depending on the old methods of office appointments and phone calls. The staff is overwhelmed with calls and has trouble keeping up with them. An office visit requires the patient to take at least a half-day off work, maybe more, and requires involvement of many others to complete registration, vital signs, examination, testing, billing, insurance filing and other tasks.

But what is the downside? It is possible in some cases that patients will see lab and imaging results before the provider has reviewed them. In most cases that is fine, but sometimes it can pose challenges that the provider and patient must address. In one recent example, a friend asked to speak with me about having received the alarming news through the portal imaging results of a mass that turned out to be cancer of the colon before the provider had reviewed it. She was understandably distressed and wasn't sure what to do, so we walked through the necessary next steps together and it eventually worked out fine and she received the care she needed and is doing well. This is one example, among many others, that point to a different way of addressing and "solving" health issues and dilemmas. Whether this potential scenario should be prevented by requiring that all results be reviewed by providers before release to the patients is one of the many debates that the "patient portal" phase of health care is posing.

Another issue has to do with the time and effort that this new component adds to the provider's list of "things to do" every day. For example, reviewing test results and communicating about them to the patients, answering staff queries on the portal, responding to requests for refills and responding to patient questions online has added at least an hour or more to my patient care duties every day. And currently there is no additional reimbursement for this work. This is a huge issue that must be resolved soon if this "new model" of health care can take hold.

Medical practice has begun its inevitable journey toward this transformation when, unless an exam or a procedure is required, most medical questions and answers, as well as virtually all medication refills and renewals, appointment requests, interpretation and discussion of the implications of lab and imaging results will be conducted online rather than in the office. The reimbursement system in the health care of the future will simply have to take this into account as we slowly transition from a fee-for-service to a care management model of care.

This post originally appeared in the Journal of Participatory Medicine's online editorials on May 14, 2014.

More Blog Posts by Charlie Smith

author bio

Charlie Smith, MD, is a practicing family physician, executive associate dean for clinical affairs, and professor of family and community medicine at the University of Arkansas for Medical Sciences in Little Rock. In 1997, he founded a web-based medical information company, eDocAmerica, which provides tools, information, and input from professionals to help individuals make better decisions about their health and health care. He has served as president of the American Board of Family Medicine, deputy editor of American Family Physician, and chair of the Group on Faculty Practice of the American Association of Medical Colleges. You can follow him on Twitter @edocarkansas and on JOPM.


Tags for this article:
Health Information Technology   Health Care Access   Organize your Health Care   Inside Healthcare   Medical/Hospital Practice   Patient Engagement  


Comments on this post
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Sleep Deprived ER Doc says
September 3, 2014 at 5:52 AM

Great to hear that more older doctors like you (how many docs are over 50 in the US?- more than half?) are finally adding portals to their practices - places like Group Health Coopeartive have had them for over 10 years now..

Sounds like you didn't redesign your workflows along with the portal though? It shouldn't take any longer to refill an RX online than over the phone and how did you communicate lab results in the past? In the past we often would ask the patient to take their time off work and come to see us so this saves the system time and money but it takes some work to figure out how to have some questions go to staff for triage and some direct to you.. (most docs don't review normal labs for example)

Compensated to communicate with your patients is a huge issue? arrgh you are kidding right? Great argument to put doctors on salary and you are right we need to shift away from FFS mentality as soon as possible but I worry about having everyone working for the hospital.

BTW - According to a study today the average salary for a primary care doc is $248,000 a year which is 6x's the average income which is only $48,000..

David Smith says
September 8, 2014 at 12:00 PM

I was involved with developing HL7 standards in the 1980's. To me, it is appalling that the "portability" aspect of HIPAA seems to have been neglected. Patient Health Records applications are not just for communications (while that may be a solid benefit). Securely sharing pertinent medical information was supposedly the goal of HIPAA. From a patient's point of view, all that has been accomplished is that patients must now sign a paper form acknowledging HIPAA privacy.

I can have lab tests performed by one doctor and within a week, the same lab will perform the same lab work but will not share it with me or my 5 other physicians. What would motivate them to turn down double or triple the revenue? It has become common that every appointment requires lab work first. This is about revenue, not about quality patient care or reducing health care costs. There is no other excuse. Evidence - Have you ever asked for and received a long-term trend of lab results for a patient? Don't the labs have this data? Would it be valuable medically?

Some of my doctors don't even have email, let alone electronic medical records. When my neurologist asked for test results from a former neurologist, I found that they had been destroyed because they were over 10 years old. Now that I have a new neurologist, I must endure (and pay for) these tests all over again. Why is it that we think evidence that is older than 10 years is no longer valid in medicine? I'm constantly asked what date I had my tonsillectomy. 1963? I don't remember! If I had been diagnosed with some kind of drug allergy when I was a child, does it matter now?

Every specialist that I see for multiple chronic disorders should have access to all tests, labs, imaging performed and be expected to communicate with my primary care physician to coordinate my care.

In one respect or another, I am paying for all of my patient care. Whether I discover a tumor on an image or my physician tells me is irrelevant. Either way I will be shocked and/or worried. I'm guessing that the first person your patient called after finding the tumor was your office. That's what I would do. There should be no debate. Its my body, its my money, its my information. I would trust my doctor even more if there wasn't such secrecy.

I've recently found that a possible disorder that I've had most of my life may be the cause of my numerous additional disorders. Would adequate portability of medical information have saved me a lifetime of suffering? One of my physicians told me that some of the tests they would run would be invalid because of all the medications I'm taking.

The AMA, the FDA and other government organizations should focus their attention on the lack of ability for patients and doctors to gain a clear picture of ALL patient data. Labs and all diagnostic tests (with the exception of employer drug screens) should be available to the patient and the patient should allow access to physicians he/she chooses. Not only is this one of the greatest causes of skyrocketing healthcare costs, it is poor medical practice in my opinion. As scientists, you should gather as much evidence as possible. In our healthcare system some are creating walls so that they can either save money or over charge.

I'm sorry if I sound cynical and harsh. But I believe I am a victim of a sometimes corrupt healthcare system, politicized and greedy. We have tremendous advances in medical care, but in some respects we live in the stone age.