Viewing Patients as Partners: Patient Portal Implementation and Adoption

Patients First serves patients in 21 locations in six east central Missouri counties. Established in 1998, the practice has expanded rapidly in the past several years, growing from 45 providers (including mid-level providers) in 2007 to 111 providers in 2011. According to Dr. Robert Halsted, the Medical Director and Chief Medical Informatics Officer, implementing an electronic health record (EHR) system facilitated this rapid growth and has been an important factor in recruiting highly qualified providers.

Patients First implemented NextGen™ Practice Management in June 2007. In May 2008, the NextGen electronic health record (EHR) system was implemented as part of a strategic decision to improve quality of care and facilitate coordination of care across the growing number of clinical sites. Patient First proceeded with:

• A phased adoption approach, initially implementing basic documentation features and eRx with a few primary care physicians, followed by order entry for diagnostics and labs.
• After the early adopters were on a complete product, Patients First rolled out the NextGen EHR system to 12 specialties and fully converted all practices by spring 2011.

As the primary physician champion for the EHR system, Dr. Halsted teamed with Pam Pavely, the former Director of Health Information Technology (Health IT), to provide leadership and guide colleagues during implementation.

• Leadership by example was central to the successful adoption effort.
• Providers, medical assistants and front-office staff in each clinic received standardized training.
• Each clinic has a designated super-user who supports that clinic and is the point of dissemination for subsequent changes to the EHR system.

Patients First employs two health IT special specialists. Guided by a physician users group, the IT specialists optimize and customize (as needed) the functionality of the EHR system.

• For example, they created templates for different types of office visits, which include relevant patient education resources.
• Patients First has implemented several upgrades to the EHR system, including a major database upgrade to NextGen version 5.6 (certified version) in February 2011.

"We were practicing across multiple locations and many of us were lugging charts back and forth between offices, and we just decided it was time to bite the bullet… The key is, we made a commitment as an organization." (Robert Halstead, MD)

Patients First leadership views the patient portal as an important way to support “patients as partners.” The NextMD patient portal was rolled out in August 2010 and serves three core functions:

• Providing patients with an electronic clinical summary,
• Providing timely access to lab results, and
• Providing secure messaging with clinical and office staff.

• Physician Champions. To roll out NextMD, physician champions were identified to lead by example, standardized in-service training was provided to all employees, and clinic-based super-users supported their colleagues after portal launch.
• Training. The implementation team created a training video and also offered one-on-one, hands-on support as needed.
• Experience. As one of the region’s largest health care practices, many of Patients First’s employees are also in-network patients. Patients First leveraged this advantage by first rolling out the portal to staff that see Patients First providers.
• Marketing and Encourgement. A well-coordinated marketing effort announced the impending portal launch across a variety of media, including the Patients First website and newsletter, informational materials available in the clinics, announcements on a local radio station, and billboards and other signage. Staff were also provided with scripted messaging and wore “Ask me about NextMD” buttons. The practice held monthly competitions for the division enrolling the most patients.
• Bulk Enrollment. Another major component of the portal launch was a bulk enrollment. To achieve this, Patients First pulled e-mail addresses—which are obtained from patients routinely as part of clinic intake—for patients who were not already enrolled and uploaded them using the NextMD Bulk Enrollment Processor. A script was created to verify valid user names and enroll patients using a pair of e-mail messages; the first to welcome them to NextMD and the second to give them a temporary password and instructions on how to access the portal to create their unique password.

Provider

• Limited flexibility to customize their use of the portal (beyond set standard requirements)
• Rely mostly on secure messaging, whereas others use it on a more limited basis
• Surprised at how readily some elderly patients adapt to using the portal
• Noticed that proxy access for adult caregivers and spouses is widely used
• Needed to help patients and family members register for and use the portal through marketing the portal at each patient touch point

Patient

• Appreciate the ease with which their clinical summary can be shared with family members and the reduced burden associated with receiving lab results and obtaining medication refills
• Appreciate the dedicated help desk and assistance from the office staff. When needed, help desk staff can access the patient’s computer remotely to provide assistance

"Patients are thrilled about us e-mailing and putting their information, their clinical summary, and their blood work on the site." (Lorinna Shniter, MD)

"For the doctors who use [the portal] regularly, the patients love it, love it, love it. They don't have to call. Because it's hard to get through our [phone] system sometimes, they really like that a whole, whole lot." (Medical Assistant)

Out of 107 eligible Patients First providers, a total of 102 providers successfully attested for the MU Medicare incentive program by November 2011.

