Patient Portals
Electronic Health Records (EHRs) are the most visible tool for modernizing the process of patient care. 20th-century healthcare was marked by scattered paper charts and handwriting by doctors and nurses. 21st-century healthcare has digital patient information in one place, portable to wherever the patient is cared for. While the EHR symbolizes modern care, it is the applications within EHRs that transform the process of care.
Two EHR applications that are basic for improving patient care are registries and electronic prescribing. The registry function allows for the planning and evaluation of care to a population of patients. All patients with a certain disease, such as diabetes, are gathered together with proactive disease management efforts and continuous evaluation of the quality of care. The registry function is necessary for efficient participation in pay for performance programs. Electronic prescribing adds great convenience to patient prescriptions and reduces the risk of medication errors.
A higher order function within EHRs is knowledge management for clinical decision support (CDS). Most early EHRs have drug-drug interaction information at the point of care and reminders for preventive services. More advanced EHRs have imbedded clinical guidelines to help the care team provide consistent best practice to patients. CDS applications make an EHR intelligent and providers are not limited to what they can think of at the moment, or have to break away from care to look something up.
The EHR application that I believe will truly transform the process of care is the patient portal. The patient portal is a secure communication function built into the EHR. Two-way communications between the patient and care team happen within the medical record, with the communication automatically captured as part of the care.
Early applications of a patient portal look more like convenience than transforming care. I visited a practice recently that just launched its patient portal, and it is being used for the patient to request appointments, refills, and to ask questions that would have been done over the telephone. The care team will use the patient portal for appointment reminders and to share information with the patient such as lab and other test results. Nothing revolutionary there.
Whether you realize it or not, the patient portal is a gateway to two major transformations of patient care. The first is that patients have direct access to their own medical record. 20th-century healthcare was paternalistic, with providers owning the medical records and patients had difficulty even getting copies. With EHRs containing patient portals, patients share in the ownership of their records. This is patient-centered care in which patients becomes active coordinators of their care. The shift to patient coordination of care is big, just like people being able to manage their own financial accounts, travel, and other services. Soon, patients will be arranging for their own preventive services, such as lab work and mammograms. They will be filling out their own checklists for the management of chronic health problems, such as diabetes. Patient responsibility for their own care increases. Through patient portals and the evolution to personalized medical home pages, patient centered care in the 21st-century will blossom.
The second transformation is that through patient portals, care does not depend on patient visits. Patients and the care team communicate in a continuous way rather than depend of getting everything done during hurried patient visits. The first rule of redesign in the IOM report, Crossing the Quality Chasm (2001), is that care is based on continuous healing relationships. Patient portals make access to care continuous, at mutual convenience, and become the new first platform of care. Face-to-face visits, group sessions, and telephone communication will increasingly be driven by communication which starts through the patient portal.
What looks like a simple new convenience for patient communication becomes a transformative tool for patient care. I think the patient portal is the most exciting and powerful application of an EHR. Methods of making patient portals financially viable are available. Like online banking, health care online will be remembered as the major transformation of care in the early 21st century.