Measuring the Impact of Patient Portals: What the Literature Tells Us

C A LIFORNIA HEALTHCARE FOUNDATION

Prepared for California He a l t h Ca r e Fo u n d a t i o n by Seth Emont, Ph.D., M.S.

May 2011 About the Author Seth Emont, Ph.D., M.S., is the principal of White Mountain Research Associates, L.L.C. He has provided ongoing program and evaluation technical assistance for a number of national and statewide initiatives, including research and evaluation of clinical care delivery and quality improvement, pediatric asthma management, diabetes management, self-management support, patient- and family-centered care, childhood obesity, end-of-life care, tobacco and substance use, and eHealth.

About the Foundation The California HealthCare Foundation works as a catalyst to fulfill the promise of better health care for all Californians. We support ideas and innovations that improve quality, increase efficiency, and lower the costs of care. For more information, visit us online at www.chcf.org.

2 I. Introduction

3 II. Background — EHR and Patient Portal Adoption Benefits of Portals and EHRs Barriers and Incentives

5 III. Research on Patient-Level Measures Volume and Demographics of Users Opinions and Concerns of Users Patients with Chronic Illness Focus on Young People

10 IV. Research Linking Portals with Clinical Outcomes and Operational Efficiency Phone Volume and Web Messaging Availability Impact on Types of Patient Contacts Patient-Physician Messaging and Visit/Phone Rates Patient-Physician Messaging and Chronic Care Patient-Physician Messaging and Provider Productivity Cost-Savings Estimates

13 V. Conclusions

14 Appendix: Summary of Study Findings

17 Endnotes I. Introduction

Pa t i e n t p o r t a l s c a n o f f e r i m p o r t a n t benefits to patients and provider organizations. These Definitions technologies — particularly when integrated with an The terms electronic health record, personal health record, and patient portal can be generally defined as electronic health record (EHR) — have the potential follows: to improve both quality and access to care through Electronic Health Record (EHR). An EHR is features that enable patients to: communicate generated by a health care provider to document electronically and securely with their provider; access patients’ medical and health information on a their medical records; schedule appointments; pay continuing basis. It may contain demographic data, bills; and refill prescriptions. By providing these tools progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, as well as easy access to online resources, portals have and radiology reports. The EHR can support clinical the potential to benefit providers by increasing care activities including evidence-based decision support, efficiency, improving the management of chronic quality management, and outcomes reporting. It can illness, and actively engaging patients and families in automate and streamline the clinician’s workflow. An EHR is not directly accessed by patients, although care. certain data may be made available through a patient This report examines published peer-reviewed portal. studies and other research documenting the Personal Health Record (PHR). A PHR is owned and implementation of patient portals and their impact controlled by the individual patient (or proxy), and may on health care delivery. It is intended to inform the have information that is not contained in a medical work of health care providers — particularly safety- record. It is used for managing health information, net organizations — as they plan and implement promoting health maintenance, and assisting with chronic disease management. Common e-health patient portals and develop measurement strategies tools focus on health information, behavior change/ for assessing their impact on patient care. The prevention, and self-management.

paper is part of a larger CHCF initiative to engage Patient Portal. A patient portal is a secure Web site early-adopter safety-net clinics in planning, through which patients can access a PHR and often implementation, and evaluation of patient portals certain information from an EHR. Portals typically to improve patient and family engagement, clinical enable users to complete forms online, communicate with their providers, request prescription refills, 1 outcomes, and operational efficiency. pay bills, review lab results, or schedule medical appointments. These tools can benefit patients and providers by enhancing patient access and increasing administrative efficiency and productivity.

