Point-Counterpoint: Patient Portals

The institution of the electronic health record (EHR) has altered the daily practice of medicine. With this change has come the associated development of secure electronic access for patients to their medical record and routine electronic communication with their physicians. Here, we debate the negative and positive aspects of the communication between physicians and patients via these patient portals.

Point: Patient Portals Are Problems

By Paul G. Mathew, MD, DNBPAS, FAAN, FAHS

Medicolegal Issues

Allowing patients to enter free text into EHRs is a dangerous proposition. Although health care attorneys will claim portal messages are not part of the medical record, just about anything is discoverable when litigation ensues. For example, courts now issue subpoenas for text messages and other forms of personal communication. Imagine rounding on the inpatient neurology service, and after generating your progress note, you present the chart to the patient, so they can enter their own addendum. This is essentially what portal messaging can be from a documentation perspective. Regarding the content, imagine if the patient sends a 2-page message, in which “chest pain” is mentioned. Who is liable, if after the patient sends this message, they subsequently experience a heart attack? The jury will see that the patient clearly reported this cardiac symptom to the neurologist who failed to recommend proceeding to the emergency department in a timely fashion. Another example is if the patient expresses thoughts of self-harm and subsequently commits suicide. Again, the jury will see thoughts of self-harm clearly reported to the neurologist, who failed to proceed with an emergent intervention. This is in clear contrast to a telephone or video encounter, which affords the opportunity of a real-time intervention and documentation by the physician only.

Communication Is Impaired, not Aided

When patients ask questions on the portal, the physician’s response will often trigger another question, another response, and then additional, and at times, redundant questions. This can be a problem when there are character limits for messages, but there are no limits to the number of messages that can be sent in a 24-hour period. Even when physician responses are short and not time consuming to generate, when more than 40 such messages appear in an inbox in a 24-hour period, responding can become a major time sink.

With portal messages, tone can be completely lost, and after reading a brief physician response, a patient may be left thinking “that is not even what I was asking” or “what is their problem?” A response from the physician, such as “We can discuss this in more detail when I see you in the office” may mean to the physician that the issue is too complex to address in a portal message but may be perceived by the patient as a lack of knowledge, concern, or time for them. Even if emojis were available in portal messages, they would probably just further distract and disrupt the use of the portal.

Unreasonable Expectations

Unlike face-to-face and telephone or video conference appointments, patients can, at times, expect that the physician will be available 24 hours per day, 7 days per week on the portal. At times, patients equate portal messages to text messages, and anticipate their physicians will answer in real time, including after office hours. Although this is clearly not the case, it drives an increase in patient messages outside of business hours. In addition, questions are often nonurgent, and could wait until a routine follow-up appointment. As such, easy access and convenience often drive patients to send portal messages, who would otherwise not bother contacting the physician by phone to schedule a telehealth or in-person appointment between routine appointments. Setting expectations is extremely important. Patients should be advised that phone calls are returned on business days within 72 hours. The vast majority of my patients have no problems waiting a few days for a call back because it means that all questions will be answered thoroughly, and prescriptions will be issued when required.

Reimbursement

Although some plans may reimburse for electronic communications, rates are often variable, and do not adequately compensate for the time spent reviewing patient charts, and then generating and editing what can be extensive responses needed to address complicated questions. Messages that do not adequately address the patient’s concerns expressed on the portal create potential for miscommunication and adverse events. A 10-minute phone conversation followed by 10 minutes to document the conversation and bill may afford better care and better reimbursement than the 7 minutes spent reading a portal message and generating a portal response with questionable reimbursement and clinical value. In addition, receiving real-time confirmation that the patient understands the recommendations and plan of care is priceless compared to clicking send, and hoping the patient understands what the physician intended.

Patient Selection

Some physicians have also opined they will have open communication via the portal with “select patients” who know how to use the portal “appropriately.” There are multiple problems with this strategy including how appropriate use is defined and how and when to determine if a patient knows how to use the portal appropriately. This approach also raises the thorny issue of how a physician is to handle a situation of “inappropriate” portal use if it occurs? Once patients have expectations regarding portal use, it can be very damaging to the physician-patient relationship for the physician to ignore messages or provide terse responses. In addition, through social media, patient waiting rooms, and other forums patients within the same practice have the potential to communicate with each other. If patient-to-patient communication leads to discovering different levels of access (ie, abilities to communicate via portal vs phone), this would also be detrimental to the physician-patient relationship. Treating all patients equally in terms of access is the best approach and having selectivity for portal access is likely a strategy destined for some degree of patient dissatisfaction. This is why, during an initial visit, I let the patient know that I do not use the portal for direct patient communication, and this is noted at the bottom of all of my encounter notes.

Standing Your Ground

I have been told by administrators that I “must” use the portal for communication. I have refused to use it for direct patient communication for all the reasons detailed above, and my approach of using phone, video, and face-to-face communications instead has always been deemed acceptable. I also remind the administration that I encourage patients to use the portal for sending messages to the staff for requesting refills and changing appointments which satisfies mandates including compliance with the Merit-Based Incentive Payment System (MIPS) for Medicare and Medicaid patients. I also encourage patients to use the portal to review test results and my notes. Like many neurologists, I write lengthy notes that can be a useful reference for both patients and other physicians.

