Meeting the Needs of a Diverse Patient Population through Patient Portals

The Institute for Family Health is a Federally Qualified Health Center (FQHC) network that serves over 80,000 patients at its 26 practices in Manhattan, the Bronx, and the Mid-Hudson Valley in New York. They provide primary care services as well as behavioral health, dental, women’s health, and other specialty care.

As a mission-driven organization, the Institute provides care to many medically underserved and vulnerable populations, including the homeless, the uninsured and underinsured, people with HIV, and undocumented immigrants. They have developed specific programs to address health care needs in these communities, including education and support for people with HIV, a comprehensive diabetes program, school-based clinics, and clinics for the homeless.

As a recognized leader in health IT, the Institute was one of the first community health centers in the United States and the first freestanding health facility in New York State to adopt an electronic health record (EHR) in 2002. They also were an early adopter of a patient portal and mobile technology.

Neil Calman, MD, Cofounder, President, and CEO, is confident that if implemented correctly, patient portals, secure electronic messaging, and other e-health tools have enormous potential to increase patient and family engagement. Dr. Calman says that most patients, even the poorest and those with limited education, “are energized about getting involved” and just need the right tools.

The Institute was an early adopter of the patient portal, introducing the Epic MyChart, MyHealth in 2007 and the Spanish-language version, MiRecord, MiSalud, in 2011.

Developing Patient Portal Policies and Procedures

The Institute developed the following policies and procedures with input from providers, administrators, and patients:

• Using provider-centric messaging. Patients should be able to communicate directly with their providers, rather than messages being routed to a central staff member and triaged. Referral requests are an exception and these are routed to a trained pool of staff for more efficient processing.
• Set up alerts so providers can check if patients have opened messages. Outgoing message status flags enable providers to see if patients have opened messages within a specified period. If they haven’t, providers follow up by phone or mail.
• Rapid posting of lab and other test results. Test results are automatically released to patients within one day, except for HIV screening results. In this case, patients are notified that lab results are available via the portal, but they must speak with a provider to receive the results.
• Providing proxy access for family members or other caregivers. Proxy access is granted to family members and other caregivers using a release form. Adult patients can terminate a proxy’s access at any time via the website.
• Establishing a policy for adolescents. For minor patients starting at age 10, the health information accessible to parents or guardians with proxy access would be restricted. In cases where minor patients have complex medical issues, these patients can choose whether or not their parent or guardian(s) can have access to their entire health record. Providers review this decision with the patient annually.

Testing and Enhancement of MiRecord, MiSalud

To meet the needs of their large Spanish-speaking patient population, a Spanish-language portal was needed. The Institute reviewed the Epic product available at the time and determined that further user testing was needed. After conducting focus groups with patients, family members, and providers, enhancements were made to MiRecord, MiSalud, including improving the translation and adding visuals to help patients navigate the portal. Changes were made by collaborating with the vendor, and the current version of MiRecord, MiSalud reflects the user testing findings and recommendations.

“Telling patients they’re going to have that direct connection with the provider and they’re able to see their test results right away is usually persuasive enough. And to tell them that you eliminate that phone call and waiting on hold for 10 minutes and you’re able to schedule your own appointments; they love those features.” – Practice Manager

The Institute is committed to having as many patients as possible use the portal and takes a comprehensive approach to getting patients registered and supporting use. Activities to promote the portal include:

• Using signage, fliers, and other print materials. Throughout the Institute’s clinics, signs are posted in English and Spanish, including messages on waiting room electronic bulletin boards.
• Emphasizing a role for each staff member. Everyone—from the front-desk and telephone staff, medical assistants, and providers—actively encourages patients to use MyChart/MiRecord. Taking advantage of multiple opportunities—on the phone, in the waiting room, and in the exam room—staff encourage patients to use the portal. In the exam room, for example, medical assistants and nurses enroll patients or help with passwords or other issues Interns demonstrate MyChart/MiRecord in the waiting rooms and register patients.
• Stressing the benefits that matter most to patients. When providers and staff talk to patients about the portal, they emphasize the convenience and access, indicating for example that “It’s the best way to reach me” or “You won’t have to wait on the phone or leave messages” or “You’ll get your lab results quickly.” Password issues are also a frequent barrier for patient portal use. This was addressed by allowing patients to reset their own passwords either online or over the phone.
• Reminding providers and staff to encourage portal use. The EHR shows if patients have signed up and are active users of MyChart/MiRecord. This serves as a reminder for providers and staff to encourage patients to use the portal. Providers advise patients who are already registered to check for their lab results on the portal and to expect follow-up communication via messaging. To ensure patients receive important information, providers can set up alerts to notify them if a patient does not open a message or check a lab result within a specified period, in which case they follow up by phone or letter.
• Suggesting alternative ways to access the portal. For patients who do not have access to the Internet or are not comfortable using the patient portal, staff suggest options such as accessing the Internet at the public library or other locations or having a family member use the portal as a designated proxy. However, staff recognize that that the portal will not work for all patients. For these patients, providing the printed clinical summary is particularly important.