2 | California He a l t h Ca r e Fo u n d a t i o n II. Background — EHR and Patient Portal Adoption

Benefits of Portals and EHRs Barriers and Incentives The use of health information technologies and Despite the potential advantages to patients and online resources has great potential to boost care providers, adoption of portals and EHRs has been quality by improving care access, efficiency, chronic slow in California, due to several of barriers to disease management, and patient and family implementation. In addition to concern about involvement.2 To facilitate access to online resources, cost, providers worry about the potential for added a number of health care organizations have created work, lack of reimbursement, inappropriate use, and patient portals. When integrated with an EHR liability issues, among others.5 Research published and other electronic health information, portals in 2006 suggested that patient portals tended to be can offer features that enhance patient-provider used more by affluent, younger, white, and healthier communication and enable patients to schedule patients.6 appointments, pay bills, refill prescriptions, and By 2008, EHR adoption among safety-net access lab results. A recent survey found that people providers was reported at less than 4 percent in pay more attention and become more engaged in California7 and less than 10 percent nationwide.8 The their health and medical care when they have easy biggest barriers were purchasing and implementation access to their health information online—and that expenses.9 Other obstacles included resistance to this is especially true for those with lower incomes.3 change in practice style, staff retraining needs, lack Patient access to a portal also can result in of internal expertise, fear of product failure, and lack longer-term payoffs, such as greater administrative of evidence on return on investment.10 efficiencies (e.g., reduced call volume) and improved However, it is likely that adoption of patient responsiveness to patients’ needs.4 Although patient portals will grow, particularly since a number of the portals have the potential for these longer-term meaningful use criteria for Stage 1 established by the payoffs, there are only a handful of peer-reviewed Centers for Medicare and Medicaid Services focus on publications and other reports that have formally patient engagement, with higher patient engagement documented their impact. This is especially true thresholds anticipated for Stages 2 and 3.11 for the safety-net population, where adoption of Also, growing interest in patient-centered care the patient portal by community clinics and health nationwide is leading some providers to embrace centers is very low. However, there are anecdotal the idea of “patient-centered health information reports, stories, and case studies from which to draw technology.”12 Promising models such as the “patient- lessons about measurement and the impact of patient centered medical home” include health information portals on quality and efficiency. Federally funded technology and analytic tools.13 – 15 Further, there projects are in progress to document measures used has been a proliferation of new products and in these studies. technologies that foster health care consumerism, including telemedicine, clinical decision support, EHRs, and health intelligence.16 Research shows

Measuring the Impact of Patient Portals: What the Literature Tells Us | 3 that a majority of consumers (72 percent) would use a tool to help them pay their medical bills, communicate with doctors, make appointments, and obtain lab results online.17 In addition, a major federal incentive program seeks to reward providers with bonuses if they can demonstrate that they are making “meaningful use” of EHRs.18 The Health Information Technology for Economic and Clinical Health Act (HITECH) provisions were designed to improve the quality and coordination of health care through the meaningful use of EHRs. Moving the health care infrastructure to an electronic framework holds promise in improving clinical decisionmaking, documentation, and patient safety, and ultimately administrative efficiency, improved access, and better patient outcomes.19 – 21 While it is expected that HITECH will transform the way information is exchanged, the framework faces a number of challenges in widespread adoption of EHRs even with the availability of incentive payments by Medicare and Medicaid.22 To help speed the adoption of EHRs in California, the California Network for Electronic Health Record Adoption (CNEA) initiative was launched in 2006 by three health care foundations. The CNEA strategy included the development of centralized support hubs that provided clinics with EHR technology, technical expertise, vendor management, and other services.23

4 | California He a l t h Ca r e Fo u n d a t i o n III. Research on Patient-Level Measures