Counterpoint: Patient Portals Are Pain Relieving

Stephen M. Gollomp, MD, FAAN

I welcomed the advent of new communication technologies with increasing adoption of the patient portal, and it came as an enormous surprise to me that many physicians would reject or discount the use of patient portals.

The Caveat of Mandates

Admittedly, the institution of the patient portal has been, at least in part, driven by federal coercion through Medicaid’s Promoting Interoperability Program (formerly Meaningful Use EHR Incentive Program). Most of us find compliance with the deluge of government mandates and restrictions increasingly burdensome. This is particularly so for independently practicing physicians, including many neurologists. Attention to and compliance with (MIPS for Medicare and Medicaid patients is a regular burden of practice to which the patient portal is integral. Noncompliance results in variable discounting of allowed reimbursement for services over an entire subsequent year, a painful hit to annual practice revenues. This compliance issue is a burden the employed physician does not experience directly, but indirectly the health system employer is under similar compliance pressure that is applied to the employee physician through various mechanisms.

Medicolegal Issues

Considering the recently implemented federal mandate to allow patients access to their own medical records, it can be argued that patients can and do already enter their own comments and addenda to their record. The fact that portals add an additional dimension to this process is of little import; it is now a fact of medical life. Being at risk of “failure to respond in a timely fashion” to an emergent concern is equally possible via telephone as it is via the portal. No matter the medium, every patient communication carries some inherent risk of delays in necessary care. The prudent adult standard dictates that a patient with concerns about an emergent medical problem proceed to an emergency medical facility rather than depending upon a non–in-person encounter, whether via telephone or portal.

Communication Efficiency and Accuracy

Putting aside the mandates for patient portals, from my perspective there is little question that these are a very positive development. Most importantly, physician communication with patients is immensely more efficient. A typical telephone interaction with a patient will last 5 to 7 minutes, followed by entering the gist of that communication into the EHR and potentially altering a medication program. That whole process typically takes at least 10 minutes. Considering the typical neurologist receives 10 or more remote contacts with patients daily, an extra 1.5 hours or more per day on telephone communications outside of clinical appointments is very demanding and time consuming. In contrast, a secure portal interaction, including reading and evaluating the e-mail, entering the reply with the concurrent recording in the medical record, and generating any medication changes typically takes about 5 minutes, a considerable time savings.

Portal-based communication can also serve as a more accurate and precise document of patient-physician interactions. With a verbal interaction, there is always the chance that the physician will not record all the relevant points of the interchange. Not so with a portal message in which all that was discussed and decided upon is memorialized. This reduces the potential for error on the part of the physician and the patient. It is, of course, up to the clinician to be judicious and measured, as is always the case in medical records. Although a patient may respond to the physician with another question, creating a potential message spiral, in my experience, this is not a common occurrence. Rather, patients are typically respectful of my time as their physician and very appreciative of the more rapid response through the portal, the elimination of phone tag, and the absence of late-night return phone calls.

Managing Expectations

Waiting to hear back from their care team has long been a pain point for patients, who typically reach out to their care team because a symptom or other change in their health status is troubling to them. The stress of waiting 2 to 3 days for their turn on a list of return phone calls to be made can cause tension in the physician-patient relationship. Because of the increased efficiency of the portal, I have been able to respond to patients within 24 hours of their request, unless personal circumstances have intervened. This creates the opportunity for consistent shared expectations about how long a patient may wait for a response.

Reimbursement

Finally, and very consequentially, electronic interactions with patients are a reimbursable service with well-established Current Procedural Terminology (CPT) codes providing compensation based upon the time expended upon the interaction. Although it is true that voice communications are also reimbursable with their own set of time-based CPT codes, the per unit time reimbursement is comparable to that obtained for an electronic interchange, therefore relatively penalizing the physician for using this less efficient form of patient communication. If an extensive medical record review is needed in order to answer portal messages, there are CPT codes to reflect this service. If issues are too complex to be addressed via portal communication, then a telemedicine or in-person encounter is clearly indicated, and it is incumbent upon the physician to indicate and document that an appointment is the appropriate next step.

Patient Selection

In our practice, patient participation is encouraged for all, and patients still self-select whether or not to use the portal to communicate with their team. Some patients still do not have or provide e-mail addresses or use electronic communication, effectively excluding themselves from this medium. As with all modes of communication, some patients use the portal more or less effectively and appropriately than others. If patient communication via phone or portal is habitually not respectful or constructive, a conversation about how to improve the patient-physician relationship and patient-practice communication may be warranted. The physician may also always choose to respond to a portal message with a phone call or by saying that an issue requires a telehealth or in-person visit.

Use Portals to Your Advantage

Although a refusal by physicians to use portal-based communication with patients may be lauded by some, it is a pyrrhic victory as the forces of mandates (eg, MIPS, reimbursement, or quality initiatives) effectively compel physicians and health care systems alike to use patient portals. Employed physicians may not be as directly coerced into using portals, but the quality measures imposed upon the employing institutional entity by various outside payors and regulatory bodies clearly are meant to force physicians to use digital communication, including portals. As noted, mandates and reduced autonomy for physicians increases the burden on the physician and increases burnout.

At the same time, considering the increased efficiency and accuracy of communicating via a patient portal can be a boon to physician practice, particularly that provided by a neurologist. I encourage all patients to utilize them and enjoin all neurologists to do so as well.