The Connected Patient

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Six years ago, at the peak of the dot-com boom, executives at Group Health Cooperative felt a sense of urgency about adding an interactive patient Web site to the electronic medical record system the health system was about to deploy. Against the advice of its EMR vendor, which advocated a one-thing-at-a-time approach, Group Health rolled out the two technologies at once.

“We figured we had to do it to survive,” recalls Ted Eytan, M.D., medical director of health informatics and Web services. “We assumed everyone else would be doing the same thing in the next two months. Here we are, six years later, and no one else is doing it.”

Healthcare—whether supplying medical information from a physician or billing information from a hospital—has advanced the art of information obfuscation. Just ask any patient who has played rounds of phone tag just to book an appointment. Or patients who wait a week to get lab test results in the mail—and then go through another round of hoops to talk to a physician about their meaning. Then the bills come, often a bewildering array of confusing statements and unclear accountabilities.

But the era is approaching an involuntary end for the industry as consumer expectation for information has forced healthcare to open its information technology cache. Systems like Group Health are the alpha testers for the patient IT experience. Through the MyGroupHealth portal, patients at the Seattle-based system can request appointments, send messages to physicians, retrieve lab results, ask for refills, and look up benefit information. The portal sports a broad demographic array of about 118,000 active users—almost one-third of Group Health’s patient base, says Ernie Hood, chief information officer. The portal, Hood contends, is a major distinguisher in an industry otherwise severely lacking in customer service. “The healthcare industry offers very poor service compared to other industries and compared to what is possible,” he says. “The patient experience in healthcare is just awful.”

Well-designed portals can tackle these shortcomings head-on. For one thing, an increasingly Web-savvy population wants to be connected to providers.

Consumers who book flights and check account balances via the Web wonder why they cannot book physicals and check their cholesterol scores online. So for many hospitals, offering interactive services—both in the clinic and the inpatient settings—is simply a matter of fulfilling demand.

Yes, tough policy discussions must precede any successful patient portal. But for hospitals that resolve those issues, the patient portal is a win-win. Online patient services can facilitate better care—and streamline business operations.

For the handful of industry leaders who welcome the “connected patient,” there is no turning back—the pioneers already are looking beyond simply pushing out lab results electronically. In essence, they want patients to push back. They are testing “e-visits” and home monitoring technologies that extend the boundaries of the traditional office visit in ways that eluded even the dot-com theoreticians.

Pent-up patient demand

Fulfilling patient expectations may be the best reason to launch a portal. But implementing a patient portal and the back-end IT to support it can be an expensive proposition; Group Health plowed some $42 million into its EMR from Verona, Wis.-based Epic Systems Corp. That’s why, before taking the portal plunge, many hospitals conduct focus groups to measure demand for interactive service.

Prior to launching its portal in 2004, Minneapolis-based HealthPartners conducted a blind survey of local citizens about what online services, if any, they would want. Booking appointments online was the No. 1 request, recalls Kevin Palattao, vice president of patient care services. Given the cumbersome nature of making appointments, the finding was no surprise, he says. “People do not like being on hold for long periods of time.”

HealthPartners promptly made appointment scheduling the cornerstone of its portal, a component of its $30 million EMR package, also from Epic Systems. For primary care and routine visits, the health system permits patients to book dates and times directly. For more complex visits involving procedures, patients request appointments within given parameters, such as weekday afternoons, and the staff try to accommodate. “Specialty scheduling takes a lot of coordination and is more difficult to do online,” Palattao says. Either way, patients appreciate the convenience, he adds.

HealthPartners logs some 50,000 online appointments annually. Despite the rapid growth, it represents only a small portion of the health system’s 2 million annual encounters, Palattao acknowledges. “We thought the adoption rate would be slow,” he says. “We studied the online banking and airline services and figured it might take eight years to take off.”

The demand has been big enough, however, to prompt HealthPartners to expand its online services. In November 2005, the hospital system added secure messaging with physicians, online results retrieval and EMR access to the mix. Now, with 36,000 patients registered to use the site, results viewing is picking up. From January through May of this year, more than 168,000 test results were viewed through the portal, Palattao says.

