Ask Jesse Ehrenfeld, M.D., about the design of patient portals, and the anesthesiologist goes on a tear about getting work done on his car.
“I went online to schedule my service appointment. Then I got an email the day before to remind me," says Ehrenfeld, an American Medical Association board member who teaches at Vanderbilt University School of Medicine. “I can't do that with my doctor's office. I have to call the practice, wait on hold, and if they're overbooked, they have to call me back. That's frustrating."
Portals were intended to alleviate those kinds of hassles. They enable patient self-service functions such as appointment scheduling, lab result viewing, bill paying, prescription refills, and secure communications with doctors or staff. And for healthcare organizations, portals can pay off: Portal adoption correlates with patient engagement and retention and can help a practice meet financial goals.
Yet patients are holding back. Regardless of practice size, only about 25 percent of patients sign up for portals. According to a survey by Software Advice, many are stifled by confusing interfaces, or find that portals are missing key functions.
Ehrenfeld places the blame squarely on the way patient portals developed — through meaningful use programs, rather than ground-up efforts to improve patient engagement.
Where's the oversight?
Portals have been a key part of the U.S. government's push to digitize medical records. But as they checked off government boxes, Ehrenfeld says, many vendors focused on accommodating minimum requirements, rather than meeting the needs of end users.
“Things like adherence to medication utilization and protocols can very well help patients through the use of these tools," he says. "But unfortunately, they don't exist in any of the commercial products."
And there are limits to the information portals do provide, he says.
“If you are a patient who sees multiple physicians in different practices, it's not uncommon that you can only get a snippet of your information because these systems don't talk to each other," he says. "There's no interoperability."
The problem stems in part from lack of oversight. The U.S. Department of Health and Human Services required electronic health record vendors to develop portals based on user-centered design — understanding users' information needs, how they process information, and how they'll use it to make decisions — and to conduct formal usability testing.
But a 2015 study spearheaded by Raj Ratwani, Ph.D., the scientific director of MedStar Health's National Center for Human Factors in Healthcare found that many EHR systems didn't adhere to design and usability standards, yet still emerged from testing fully certified.
Ratwani has argued that developers missed out on the real promise of portals. In September 2015 testimony before the U.S. Senate Health, Education, Labor & Pensions Committee, he said all of a patient's health information should be securely available in one central place, making it easy to access.
It's also important to present information in simple terms, not clinical jargon, he said. A medication list, for example, should simply state which drug to take, at what time, and for which conditions.
And he said patient-provider communications should be integrated with clinicians' workflow, so that doctors can give their patients relevant support.
“As we look at how we can improve access — how the terminology used in patient portals is represented — it will take input from patients and physicians to make all that work," Ratwani told the committee.
Pressure for change
With so many shifts in healthcare on the way, there's increasing pressure to change portals for the better.
At the HIMSS16 conference in March, Andy Slavitt, acting administrator for the Centers for Medicare and Medicaid Services, said his agency would be taking a “user-centered approach to designing policy" that affects healthcare technology. At the same time, he urged vendors to “step back and look at what you don't think is working, and make it better."
And Ehrenfeld says the American Medical Association intends to push for more strictly enforced regulation, with the aim of holding vendors accountable if they don't build products specifically geared to meet the needs of end users.
“We hope that this is addressed and changed as the meaningful use program is reformed and migrated into the next iteration," he said.
Ehrenfeld says he's optimistic, since portals fit well into the emerging world of value-based care.
Portals and digital technologies "should help us understand if we're doing the right thing when we provide care — if the care delivery process is actually providing real value," he says.
Frank Irving is a writer based in Philadelphia.