'Patient portal' designed for elderly patients

Pregistration function to be enhanced

A University of Arkansas for Medical Sciences (UAMS) project that began with the Center on Aging identifying a need to communicate better with elderly patients has become an ambitious Internet initiative encompassing the entire campus.

The Center on Aging, one of the UAMS Centers of Excellence, wanted a way to get elderly patients more involved in their own health care, specifically through an exchange between institution and patient that would tie into the electronic medical record system, says Alan Gardner, MBA, director of process and planning for the UAMS information technology (IT) department.

After the IT department created a prototype for this "patient portal" — based on a list of functions submitted by the center — other UAMS institutions discovered what was going on and expressed a strong interest in becoming part of it, adds Gardner.

Among the functions included in the prototype were the ability to request and view appointments, a list of known medical conditions, a medications list, and a patient education resource center featuring web sites that the Center on Aging deemed good places for information on senior health, he says.

After the interest expressed by other campus departments — and the realization that a patient portal would be "a very visible component of UAMS" — the decision was made to include oversight and representation in the project from other key areas on campus, Gardner notes.

Project leaders would need to adapt the portal — which was designed for seniors — for broader use, as well as address some issues that were specific to the elderly population, he says.

"Say there was a patient who couldn't care for himself anymore — someone with dementia — and the family had decided that they didn't want him to have access to information about all of his medical conditions," Gardner says. "They might have concerns about the patient knowing too much about what was going on and getting stressed out."

UAMS already has a preregistration component on its standard web site, he says, but as part of the new project "we will pick that up and enhance it and plug it into the patient portal."

As with the Microsoft Wizard, which "steps you through a process and does two or three little chunks at a time," users will be pretty sure they have answered all the preregistration questions correctly, Gardner says. "It will be a huge benefit for us on this campus. Today, if patients call for an appointment, many times we don't gather next of kin, address, and guarantor information. Information that is needed to submit a bill often is not included."

Staff will have the ability to send appointment reminders to patients via e-mail, with an instruction like, "Please click on this link to preregister."

Patients then will be able to easily enter on-line information they normally write by hand while sitting in the waiting room with a clipboard, he adds. "Our inpatient [department] provides this function over the web, but we want to make it more prominent. Now it is hidden behind screens and not many people are aware of it. We also want to include outpatients."

In addition, Gardner says, the preregistration function will be visually integrated into the patient portal, with identical colors and graphics.

One of the issues that surfaced regarding the design of the patient portal had to do with "secure messaging," a process whereby patients would be able to send a message — more secure than an e-mail — to a clinic or a physician, he notes.

The primary concern there, Gardner adds, was what processes need to be in place to make sure someone actually responds to such a message.

"We didn't want patients to send a message and not get a response for two days, or for a nurse to think a physician responded, and the physician to think the nurse did, and no one responded," he says. "There are downstream policies and procedures that need to be in place."

Contributing to those "downstream" issues is the way in which a university health care environment differs from its non-academic counterparts, Gardner points out. "We have tenured faculty that work in clinics 20% to 25% of the time, and otherwise are involved with surgery, classes, and research, so their direct patient interface time is much less than in the private world."

Within that scenario, he adds, "each clinic operates differently and has its own work flow that works best for its faculty."

At the large UAMS cancer research center, for example, patients may come in for treatment at 8 a.m. and not leave until 4 p.m., Gardner says, while the family medicine clinic sees walk-in patients who come and go in a short time.

Those differences may impact how information is entered into the medical record system, he says. "We don't have 100% participation in the EMR across the board. In some clinics, [staff] are putting notes into a laptop computer as they examine the patient. In others, they do the exam, go back to the office, write up the notes, and then scan them into the electronic system."

"If we're going to have a patient portal that allows patients to see discharge summaries and letters that have been written, and timeliness is good in some clinics and not good in others, patients will be irritated," Gardner adds.

Another example is how different clinic staffs handle prescription refill requests, he says. "Some collect them in the morning and when they catch the physician, say, 'Here are six — will you sign off on them?' Other physicians may prefer to get them directly. The point is that each clinic operates differently."

In view of those kinds of issues, and with the increased scope of the project, Gardner explains, the project steering committee decided to "step back, reassess the whole project, and then move forward with a more planned, enterprise-wide solution."

UAMS did a survey of its various departments to determine what functions they felt were most important to include in the patient portal, Gardner says, based on level of effort required to implement, as well as benefit to the patient and to the department itself in terms of cost-savings.

Survey results, he adds, included the following functions, in the order in which they were ranked by respondents:

  • preregistration;
  • prescription refill request;
  • appointment request;
  • medications list;
  • appointment viewing;
  • patient education resources or links;
  • requests for medical records;
  • lab test results;
  • medical conditions list;
  • on-line bill or invoice viewing and bill payment;
  • clinical care team list;
  • secure patient-clinic messaging, with the nurse, physician, or appointment desk, and the integration of that messaging with the EMR system;
  • ability to update insurance and registration information;
  • a wayfinding system that would be tapped into with the patient portal.

The project steering committee — a group of between 20 and 25 administrators, clinicians, and other interested parties that meets monthly — will determine what the policies and priorities are regarding the patient portal, Gardner says.

While there potentially are task groups for 15-plus functions, he notes, some of those likely will be combined — the medications list and the medical conditions list, for example.

Because of the downstream issues that are being encountered in some clinical areas, project leaders have decided to work first on the operational, administrative functions such as appointment requests, medical record requests, and bill payment, Gardner says. "We don't want to delay getting the portal out to our patient population because of all of the downstream policies [on which] we will have to get agreement and then institute."

Some of the clinical functions already are being performed with one large UAMS department, he notes, "but the way we implemented the functions for them may not be best for everybody."

The decision to offer functions such as refill requests and lab test results notification first was validated by his visits to other medical university health centers that have implemented or begun work on patient portals, Gardner says.

'Secure messaging' hot topic

"One of the most valuable things I've learned in that process has to do with secure messaging, which is a hotly debated topic. If you open up that pathway and respond to that message, there is no good way for the physician to get paid."

There also could be a liability issue, he adds, in instances in which the patient doesn't tell the whole story, gets advice from the physician, and later has complications.

"What I found out from other universities is that what they did is offer all the other functions first," Gardner says. "Those are the things patients usually ask about. Less than 3% of the questions [the other institutions] were getting actually needed to be forwarded to a physician."

Delaying implementation of the secure messaging feature "makes a world of difference," he adds. "Everything is more directed to where it is supposed to go, and you don't have physicians looking at an abundance of messages that someone else in the clinic is responsible for."

During his visits to the other facilities, he also "heard good success stories" about on-line collection rates, Gardner says. "At one institution, over a short period of time close to 30% of their patients were making electronic vs. check payments."

In addition to improving its own cash flow with on-line bill payments, UAMS thinks the patient portal will have the following benefits.

  • improve patient satisfaction;
  • get patients more involved in their own health care, in line with national initiatives such as consumer-driven health plans;
  • reduce administrative costs;
  • improve work flow through on-line preregistration and appointment requests.

(Editor's note: Look for more information on the UAMS patient portal, including the wayfinding function that will be implemented in a later phase of the project, in a future issue of Hospital Access Management.)