Novant Health, a Winston-Salem, N.C.-based hospital system, also found that patient demand for online service can grow rapidly. Looking to revamp its billing operation, Novant conducted focus groups with some 200 patients over the course of two years. In 2002, overall interest in online billing services was lukewarm, with Medicare patients having little interest. By 2003, however, support for the online service had mushroomed, says Lesa Klepper, director of one of Novant’s two central business offices.

As a result, Novant deployed an online billing service from Mt. Prospect, Ill.-based HealthCom Partners (recently acquired by McKesson Corp.). Through an interface with the hospital’s financial information system, patients can view bills from any of Novant’s eight hospitals in one location, updating their insurance and demographic information as needed. “Patients wanted 24-7 access to us,” Klepper says. “With Gen X and baby boomers, a lot of bills get paid at 11 p.m.”

Novant’s focus groups revealed that although patients wanted to view and pay statements electronically, they were concerned about the security of looking at clinical information online, Klepper says. To address that concern, Novant strips its online information of any detailed clinical references, giving instead the date and location of service. Due to the financial system interface, patients can get up-to-date information about pending insurance payments through the online billing office, Klepper adds. It’s more convenient for them than calling, she says, citing patients’ ability to initiate online communication even after office business hours.

Thorny policy issues

Novant’s security caveat highlights the many policy discussions that must precede the launch of any online patient service. Although setting up portal technology is fairly straightforward, authenticating users and developing access policies is anything but. “The tough part is making everything that patients want to see available and doing it securely,” advises Bill Cashner, revenue cycle officer at Shawnee Mission (Kansas) Medical Center, a 364-staffed-bed community hospital that is dabbling in online services. Since 2004, Shawnee patients have been able to pay bills, refill prescriptions, book appointments with the center’s 42-member physician group and pre-register for procedures online, rather than going through the admissions office.

To sign up for the online services, patients provide their name, Social Security number and date of birth. At least two of the three items must match with hospital records before registration can proceed, Cashner explains. “We are working on putting patient statements online, upon request, just like any other modern company,” he says. “We just have to be cautious. Signing up online is not a complicated process, but it is precise.” To date, about 15,000 people—roughly 30 percent of Shawnee’s patient base—have registered for the online financial services. Now the facility is considering granting patients online access to portions of their health records.

Before that happens, however, Shawnee can count on some sticky debates with the medical staff. Granting patients electronic access to their charts and the physicians who create them requires careful planning, portal veterans say. Physicians at HealthPartners voiced “healthy skepticism” about the hospital’s proposed online medical record and secure messaging services, recalls John Butler, M.D., assistant medical director, informatics. “Giving patients their own data looks good on the surface, but there can be discomfort in how it will roll out,” he says. “The old view of medicine is that the doctor is in charge. But e-care expands the connection between patient and provider to a continuous relationship.”

Physicians feared that with messaging capabilities, the relationship might be a little too continuous. “Physicians were primarily concerned about getting too many e-mails,” Butler says. Patients generally have been respectful of their physicians, however, and have not abused their secure messaging privileges. And having electronic messaging with patients proves to be a time-saver for physicians, adds Butler, who practices primary care part-time. “We can respond when it is convenient for us, and it creates a documentation trail,” he says. “Releasing lab results is easy.”

At Group Health, some physicians balked at offering lab results online. “The physicians wondered what would happen if patients saw abnormal results and were confused. So we said we will just send out normal results,” Eytan says. In time, patients began clamoring to see all their results, and physicians groused about the extra time it took to keep track of delivery. Now, Group Health gives physicians one day to intervene before a test result is automatically dispatched to a secure Web site. Rather than send the results in standard e-mail, patients receive an e-mail with a link to the secure site, which they access with their password and identification. Eighty-three percent of lab results go to patients this way—without physician intervention, Eytan says. Group Health routinely withholds pathology, radiology and HIV tests.