Tw o t y p e s o f m e a s u r e s a r e h e l p f u l in Volume and Demographics of Users assessing an EHR-integrated patient portal. Short- ◾◾ myGeisinger. Geisinger Health System, an term, patient-level measures can help clinicians integrated health system and health plan located document how successful they are at implementing in Danville, Pennsylvania, launched a patient a patient portal, while long-term measures help portal, myGeisinger, in 2002. About 25 percent document the impact on clinical outcomes and of the system’s primary care patients are registered operational efficiency. A summary of the literature with the portal, with an expansion of about 2,000 addressing these two types of measures is presented patients per month. Most users fall into three below and summarized in the Appendix. groups — young parents, family members caring Given the paucity of research on the impact for elderly parents, and patients with chronic of patient portals on health care utilization, peer- illnesses.24 reviewed studies and unpublished reports most ◾◾ KP HealthConnect Online. Kaiser Permanente, commonly document characteristics of portal users an integrated delivery system with 8.5 million and overall uptake (i.e., portal usage) by patients. members, launched KP HealthConnect ™ Online Many of the studies and reports looked at frequency in 2002 for members of its Northwest region. In of use of patient portal features. This measure is 2005, Kaiser reported that 6 percent of its adult important in improving the usability of portals population in the region were registered users of through user feedback, and also it can be linked with its integrated EHR. By 2009, about 25 percent clinical data to document longer-term changes in were registered.25 A tripling of registrations patient behavior, clinical outcomes, utilization, and between 2005 and 2008 coincided with improved operational efficiency. health record functionality, including availability In the majority of studies reviewed, the most of online test results and secure emails to frequently used patient portal features were similar providers.26 The online users were significantly across studies, patient populations, and type of health more likely to be older and have diabetes, care delivery system. In general, the most frequently compared to the general adult membership.27 accessed portal features for regular users include viewing laboratory results, scheduling appointments, Kaiser has been collecting user data on its secure messaging with providers, and prescription member population since 2004.28 By 2007, the refills. system documented more than 90,000 visits per A literature search uncovered the examples that day to its member Web site. Between 2004 and are described below. They are arranged by area of 2007, the three most-visited features were review special focus, although there is considerable overlap of laboratory tests, prescription refills, and email in groupings. messages to providers.29 Kaiser also documented the leading reasons for patients to email their physicians: discussion of a change in health

Measuring the Impact of Patient Portals: What the Literature Tells Us | 5 condition, laboratory results, new condition, Although the health care systems described above prescription dose, or the need for a new have been successful in recruiting users to their prescription. Sixty-three percent of the patient- patient portals, other studies have reported slow initiated emails required clinical assessments or uptake. decisions, and 24 percent required clinical actions ◾◾ HealthSpace. Using Kaiser’s experiences as (such as a laboratory test).30 a model, the British National Health Service Kaiser’s patient portal and personal health record, launched HealthSpace in 2007, an Internet-based My Health Manager, is used by more than personal electronic health record.36 Users are able 3 million members.31 Silvestre et al.32 reported to sign up for a basic account to enter values or that members who use the Web site are more record appointments on a calendar; through an likely to be female (60 percent) and between the advanced account, they can gain access to their ages of 40 and 60 (although the age range of site summary care record, schedule appointments, or users is 13 to 95 years). A survey of registered exchange secure emails with their provider. users also found that half of the survey sample However, by October 2010, only 0.13 percent reported household annual incomes of less than of individuals invited to open up an advanced $75,000, and almost half had not completed HealthSpace account had actually activated a college degree. The percentage of registered their account. The authors reported that low users who accessed the site two or more times uptake was due, in part, to limited interest by in a six-month period more than doubled from patients and a cumbersome and bureaucratic 28 percent in 2005 to 62 percent in 2007. registration process. The original business plan anticipated that about 10 percent of the patient ◾◾ My HealtheVet. The U.S. Department of population would register for an advanced Veterans Affairs offers an online personal health HealthSpace account. The authors noted that the record to veterans, active duty soldiers, and their software is being upgraded with improvements in dependents and caregivers. Users of MHV have functionality. access to health care information and services, including access to personal health journals, ◾◾ PatientSite. Weingart et al.37 reported on users of vitals tracking, activity and food journals, and the PatientSite Web portal, which was introduced medication refills.33 There are three levels of in 2000 at a Boston teaching hospital and MHV access with increasing functionality with affiliated community practices. Over a four-year each level.34 In addition, MHV uses veteran period, more than 18,000 patients enrolled in feedback to guide improvements with the portal the portal and logged on at least once. PatientSite and add-on features. As of March 2010, it was enrollees were more likely than non-enrollees reported that MHV received over 38 million to be White and less likely to have Medicare or visits with over 976,000 registered users, Medicaid insurance. Enrollees also tended to be 75 percent of whom are VA patients.35 healthier; they had fewer prescriptions, medical problems, office visits, and hospitalizations than non-enrollees.

