Patient Portal Success

“Doctor Nieder, my wife got this new smartphone and she wants to know why she can’t communicate with you using it. Can she?” This coming from a 70 something patient. I’d seen his wife a few days previously and she had a question about her medication. She wanted to know why she couldn’t just email me about it.

We talked a little bit about the insecurity of email and personal health information (PHI in my world). Then I happily explained that,  indeed she could communicate directly with me using her smartphone. I gave him my card with the RelayHealth information on it, directed him to look to the upper right-hand corner of the website and click “register”. This will take her to this page:

Relay Health Sign in

 

After finishing the registration process, pick a provider – me – and then RelayHealth sends me notification of the registration. After that she can directly communicate with me. He left the office happy to have good news for his wife.

I know many of my colleagues are hesitant to give patients direct access but consistently the portal has saved me more time than cost me. Patients ask thoughtful appropriate questions. If an appointment is needed a staff member calls them. Otherwise I can give an equally thoughtful response on my own time. As they say “It’s a win-win.”

 

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What would you do?

A text lights up my phone late in the evening. It’s from someone who is a patient but we’ve been together for so many years I consider her a friend. She has my phone number from other times she’s needed medical advice. She knows me well enough that she can assume I am adept at texting though we’ve never communicated that way before. The patient is immune deficient and somehow managed to scratch her leg. It didn’t originally look all that bad but in the last hour or two it has become red and swollen around the scratch and she is concerned about cellulitis.

 

There are no Immediate Care Centers open this late on a Sunday night. It is not clear to me from the description, even after speaking with her on the phone, if it is bad enough to need hospitalization. If not, the best care would be to start an antibiotic tonight and check it in the morning. My choices: send her to the ER at the height of flu season (a terrible idea for anyone but especially an immunocompromised individual), have her wait eight hours until morning and I can see the wound, treat it empirically, or have her send me a picture. The picture can’t be in a text because that’s not HIPAA compliant. It also can’t be email because that’s not HIPAA compliant. SKYPE? Maybe but I’m not sure how good the encryption is.
So I sit on my couch and weigh options–all the while thinking, “How did we get in such a quandary, where taking the best care of the patient is not first on my list of considerations? Where common sense is delegated to the back of the bus behind government regulations and insurance rules? And where the technology to make all this simple can’t be utilized to help my patient or me?” Patient portals are great but can she figure out how to load the picture on it? And our portal only accepts up to a 50 MB file. What if it’s larger? Will she know how to reduce the size? Yes, I could do what my 1950’s MD ancestor would do, which is hop in the car and make a house call, but he only saw 12 patients in the office the next day and made relatively leisurely rounds at the hospital. Not the frantic 20+ I’ll see tomorrow, needing all the rest I can get.

What would you do?

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Physician Patient Communication

All professions need good communication skills. Obviously in healthcare the ability to communicate with patients should rank high in a physician’s list of talents. These days that interaction occurs in a number of ways: face-to-face, direct telephone contact or though a staff member, via emails, patient portals, or even texting. Because the communication is in the arena of medicine, the protection of an individual’s health information is paramount. Enter HIPAA, which is a federally mandated program to ensure patient confidentiality.

The face-to-face form of interaction is the most rewarding because multiple senses are used in the process. First, I listen to the words while hearing the tenor of a patient’s voice; a few octaves higher with anger or fear, deep and gnarly from years of smoking, “push” of speech in an anxious or grandiose individual, or an accent that might be heavy enough for me to wonder if there is a cultural or comprehension problem. Sight gives me other cues; body language–crossed arms, angry face, tearful, an open posture, a resigned facial expression, stiff limbs or back. Sometimes my sight reveals more concrete things–bizarre tattoos, picked at sores, expensive accessories, worn and torn clothing. My nose may be assailed by the scent of the smoker, too much perfume, not enough soap, musty clothing or pleasant shampoo–all of that speaks to me. Finally touch–dry and peeling skin, a mass somewhere it shouldn’t be whose texture may speak to me of reassurance or of terror.

The opposite must be true as well. We speak volumes to our patients without opening our mouths, or despite opening them. The tenor of our voices may be patronizing, authoritative or uncertain. Our faces and body language reveal our thoughts with a roll of the eye, crossed arms, or open facies. We can look professional or casual. Smell can be important–what asthmatic wants to see a physician whose aftershave or perfume is overwhelming? Perhaps touch is the most expressive. Early on I learned that even when I don’t need to, patients expect to have a “laying on of hands” in some fashion. They may trust you less if you haven’t at least looked in an ear or listened to a heart.

The hardest communication for me is remembering to finish with eye contact and a plan: “We’ll contact you with the lab results”, “I will have our referral clerk Megan call you” or just “Have a great holiday” instead of rushing out to see the next patient. But the best visits include a hand shake or on a good day, a hug.