Group Health’s debate over releasing lab values, however, paled in comparison to the system’s controversy surrounding granting parents proxy access to their children’s medical records, observes Hood. Hammering out the policy took a year, and writing out the supporting computer code chewed up several more months. Now, some 5,000 parents have access to their children’s records. “Figuring out parental access was one of the hardest projects I have ever done in my 20-year career,” the CIO says. “It had nothing to do with the technology.”

What gave Hood fits was the complex maze of state law governing the rights of children to their medical records. For example, once their child hits age 12 in Washington, parents are not allowed to see records pertaining to sexual issues. Then, at age 13, mental health records are off-limits. Further compounding the dilemma, Group Health spans two states and had to contend with multiple laws. “The topper issue was, who is the parent and how do you know? There is no master registry of parents,” says Hood. HealthPartners also struggled with granting proxy access to parents, recalls Palattao “Understanding the business processes in applying the rules associated with minors, emancipated minors and parents with revoked rights is challenging,” he says. “Lawyers become key partners.”

Enabling parents to see their kids’ medical records, however, can be a public relations coup. “Parents want access to immunization records,” says Hood. Beth Averback, M.D., splits her time between her role as associate medical director for care improvement at HealthPartners Medical Group, the 600-physician practice affiliated with the medical system, and her own internal medicine practice. As an internist, she uses the portal’s messaging capabilities to get updates about her patients. As a mother, she uses it to keep tabs on her son’s immunization history. “It is easy for me to pull it up at 10 p.m. when I realize he needs it for some sports camp,” she says. “Otherwise, parents have to keep records by hand and remember where they put them.”

That very convenience factor is what makes online services so popular among patients. “It is the ultimate in consumer-driven healthcare,” gushes HealthPartners’ Palattao “Online services extend the patients’ conversation with their doctors and gives them control over their healthcare situation. And they can do it from the comfort of their homes.”

Two-way benefits

The convenience scale balances for patient and hospital. Every patient appointment booked online means one less appointment booked manually. Every query handled electronically means one less phone call to field. “Delivering test results electronically is a huge efficiency for us,” Palattao says. “It is less work than sending a letter, and there is no mail lag. We have gone from days to hours in delivering results.”

Even though Group Health has seen substantial growth in online lab results retrieval (see “A Busy Portal,” page 26), the integrated delivery system still mails out duplicates. It may eliminate the paper backup if patients opt out, Hood says. “We did not pitch this service as a way to save money,” he says. “We saw the portal as a way to get patients more involved in their own care and make our physicians more present.”

One potentially large area of economy for Group Health lies in its online refill request service, Hood says. Rather than calling a physician or returning to a clinic, patients can request refills through the Web site. Group Health fulfills the orders at a central distribution office. “Carrying an inventory in all our clinics is expensive,” Hood says. “It is cheaper to centrally fill and mail out orders.”

For its part, Novant Health has enjoyed substantial financial returns since it revamped its billing services. After it launched the online billing center in 2003 and overhauled its patient communication tools, Novant saw a $5 million increase in self-pay collections in two years, says Klepper. “An easier statement to read and access to the billing office are the keys to better collection, not calling people up and harassing them every 14 days,” she says. For Novant, the online billing center supplemented other efforts, including the redesigned statement and increased effort on upfront collections at its facilities. Although she declines to provide the cost of the online billing service, Klepper says it is two-thirds the cost of sending out paper bills. The amount of staff time spent on the phone answering billing questions has been sliced in half, she adds.

Financial considerations aside, many physicians point to improved care as the best reason to engage patients electronically. Merely presenting graphs of critical lab values can be a dramatic reminder to patients struggling with chronic diseases such as diabetes. HealthPartners’ patient-accessible EMR “makes patients feel more responsible for their own care,” says Butler, the informatics director who doubles as a primary-care physician. “If you give advice, and patients own the information and are part of the decision, they are more likely to make the changes you recommend.”