6 | California He a l t h Ca r e Fo u n d a t i o n Opinions and Concerns of Users Patient-provider interaction was one of the Some quantitative and qualitative research went focuses of a pilot study of My Wellness Portal beyond demographic assessments to look at which conducted through the Oklahoma Physicians online features are popular and what user concerns Resource/Research Network.42 While the majority of are. Following are examples. patients found the portal to be a valuable resource, In a small pilot study of Medicaid beneficiaries only 60 percent believed it improved patient-provider in North Carolina, individuals were very concerned interactions. On the other hand, Tang and Lansky 43 about having their personal health information reported that users of PAMFOnline, a personal available online, and estimated that their actual use health record available to patients of the Palo Alto would be just a few times a year. The research also Medical Foundation (PAMF), felt more connected found that these beneficiaries were most interested in to their providers than non-users did. PAMF accessing portal services related to prescription refills, launched its personal health record in 2002, and scheduling appointments, and communicating with it provides patients with access to medical records, their provider, which is consistent with most other appointments, prescription refills, and secure emails studies.38 In contrast to other reports, the sample with their providers. Over 90 percent of patients and of Medicaid beneficiaries was least interested in physicians are satisfied with PAMFOnline. laboratory test results. These results contrast somewhat with research Patients with Chronic Illness on the Institute for Family Health’s HRSA- A small number of studies have documented the funded patient portal, MyChart-MyHealth. use of patient portals for individuals with chronic The Institute provides services to about 72,000 illnesses, particularly diabetes. Health information patients in Manhattan, the Bronx, and mid- technology with real-time interactions can enhance Hudson Valley — including 13 percent uninsured the effects of chronic disease management, and 44 percent publicly insured patients. Focus particularly when used in conjunction with behavior group findings indicated that patients were not change programs.44 as concerned about privacy and confidentiality An interesting qualitative study by Zickmund as anticipated. Further, the research found that et al.,45 documented the impact of the patient- participants were concerned that the patient portal provider relationship on use of a patient portal. The might actually hinder communication with their researchers conducted ten focus groups with patients providers, which is consistent with the findings with diabetes to better understand the link between from other studies described below.39 The portal the patient-provider relationship and use of the had 1,100 patients signed-up as of February 2009. University of Pittsburgh Medical Center’s (UPMC) The most frequently used features were: viewing test HealthTrak, a portal that includes online tracking of results, secure email messaging, prescription refills, patient-entered glucose, blood pressure, and physical and problem and medication list viewing.40 Rockoff activity. The portal was offered to patients from two reported that as of December 2010, 16,366 access internal medicine and two family medicine practices codes were generated for MyChart-MyHealth and in the greater Pittsburgh area. 59 percent were “users” (i.e., the portal was used Two themes emerged from the UPMC research. more than once after initial activation).41 First, interest in portal use appeared to be linked to

Measuring the Impact of Patient Portals: What the Literature Tells Us | 7 dissatisfaction with the patient-provider relationship; patients to view lab results, obtain prescription and, second, disinterest in portal use appeared to refills, view their medical problems, and update be linked to satisfaction with the relationship. The health information. The program emphasizes self- findings underscore the importance of maintaining management support, so that patients can take the patient-provider relationship even when (or action to manage their own health. Patients without especially when) health information technologies are computers can get access in the clinic waiting room. introduced to improve medical care. As described by In addition, because many of the patients were the researchers, “some participants in our study were homeless at the time the report was published in worried that the use of the portal would gradually 2009, plans were being made for a mobile platform erode their ability to communicate with their health for patients.48 care team. The suspicion of the portal supports Ross et al.,49 conducted a randomized trial to the relative importance participants place on the determine characteristics of patients using Diabetes- traditional patient-provider relationship….” STAR and whether personalized content facilitated A qualitative study of the UPMC patient portal sustained use of the patient portal. While the initial was conducted by Hess and colleagues 46 to obtain log-on to the patient portal was the same between the feedback from patients with diabetes on portal intervention group and the control group, patients features that would be of value to them. Top features exposed to the personalized portal used the portal identified by patients included a log for tracking for twice as many days as the control group. The blood glucose levels and a calculator to estimate authors concluded that interactive content resulted in average glucose control. When asked to estimate a sustained use. dollar value for monthly access to the portal, nine of 17 patients gave a value of zero. The investigators Focus on Young People reported that although users saw positive value A few studies and reports have documented the in the portal, they were not supportive in paying use of patient portals by adolescent populations. to maintain the costs of the portal. However, Bourgeois et al.,50 reported on the implementation of Adler noted that in a survey of patients in his own MyChildren’s, a provider-tethered portal that allows practice, patients were willing to pay a small annual patients and their guardians access to a personal subscription for access to a patient portal: 60 percent health record. Features of the portal include access to of Internet-using patients were willing to pay $10 or patient health information, secure messaging, billing, more per year and about one-third of patients were and scheduling appointments. The information willing to pay $50 or more each year. In addition, the released to the “personally controlled health record” three services of most interest to patients included reverts to the control of the patient or guardian to Web messaging with their provider, access to their ensure transparency of the health information. In medical record, and prescription refills.47 addition, patients or their guardians may choose The Healthcare Evaluation Record Organizer to hide selected problems, medications, or results, (HERO) is a Web-based EHR used by the San making them invisible to any other user of the PHR. Francisco General Hospital HIV/AIDS Program’s MyChildren’s was launched hospitalwide in 2009 Ward 86 clinic. HERO is integrated with myHERO, at Children’s Hospital Boston with over 900 active which is a personal health record that enables accounts within three months of full launch. The

