• Patient Portals
  • Patient portals are under-utilised and need promoting

    Portals are a routine way to access information from entities. It seems that US residents haven’t been as keen on them for health and healthcare information as they are for other requirements.

    A US survey of more than 5,000 people aged over 17 in 2015 by the Council of Accountable Physician Practices (CAPP) and the Bipartisan Policy Center found that most Americans were either unaware of, or don’t have access to the technology they could use to communicate with their doctors for better quality healthcare.

    Conducted by Nielsen Strategic Health Perspectives, the results were: 

    While portal use was low, it had the highest growth rate of the nine components, 13% since 2014, the year before. Does it mean it’s on the rise? If it is, will it a slightly rising or steep trajectory?

    Four groups most interested in using digital and electronic technology for greater access to their doctors are: 

    Parents with children covered under their health plansChronically ill patientsPatients with acute conditionsAdults younger than 35.

    These factors of reluctance and specific high-use groups are important insight for Africa’s online services. Determining the high-use groups is helpful in determining capacity and content. Both need establishing to ensure a foundation for future growth.

    Identifying the time scale to reach high levels of utilisation was beyond the survey’s goals. With specific high-use groups, it may take several years for contagion to change other groups’ portal behaviours.

  • e-Hospital portals can improve hospitals

    The world we live in has seen a revolution of digitisation in mobile phones, banks and the internet are examples.  People want to avoid or reduce the time they spend doing things manually, and would rather opt for using the latest technology.

    An e-Hospital portal is an example. It’s a project introduced by the government of India. An aim's to use technology to empower people and help them connect to areas of health.

    e-Hospital enables the public to book outpatient appointments, view diagnostic reports, check the availability of blood, lab reports and pay their fees. Using this type of eHealth offers quicker access, remote diagnosis and faster medical prescriptions. Time taken to receive treatment or see a medical expert is expected to be reduced considerably.

    Services provided by an e-Hospital portal maximises the contribution of existing healthcare professionals. It enables networks of nurses and doctors to achieve more efficient treatment and monitoring.

    The large scale of the project offers an insight for Africa’s eHealth strategies. Planning directly for national coverage can offer bigger scale benefits, even where, as in India, roll out's phased.

  • A portal doesn’t improve US hospital outcomes

    As the internet and web have spread across healthcare, portals have been seen as an essential link between patients and clinical teams. It seems they don’t make any difference to hospital outcomes. A study at Mayo Clinic Hospital, Jacksonville, published in the Journal of the American Medical Informatics Association (JAMIA), found the 30-day re-admissions, inpatient mortality and 30-day mortality rates were virtually the same for hospital patients who used portals without prompting and those who didn’t have accounts to use them. The 30-day rates were adjusted for Lengths of Stay (LOS).

    Interpreting the results needs to incorporate the limitations of the portal. It has no specific features for communication between patients and healthcare teams. It only includes admission notes, operative notes, consultations and laboratory studies in real time. Daily progress notes can’t be viewed, and there’s a 72-hour delay in viewing radiology and pathology reports. There’s no educational material about patient-specific diseases and processes.

    Patients with portal accounts seem to drop their access on admission. About 44% of patients who had a portal account when they were admitted, but fewer than half, about 21%, accessed it when they were inpatients. Other studies have found similar results, such as 34% and 23%. For tertiary services, the rates were 25% and 16%.

     of registered users accessed their account.22 The lack of features designed specifically for inpatient use was previously emphasised in a systematic review.14 Consequently, several medical centres designed hospital-specific applications aimed at improving the use and usability of inpatient portals.23–25 In a realistic review, Roberts indicated that patient participation with inpatient health information technology (including patient portals) can be augmented by interactive learning focused on information sharing, self-assessment and feedback, tailored education, user-centred design, and user support. Outpatients with severe diseases use portals more frequently. 

    Patients who access portals have better outcomes for some chronic conditions such as: 

    ·             Diabetes, with lower haemoglobin (HbA1c) after 6 months

    ·             Hypertension, with improved blood pressure control at 12 months)

    ·             Depression management, with increased medication adherence

    ·             Preventative care, such as up-to-date immunisations and mammograms. 

    Portals can have benefits. African health systems need to be explicit about what their portals can achieve and ensure that these are maximised.