Gary Baldwin is technology editor of HealthLeaders magazine. He can be reached at

Triage Needed

An electronic medical record system must be in place for a patient portal to work. Ironically, while the EMR can boost patient access to their physicians, the same automation can reduce face-to-face time the back office staff have with one another. Rather than handing off paper forms, staff trade electronic messages. That’s one reason it is crucial to standardize workflows created by patient portals, notes John Butler, M.D., assistant medical director, informatics, at HealthPartners.

Using the HealthPartners portal, patients can request medication refills. But fulfilling those requests internally required HealthPartners to develop a standard workflow, Butler says. “We needed to figure out who takes the request, what they record about it, which in-basket it goes to, how questions should be forwarded to the nurses and what happens before the request goes to pharmacy,” he says. “The EMR amplifies everything we do.”

While workflow analysis can be an exercise in tedium, Butler takes it all in stride. “In the future, patients will require these services,” he says. “Is there a bank without online banking? It will be hard for hospitals to be competitive without online services.”

—Gary Baldwin

Not for Outpatients Only

A patient portal seems like a natural fit for many outpatient services, such as booking appointments, asking for refill orders and sending follow-up questions to physicians. But some hospitals have found that online services can fill voids in the inpatient setting, as well.

Organization: Children’s Healthcare of Atlanta
Service: Personal Web site creation

Being in the hospital is never easy, but for children, it can be especially draining. That’s one reason Children’s Healthcare of Atlanta has put Web site creation tools in the hands of its pediatric clientele—and their parents. Using a subscription-based service from Chicago-based TLContact, which operates, Children’s has seen tremendous interest in personal Web pages since it began offering the free service three years ago across its three hospitals. “It helps patients connect with family and friends outside the hospital and network with other children going through the same experience,” says Melissa Rehberg, project manager.

Patients can use personal computers scattered throughout the hospital’s public areas or any computer with Internet access to set up their personal Web sites through a link from the hospital’s home page. They can post photos and content to the site, or set up discussion areas. A cadre of teenage volunteers roams the hospital floors with wireless laptops and digital cameras to help. Patients can control access to their sites if they prefer, Rehberg says. “The sites look alike, but the content varies tremendously,” she says. “Some of our ongoing cancer patients have really big sites with thousands of postings.”

It’s the connectivity with the outside world that pediatric patients crave, she says. Children’s usage data suggest there are plenty of connections to go around (see “Traffic Patrol”). The personal sites also cut down on the number of incoming phone calls to the nursing stations asking about the patient’s status, Rehberg reports. “We can’t tell them anyway because of HIPAA,” she says.

The hospital does not monitor the content posted to the personal sites, Rehberg says. That responsibility goes to Patients must agree to the hospital’s ground rules before the sites are created, however. For example, the language needs to be appropriate and disparaging comments about physicians or the hospital are prohibited. “We want the Web site to be the patient’s responsibility,” Rehberg says.

Organization: Inova Fair Oaks Hospital
Service: Interactive television monitors

The key to inpatient satisfaction is creature comfort. If the food is too cold or the room too hot, odds are already against sick patients feeling any better. To keep tabs on such issues, Fairfax, Va.-based Inova Fair Oaks Hospital has deployed an interactive patient communication system. The system, from Bethesda, Md.-based GetWellNetwork, resembles the in-room television services at some hotels, says Todd McGovern, senior director of operations & business development. To use it, patients use a wireless keyboard and remote control, which enables them to surf the Web, watch premium movie channels, and dispatch complaints—and kudos—to the staff.

If the room is too hot, for example, patients can click a box on the screen. The message is routed to the hospital’s engineering department, which adjusts the room temperature from a central location. Then, 15 minutes later, a department member is prompted to call the patient to follow-up. There are similar messaging features for food quality and room service, issues once directed to nurses, McGovern says. “If there is an issue, we can react before the patient leaves the hospital,” he says. Since Fair Oaks installed the GetWell system in late 2004, nurses field far fewer room-related issues, McGovern adds.

