By Marc P. DiFazio, M.D., VP, Ambulatory Services, Children’s National Hospital
Twitter: @ChildrensNatl
Twitter: @marcdifazio
Clinician to Patient communication is critically important to facilitate the best of medical outcomes. Communication starts at the bedside or in the clinic but must continue beyond these venues to ensure safe transitions, medication compliance and to provide feedback and guidance during medical management. Modern communication leverages technology to facilitate asymmetric communication between clinicians and their patients, and one such technology offers several potential benefits over others.
The Patient Portal benefits patients AND providers
Portals are generally an extension of an electronic health record, and as such, serve as a conduit for secure delivery of important clinical results, chart documentation and alerts and reminders for appointments and procedures. Provision of all of these materials is critically important for those hoping to gain more control over their health maintenance, and to ensure their complete understanding of a clinician’s directives. More experienced patients and families use the portal to deliver information related to their condition. For instance, a child with epilepsy who develops a tic disorder poses challenges for families and clinicians who may grow concerned that the tics represent seizure, rather than a less urgent movement disorder. Such families may record movements on their phone and upload to a portal for their clinician to review, possibly allowing for a clinical distinction between Tourette and seizure, and eliminating the need for an urgent appointment for the more serious condition. Teaching can then be simultaneously provided in written format regarding tic and Tourette, and if needed the family can request an appointment to discuss.
Forgotten appointments represent lost revenue for a clinician, but also a lost opportunity for a patient to receive updated care, medication refills and timely management of their condition. As has been evident during the recovery of the Pandemic, delays in care result in worsened health outcomes and increased expense in the management of a condition. Reminders and the ability to communicate with a clinical team regarding the need to cancel or reschedule facilitates appointing (thereby allowing for appointing of an alternative patient to eliminate gaps in a caretaker’s schedule) and ensures that a patient is directed to maintain engagement with the clinical team, so that their condition is optimally managed.
Clinicians are human, and errors and gaps in care management occur not infrequently. A patient or family who is sharing in their medical management is empowered to catch such errors, asking for clarification or correction of the medical record. A patient portal allows engaged patients to review documentation and ensure that their clinician has attended to the most important aspects of their concerns, and to offer additional information if necessary. These communications are recorded safely and securely logged in a patient’s chart, ensuring that the clinician (and patient) is protected, with memorialization of all communications and guidance given. Additionally, patient management is documented and visible across the continuum of care. For instance, changes to medication management are broadly visible in a patient’s chart, allowing other clinicians and the care team to note such modifications and dose appropriately.
Revenue gains may result from Patient Portal use. A good example is the demonstration that patient no-shows are reduced significantly if they are enrolled in the patient portal. Multiple reasons may account for this, including facilitating communication of the inability to attend an appointment, or that the engagement of the portal use itself ensures that a patient is more focused on their medical management.
But Challenges remain…
While there is a growing patient adoption of portal technology, uniform adoption rates are elusive. Once enrolled and used consistently, the patient portal becomes a resource that benefits the entire care team. However, enrollment can be challenging for those with less technological experience, and navigation for those with visual, language or cognitive impairments remains very limited. Additionally, certain circumstances (e.g., families with multiple children in the same system) may pose barriers in maintaining portal communications in separate accounts related to undue complexity. Lastly, clinician bias may cause a reduction in engagement with certain categories of patients, limiting their access to care.
Clinicians are likewise not uniformly advocates for use of a patient portal. Communications must be addressed, and by facilitating access to a clinician, a patient or family may increase their requests for information. Such communications are typically not something that clinicians can charge for, so, while it may be of benefit to a patient or family, saving travel time and optimizing outcomes, the clinician does this work on top of her busy clinical schedule, for free. Additionally, a small office staff with limited clinical resources in support of a clinician may not have the time to respond to messages/requests on top of supporting a busy clinical day.
Solutions for fair and efficient use of Patient Portals
While Patient Portals offer a conduit to safely communicate critical information, guidance and corrections, further refinements are necessary to ensure that they are embraced and used maximally by all parties. While our current model of fee for service remains largely in place, clinician time is limited by revenue collections, and additional time spent communicating via a portal is unlikely to be reimbursed. Payer negotiations that prioritize this type of communication are key, and given the wealth of data supporting their use and improvements in clinical outcomes, they should certainly be motivated to consider this. If these communications reduce such expenses as unneeded Emergency Department care, readmissions or medication related errors and injury, the ROI is likely to be real and robust.
Well established rules and expectations for the use of portals are requisite to reduce clinician burden. Frequent or very long communications require additional time (expense) and if significant communication is necessary to respond, a telemedicine appointment could be substituted, thereby allowing the clinician to recoup some revenue as compensation for medical management. Likewise, careful oversight of a portal system ensuring that communications are responded to with expediency and that coverage with a proxy during clinician absences (as with call coverage) is offered to ensure seamless medical oversight of communications.
Lastly, clinician engagement is critically important to establish a mandate for patients and families to adopt and utilize the patient portal. Clinicians who believe that a Portal will impede function or increase workload may actually reduce the likelihood of patient adoption during the patient interaction. A clear understanding by clinicians of the outcome related benefits and improved revenues may help with this important aspect of engagement with the adoption process.
A better day…
Ultimately, and especially given the shortage of clinicians and overall challenges with the American Health Care system, communications that leverage a safe, asymmetric platform facilitates care and enhances safety, revenue and outcomes. Patient portals have grown in their sophistication and offerings, and gains made offer a promise of even more benefits to come for patients, their families and the health care provider.