Greater Portal Use Gives Patients Access, Doctors Headaches

Ken Terry

September 29, 2021

The use of patient portals that provide access to electronic health records (EHRs) has dramatically increased in the past several years, and patients whose healthcare practioner encouraged them to use their online portal accessed them at a higher rate than those who were not encouraged to do so.

These were among the topline results of a national survey of US adults conducted by the National Institutes of Health from January 2020 to April 2020. Although the COVID-19 pandemic hit the United States in the middle of that period, a report on the survey by the Office of the National Coordinator for Health IT (ONC) stated, "These findings largely reflect pre-pandemic rates of individuals being offered and subsequently using their online medical record, also known as a patient portal."

But with more patient access can come additional work for physicians and other healthcare practitioners, ranging from an onslaught of patient communications to managing data sent to them by patients.

According to the report, 59% of individuals were offered access to their patient portal, and 38% accessed their record at least once in 2020. By comparison, in 2014, just 42% were offered access to their portal, and 25% used it. But these percentages hardly changed from 2019 to 2020.

The increase in the percentage of people who accessed portals reflects the fact that more people were offered access. In addition, there were signs of rising activity among portal users.

Among patients offered access to their patient portal, 64% accessed it at least once in 2020 — 11 percentage points more than in 2017. Twenty-seven percent of those who had access to a portal used it once or twice; 20% accessed it three to five times; and 18% used it six or more times. The latter two percentages were significantly higher than in 2017.

Of the respondents who were offered access to portals but didn't use them, 69% said they didn't access the portal because they preferred to speak with their healthcare practitioner directly. Sixty-three percent said they didn't see a need to use their online medical record. This was similar to the percentage 3 years earlier. Other reasons included respondents' concerns about the privacy/security of online medical records (24%), their lack of comfort with computers (20%), and their lack of Internet access (13%).

The Pros and Cons of Patient Portals, Greater Access

Among portal users who accessed their records through a mobile health app, 51% used the app to facilitate discussions with their healthcare practitioner in 2020, an eight-percentage-point increase from 2017. Fifty-percent of the mobile health app users utilized it to make a decision about how to treat an illness or condition, up from 45% in 2017. And 71% of these individuals used their app to track progress on a health-related goal, just a bit more than in 2017.

Individuals who were encouraged by their healthcare practitioner to use their patient portal viewed clinical notes and sent secure messages with their practitioner at higher rates than those who had not been encouraged. This is not surprising, but it reflects an unintended result of patient portals that many physicians have found burdensome, especially during the pandemic: overflowing electronic in-boxes.

Robert Wachter, MD, chairman of the Department of Medicine at the University of California, San Francisco, recently tweeted, "We're seeing huge uptick in in-box messages for MDs during COVID — now seems like biggest driver of MD burnout. The fundamental problem: we turned on 24/7/365 access for patients (who of course like it) with no operational or business model to handle it. Crucial that we fix this."

Steven Waldren, MD, vice president and chief medical informatics officer at the American Academy of Family Physicians, told Medscape Medical News that he agrees that this is a major challenge. "In-box management is a burden on physicians and practices," he said. "However, it can be done better, either through a team in-box or through better use of technology."

The team in-box he refers to is a mechanism for triaging patient messages. For example, a triage nurse can look at the messages and decide which ones can be handled by staff and which ones the doctor needs to see. Or physicians and front office staff can see the messages at the same time; a nurse can triage some messages according to protocols, and the physician can respond to any message, depending on what he or she knows about the patient.

Technology can also be enlisted in the effort, he suggested, perhaps by automating the triaging of messages such as prescription refill requests or using artificial intelligence to sort messages by content.

Making Patient Records Portable

Nearly 40% of portal users accessed it using a smartphone app (17%) or with both their smartphone app and their computer (22%). Sixty-one percent of users relied exclusively on computers to access their portals.

About a third of patient portal users downloaded their online medical records in 2020. This proportion has nearly doubled from 17% since 2017, the ONC report noted.

Although the survey didn't ask about multiple downloads, it appears that most people had to download their records separately from the patient portal of each practitioner who cared for them. Although the Apple Health app allows people to download records to their iPhones from multiple portals using a standard application programming interface, the ONC report says that only 5% of respondents transmitted their records to a service or app, up slightly from 3% in 2017.

Waldren hopes most patients will have the ability to download and integrate records from multiple practitioners in a few years, but he wouldn't bet on it.

"A fair amount of work needs to be done on the business side and on figuring out how the data gets connected together," he said. "And there are still privacy concerns with apps."

Overall, 21% of portal users transmitted their data to at least one outside party in 2020, compared to 14% in 2017. Seventeen percent of them sent their records to another healthcare practitioner, up from 10% in 2017. Five percent of the users transmitted their records to a caregiver, slightly more than in 2017.

Managing Data Is a Challenge

Asked how physicians feel about portal users adding information to their record or correcting inaccurate information, Waldren says, "Doctors are already comfortable with patient-generated data. The challenge is managing it. If the patient provides data that's not easy to put in the EHR, that's going to add work, and they don't want to see 100 blood pressure readings.

"You'd be hard-pressed to find a doctor who doesn't welcome additional information about the patient's health, but it can be onerous and can take time to enter the data," Waldren said.

Overall, he said, "Giving patients the ability to take more ownership of their health and participate in their own care is good and can help us move forward. How this will be integrated into patient care is another question."

Ken Terry is a healthcare journalist and author. His latest book is "Physician-Led Healthcare Reform: A New Approach to Medicare for All."

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