To understand the details of the MU requirements, Patients First consulted with Primaris, a partner to the Missouri Health Information Technology Assistance Center, the Regional Extension Center (REC). Patients First has also agreed to collaborate with the REC to provide technical assistance to other practices adopting NextGen.

Patient-Specific Education Resources

The NextGen version used by Patients First currently includes the McKesson patient education materials, but will soon transition to Healthwise® products. The Healthwise collection is available to patients directly through the patient portal as well as to providers for use during the consultation. UpToDate® educational materials are also available on the Patients First website.

Patients First created templates for specific visit types that include links to relevant patient education materials. The template for Medicare wellness visits, for example, includes educational materials about carbon monoxide poisoning smoking cessation, secondhand smoke, seat belts, firearm safety, radon testing, and smoke detectors.

"The number one educational piece of material that I give my patients is a copy of their clinical summary as they walk out the door. On that they have their complete med list with directions; medical problems we addressed that day, including my thoughts and what the plan is for them; their preventive health care s

Provide Clinical Summaries

Providers are encouraged to complete their documentation during the clinical encounter. The summary is delivered automatically to the patient portal and a notification is sent to the patient’s personal e-mail address to alert them that their summary is available for review. The summary is also provided to patients in hard-copy form at the time of the clinic visit. The summary includes the health assessment and care plan, a list of medications, and health maintenance information with due dates for tests and exams.

The clinical summary is particularly helpful for elderly patients and patients with multiple health conditions who have difficulty understanding or remembering the complexities of their care plan. The physician expressed that “the clinical summary is a huge, huge asset to the patient and the family” because it allows information to be shared accurately and efficiently. Providers feel that the clinical summary fosters patient engagement in health care, and helps patients understand what the provider is planning.

"I warn them, 'You're going to be getting a summary of today's office visit and when the labs come in we'll send them.' There is a learning curve for them and we try to remind them so they can access their information this way." (Peter Bettonville, MD)

"The clinical summary is a great educational tool. It is amazing how many patients are not taking their medications correctly, and the clinical summary helps them." (Dana Hellebusch, RN, FNP, CDE)

Access to Health Information

Currently, patients can access their lab results and clinical summaries on the patient portal. Notifications are sent to patients’ personal e-mail alerting them when results or summaries have been posted to the portal and instructing them to login to the system to access the materials.

Providers recognize that there is a learning curve as patients become accustomed to receiving information via the portal, so they give patients a heads-up that they will be sending information this way rather than calling. According to providers, once patients get used to this method of information exchange, most appreciate the convenience.

• In December 2011 more than 15,400 patients had enrolled in the patient portal. Patients can make requests for appointments, request medication refills, and ask medical questions via the portal.
• Between August 2010 (when the system was launched) and December 2011, the number of messages sent and received by providers has increased steadily to more than 7,000 and 6,000, respectively.

• The bulk enrollment process was effective (12,000 patients enrolled), however some patients were not aware they were enrolled because the enrollment message went to spam.
• Patients First has no way of knowing whether enrolled patients are actively using the portal and there are no read receipts to confirm that patients have read messages.

• Educating Patients. Educating patients about the portal requires a sustained effort on the part of providers as well as front-office and other staff. After promoting the portal at the initial launch, it is critical to reinforce the value of using the portal and to periodically undertake promotional efforts, especially when new portal features are rolled out.
• Culture Change. Providers need to adjust to completing their notes at the time of service and writing their notes in plain language because they will be read by patients, rather than relayed to patients by medical personnel. Also, providers and patients need to adjust to secure messaging as a new mode of communication.
• Allowing Flexibility Encourages Adoption. Providers have given input into the development of templates for different clinical situations and they are able to tailor the clinical summary according to their own preferences.

• Group Communication. This might include reaching all patients who are due for a specific screening or all patients using a specific medication or medical device to share critical information such as alerts or recalls.
• Prior Communication. To initiate communication with patients prior to the clinic visit and make the most of limited clinic time, Patients First plans to push out forms for patients to complete before their appointment to update demographics, provide family and social history, and review body systems.