• Most reliable way to get in touch with some patients, such as those who do not have a stable address or phone number.
• Allows greater confidentiality for patients, avoiding the need for phone messages.
• Patients are more comfortable communicating about sensitive issues via secure messaging.

The Institute has found that many low-income patients have greater access to smartphones than computers. Currently, they are using text messaging to alert patients when there is new information available on the patient portal, for appointment reminders, and for general announcements such as changes to clinic hours. The patient portal, and mobile access in particular, has a number of benefits for the Institute’s patient population.

“By reviewing the clinical summary with the patient during the visit, there is an opportunity to see if the patient understands and if anything was missed. We use the after-visit summary not just as a random piece of paper you hand a patient, but as an engagement tool.” – Sarah Nosal, MD

To support mobile access for providers, the Institute implemented Epic’s Haiku alongside the rollout of MyChart. As a native iOS and Android smartphone application, Haiku enables providers to access their EHR on their personal devices. Some providers use the app to review and respond to messages between patient appointments; others said it is a convenient way to engage with patients after hours, away from work. Currently, providers can review patient information, lab results, and secure messaging. Updates are planned for 2013 to add more functionality for providers.

The Institute is committed to providing patients with a user-friendly clinical summary during the consultation because they view the summary as an important patient engagement tool.

Success with Clinical Summaries

Providers review the clinical summary during the office visit. To share the clinical summary during the office visit, providers finish their progress notes during the visit and print the clinical summary right in the exam room. Dr. Calman stresses the importance of finishing the progress notes during the visit and reviewing it with the patient: “I like to read it back to them and patients really appreciate that. You’re saying to them that you’ve heard them and that you’re trying to accurately reflect what they shared with you.”

Ruth Lesnewski, MD, stresses the importance of handing the clinical summary to patients personally (versus at checkout) as part of her “personal connection” with the patient. Dr. Calman also emphasizes the “symbolic importance” of handing the patient a clinical summary. By giving the patient their medical information, educational resources and instructions, providers are empowering patients to take the next step in their own health care. Another provider notes that his patients have become accustomed to receiving the clinical summary and won’t leave without it.

“There is a symbolic gesture of handing somebody the after-visit summary, and I try to make that explicit. At the end of the visit, handing them the summary is like saying, “what you do is in your hands now.” – Neil Calman, MD

But providers recognize that not all patients want to receive a printed copy of the clinical summary. For example, some of the younger patients prefer to access the clinical summary via MyChart/ MiRecord. Also, some teens and patients with sensitive health information—for example, concerning HIV status or mental health conditions—are concerned about confidentiality and opt not to take a printed clinical summary with them. However, even in these instances, providers review the clinical summary with the patient during the visit.

Common Clinical Summary Challenges and Solutions

Currently the Institute’s clinical summary is available only in English. But providers still give the clinical summary to Spanish-speaking patients because they can include Spanish-language educational resources and add notes and pictures to help with understanding medical information.

Because of challenges with medication reconciliation, the medication list is sometimes problematic, as it may include errors such as discontinued medications. The Institute is undertaking a new approach to address this challenge by involving nurses to have a greater focus on medication reconciliation.

Clinical Summaries: Challenges and Solutions

“An underpinning of the Institute’s approach to patient education is “the conviction that everybody is in need of becoming educated and empowered about their own health care decisions.” – Neil Calman, MD

Providers use the EHR as an educational tool. Exam rooms are configured so that patients and providers can sit together to view the computer.

This approach helps patients feel more comfortable with computers in the exam room and encourages their participation in building their EHRs. Providers can point out information and check for accuracy, use tracking tools (for example, A1c, blood pressure), share educational resources, and discuss any alerts (for example, for screenings or vaccinations). One provider says she explains to patients what she is writing and asks, “Do we have your story right?” This approach builds a patient-provider partnership.

• System for patient portals, EHR systems, or health IT systems to link to patient health information from MedlinePlus.gov
• Up-to-date content from reputable sources—the National Institutes of Health, other government agencies, professional associations, and others
• Information in English or Spanish, with links to content in more than 40 other languages
• Available at no cost

Using the MedlinePlus Connect Tool

The Institute was a key partner in the development of MedlinePlus Connect, a patient-education resource offered by the National Library of Medicine. Patients access educational resources via MyChart/ MiRecord by clicking on a diagnosis/problem and medications. Dr. Calman was eager to implement MedlinePlus Connect so that patients would have easy access to reputable health information to help them understand their health conditions and lab results. In his view, MedlinePlus Connect “democratizes health information,” making high-quality and usable information widely available to patients.

The Institute tracks use of MedlinePlus Connect and can analyze use of the tool and the topics searched.

The Institute looks forward to implementing additional portal features, including “MyConditions” and patient-generated data. The MyConditions feature will allow patients with specific conditions, such as diabetes, asthma or high blood pressure, to submit health data such as blood glucose levels and blood pressure, and track their condition. Patients will also be able to submit information about their health and health care—including allergies, medications, and immunizations—which providers would then reconcile with information in the record. There are also plans to expand the use of text messaging to support patient self-management. Throughout the process, the Institute will continue to work with provider champions and seek patient and family input.