  • Portals alone might not help BP control

    “One way to get high blood pressure is to go mountain climbing over molehills.” This’s the insight of the late Earl Wilson, a US journalist. Bringing it back down may be more challenging. A study in the Journal of the American Board of Family Medicine (JABFM) starts from the position that evidence is inconclusive that patients who use portals to improve their disease management do benefit. For Blood Pressure (BP) interventions, randomised controlled trials (RCT) have found no benefit of using web sites for communication between patients and providers. The team says there’s the RCTs relied on patients not selected for uncontrolled hypertension, nor measured portal use in real-world settings as captured in their EMRs. The team set out to determine if patients with treated, incident hypertension achieved BP control when they used portals designed to support them in the quest.

    There were two important findings:

    After adjusting for age, portal users were more likely than nonusers to achieve BP controlAfter adjusting for socio-demographics, using portals wasn’t associated with BP control.

    Patients’ socio-demographic factors included race, sex and socioeconomic status. These account for the finding that using portal leads to better BP control in people  with newly diagnosed hypertension. Patients’ ages makes a difference too. Those who achieved control were significantly older than those remaining uncontrolled.

    For eHealth, the study raises an important conundrum. Does it mean that portal services have to be much better to achieve more benefits, or does it mean that even better portals might not make much more difference? It’s an important theme for Africa’s eHealth, especially its mHealth. What role does mHealth play in better health? Does effective mHealth need socio-demographic or other dependencies to succeed? These need explicit evidence for rigorous mHealth business cases.

  • Patient portals are effective

    Should patients have access to their medical records? It’s an important decision for Africa’s eHealth if it increases the benefits of EHRs. There may be trend emerging.

    In 2012, a study in the Journal of Internet Medical Research (JMIR) of patient portals’ effectiveness by and Austrian team found:

    Five papers presenting found studies No statistically significant changes between intervention and control group in the two randomised controlled trials investigating the effect of patient portals on health outcomes Significant changes in the patient portal group, compared to a control group for: Quicker decrease in office visit rates Slower increase in telephone contacts Increase in the number of messages sent Changes of the medication regimen Better adherence to treatment.

    A USA study in 2015, also reported in the JMIR, found the availability of notes following visits to GPs was associated with improved adherence by patients to prescribed antihypertensive medications, used to treat high blood pressure. It didn’t find an improvement for antihyperlipidemic medications, used as cholesterol busters.

    Surveys, interviews, and focus groups have shown that patients taking medications and offered portal access to their GPs notes reported better adherence to their regimens. There’s a big but. The study says that objective confirmation hasn’t been reported, so the team completed a retrospective comparative analysis at a site of the OpenNotes quasi-experimental trial. Quasi-experimental research has similarities with the randomised controlled trials, but they don’t have a random assignment to treatment or control.

    Patients in Danville, Pennsylvania, older than 17, in the Geisinger Health Plan insurance, and taking at least one antihypertensive or antihyperlipidemic agent from March 2009 to June 2011, provided data for the study. From 2010, patients were invited and reminded to use the portal to read their GPs notes. Control patients had portal access too, but their GPs notes weren’t available. There were 2,147 patients, 756, 35%, in the intervention group, and 1,391, 65%, in the control group.

    The 756 patients with access to their GPs notes were more compliant to antihypertensive medications regimens. The rates were nearly 80% compared to 75% for the control group. For antihyperlipidemic medication, the rates were about 77% for both groups.

    The study says as the “Use of fully transparent records spreads, patients invited to read their clinicians’ notes may modify their behaviours in clinically valuable ways.” How can Africa’s eHealth take advantage of it?

  • Patient portals are valuable, or are they?

    Findings from a study in New York on patient portals into EHRs, reported in the Journal for Medical Internet Research (JMIR), says that “Most consumers were enthusiastic about patient portals and perceived that they had great utility and value. Study findings suggest that for patient portals to be effective for all consumers, portals must be designed to be easy to read, visually engaging, and have user-friendly navigation.”

    The experience of Estonia is different. An EC report says that few patients took advantage of the portal into its national EHR. Most of the patients seemed to lack the enthusiasm of the much smaller study group in the JMIR report. After about two years, some 5% of the population used the portal extensively, with an average of about 24 times, so about twice a month.

    A previous JMIR report on patient portals found “disparities in patient portal use, patients use portals to manage their medications, are enthusiastic about further leveraging portals to support medication management and adherence, and those who use a portal more frequently have better glycemic control. However, more features and functionality within a portal platform is needed to maximize medication management and adherence promotion.”

    Taken together, these may show that patient portals are not always straightforward. For Africa, access by mobile phones is more likely to offer more success than using various types of computers.