Basic services, such as the “instant response tool and access to educational videos,” are free. Patients pay $10 a day for premium services such as Internet access and first-run movies, except on certain units that offer those services free. Patients hitting the button have sparked some quality improvements at Fair Oaks, which staffs 182 beds. For example, after several patients complained about the temperature of their food, Fair Oaks upgraded its delivery carts. Patients can also use the system to acknowledge individual caregivers, a recognition program that has been a great hit with the staff, McGovern says. “It is a great way to reinforce the need to do the right thing for the patient,” he says. “The system is not a silver bullet, but it is a great tool to hold staff accountable and build satisfaction.”

—Gary Baldwin

Look Into the Web Cam and Say, ‘Ah’

Just how far can interactive online patient care technology go? Much, much further than merely booking appointments and retrieving lab results, some say. A handful of pioneers are in the early stages of conducting “e-visits”—online interactions between physicians and patients that may one day supplant routine office visits. Henry Ford Health System, a Detroit-based integrated delivery system, began an e-visit pilot in July, says Pam Landis, director of Web services.

In Ford’s model, patients would log on to a secure page, type in a description of their ailment and then answer a series of questions based on their self-reported problem. The homegrown system will “search the keywords the patient has typed and then a clinical interview kicks in,” Landis says. “Then it collects the questions and answers and presents to a physician. It asks all the same questions the doctor would ask in person. The patient will get an answer back in one day.”

The e-visit service builds on Henry Ford’s patient portal, operational since 2000. Accustomed to looking at lab results and making refill requests online, Ford’s patients would have more convenient access to physicians with nonurgent conditions, Landis says. Ford’s health plan will reimburse physicians for the visits in the pilot, she adds.

Beyond e-visits, connecting home health devices with provider electronic medical record systems may be the next frontier of patient connectivity. A newly launched group, the Continua Health Alliance in Beaverton, Ore., is looking to build data exchange standards that would enable delivery of data among a wide array of devices and EMRs. Launched this past summer, the Alliance has 22 corporate members whose products include cell phones, heart monitors and weight scales, says Dave Whitlinger, president and chairman. Founding members include Cisco Systems, Motorola and GE Healthcare. Funded by membership fees, Continua is a nonprofit group run mostly on volunteer labor, says Whitlinger, who declines to state the organization’s annual operating budget.

Joseph Kvedar, M.D., says standards are sorely needed for home health devices. Kvedar is director of telemedicine at Boston’s Partners HealthCare System Inc., a Continua member. Partners remotely monitors the vital signs of about 60 congestive heart failure patients using Web-based technology, and its goal is to have around 300 patients monitored in the next year or so, Kvedar says. Partners is currently working on feeding data about patients’ blood pressure, heart rate and weight directly into its EMR. Partners must send in a nurse to set up the system, and on occasion an engineer. Having “plug and play” at-home medical devices would greatly enhance adoption, Kvedar says. “The imperative to find new ways to improve quality is too strong to ignore,” he says.

—Gary Baldwin

Portal Patter

Musings about the impact of online patient services

“If the patient wants to communicate online with their physician, and the physician chooses not to do so, I would expect the patient to go to another physician.”
—John Butler, M.D., assistant medical director, informatics, HealthPartners

“This is a better way to practice medicine.”
—Ted Eytan, M.D., medical director of health informatics and Web services, Group Health Cooperative

“It is more convenient for physicians to respond to secure messages than a barrage of phone calls that interrupt them.”
—Ernie Hood, CIO, Group Health Cooperative

“If a patient’s labs are abnormal, I will message them to come in and see me. You don’t want to give a diabetes diagnosis by e-mail.”
—Beth Averback, M.D., associate medical director for care improvement, HealthPartners Medical Group

“We are a complicated health system. Just getting through a simple phone call to a physician can be hard. So we look where our pain is and try to fix it with technology.”
—Pam Landis, director of Web services, Henry Ford Health System

“In the near future, you will need a patient portal to survive. It will become a baseline expectation for how patients select their doctors. You can either lead this or chase this. I would rather be leading it.”
—Kevin Palattao, vice president of patient care systems, HealthPartners




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