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Patient Access to Their Data

The Open Notes initiative has created a flurry of interest in the on-line medical community but not even a blip that I can tell in my personal world. Patients appear oblivious. The story was not covered by our local newspaper. No physicians are nervously or otherwise discussing it in our doctor’s lounge.


Despite Meaningful Use criteria breathing down our organizations’s neck, which includes patient portals with the capability to obtain their records electronically, no one is talking about this important study: three healthcare systems, Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in  Pennsylvania, and Harborview Medical Center in Seattle participated. This included 105 doctors and more than 13,000 patients. When the study was finished 99% of patients surveyed wanted continued access to their notes and NO DOCTORS opted out. 

The last phrase is the most important one to me as a physician. In my world doctors are often very nervous at the thought of patients obtaining access to their own records even though technically the patient owns the record. Yet the more I see of charting, especially electronic charting, the more important it is that patients have the ability to access and help us improve their records. 

As an example, I recently had a new patient who related being involved in a motor vehicle accident many years ago. He’d had surgery shortly after but he wasn’t sure whether or not he’d had his spleen removed, though he knew it had ruptured. This is important because individuals who have no spleen are at increased risk of certain kinds of infections and need routine and regular followup vaccinations to protect them. The first thing I did was access records from an abdominal hernia surgery he’d had just a few years ago, to repair a hernia he had as a result of the first surgery. The operating doctor dictated in his note that the patient had had a splenectomy. I wasn’t convinced so I dug a little further and fortunately the hospital still had records of the first surgery (by law the hospital does not have to keep records from over twenty years ago). The patient did not have his spleen removed and thus needs neither recurrent vaccinations or  expensive imaging to figure out the answer. But what if I’d just taken the mistaken word of the second surgeon? How much better if the patient had been given easy access to his records years ago when he’d first wondered? 

Soon, patients will have access to their own charts and will be capable of giving much better histories or better yet, will have their medical stories in their own Personal Health Records. This can save a lot in time and unnecessary tests, not to mention improved accuracy in patient records. Because after all, who has more at stake in the accuracy of the record than the patient? Or as e-Patient Dave deBronkart says: 
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Communicating via Patient Portal

It’s Saturday night and I’m tying up loose ends, signing off patient referral letters, sending messages to staff to do on Monday and “playing” in the test environment of our EHR to try to better understand it. My husband is working a 12-hour shift at an immediate care clinic, my daughter is with a friend and the cats are not trying to get in my lap right at this moment. The house is quiet, with nothing but the soft swishing noise the dishwasher makes and for some reason, that always soothes me. Maybe because cleaning is happening without my active participation. It occurs to me that I haven’t checked RelayHealth.com, our patient portal, since early yesterday morning. 

RelayHealth.com

I log on and there are two messages. One from a patient that needs her atorvastatin refilled. I thought it had been done at the time of our visit yesterday but when she arrived at the pharmacy only her blood pressure pills were there. Apparently I neglected to check the drop down box in the prescription area of our EHR. In her case the default setting was “record” instead of “send to retail pharmacy” (it varies per patient for some mysterious reason) and I missed checking ONE of the three prescriptions correctly. This is a system problem that needs to be addressed but in the meantime my patients will sometimes get less than all of the multiple prescriptions they need refilled. The good news is that she figured out how to use the portal, sent me a message, I read it and immediately logged back into the EHR system and sent the prescription to the pharmacy. Then I messaged her back to say the prescription should be ready in the morning. COOL!

The second message is from a patient who has found data regarding the use of metformen and psychiatric disease. She is tech savvy and figured out how to scan and send me a PDF file of the published research. COOL! Now I’m learning from my patients even when I’m not in the office. I send her a message promising to read the article and get back to her and jokingly tell her that I hope all my patients aren’t as smart as she is or I’ll be inundated with reading material. Tomorrow I can respond to the article.

So far not a large number of my patients know about or have bothered to sign up for the portal but I’ve been very happy with the interactions I’ve had on it. Earlier in the year a woman had an illness that seemed to linger forever. I was running tests and talking to specialists and was certain that this would pass but it was frustrating for her. I think it helped both of us that she could communicate directly with me throughout the illness and may have saved her some trips to the ER or Immediate Care Center because she had direct contact with me on a nearly daily basis. In return it was a relief to me to know how she was doing.

Physicians often hesitate to give this kind of access to patients because they are afraid it will be abused but that is short-sighted. Just like with the telephone, I have complete control over whether I answer or my medical assistant does. This way it can be done at my convenience and, in general, I hate communicating by telephone. Most patient messages are quick and to the point. If they need to be seen, I tell them so. It’s a plus to patient care from my perspective and am pleased with the results. I hope my patients feel the same way. 

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