8 | California He a l t h Ca r e Fo u n d a t i o n mean patient age was nine years. The most frequently accessed features included lab results and summary forms. Bergman et al.,51 conducted a qualitative study using a series of focus groups of teens and parents to better understand their attitudes toward use of a patient portal. Patient portals may enhance communications between providers and adolescents, particularly for services that require confidentiality between the teen and provider. Focus group participants were patients of primary care providers at the Palo Alto Medical Foundation. In general, while both parents and adolescents were enthusiastic about using the portal, teens and parents had conflicting feelings about what should be shared with parents and what should remain confidential. Teens were more comfortable in scheduling appointments or communicating with their providers through email as opposed to talking in person. In addition, while some parents wanted to know exactly what services they were being billed for, teens felt strongly that their parents should only see general billing information without detailed charges for more sensitive services. The authors concluded that the patient portal can enhance communications between teens and their parents, and that negotiation about confidentiality issues would be the best solution.

Measuring the Impact of Patient Portals: What the Literature Tells Us | 9 IV. Research Linking Portals with Clinical Outcomes and Operational Efficiency

Be c a u s e t h e p a t i e n t p o r t a l is a r e l at i v e ly patients per workday) and fell over six times faster. recent technology, studies evaluating portals’ impact Case message (i.e., phone plus Web messages) volume have only recently emerged in the literature, and averaged 13.7 percent less than that of the control studies on the cost-effectiveness have not yet been clinic (i.e., phone only) (22.8 versus 26.4 total published. However, some limited information is messages per 1,000 panel patients per workday) and available. fell nearly six times faster. The investigators suggested Research linking patient portal use to clinical that with the decline in total message volume, Web outcomes and operational efficiency is summarized messaging may have enhanced the efficiency of non- below. Most of these studies were conducted through visit care. integrated health care delivery systems — particularly systems with mature, integrated EHRs. However, Impact on Types of Patient Contacts it is not possible to disentangle the contributions Chen et al.,53 conducted a retrospective study using of EHRs and patient portals on health care 2004 – 2007 administrative data from the Kaiser utilization — although there may not be any practical Permanente Hawaii region, the first region to fully reason to do this given the feature-rich services implement KP HealthConnect ™ in the outpatient offered through bundling these complementary setting. The purpose of the study was to document HITs. the impact of the portal on outpatient, urgent care, and emergency department visits, referrals, telephone Phone Volume and Web Messaging visits, and patient-physician email messaging. Availability The researchers found that per member age- and Liederman et al.,52 conducted a study using one sex-adjusted office visits decreased 26 percent and primary care practice as the case study site and one as per member scheduled telephone visits increased a control site from the Sacramento, California region almost nine-fold over the study period. Secure (part of the University of California Davis Health online patient-physician messaging increased System’s primary care network). The case clinic’s significantly between 2005 and 2007 (an increase of telephone and total incoming message volume were 0.03 messages/member to 0.23 messages/member). compared to that of the control site using data from The total number of patient contacts (i.e., office November 2001 to November 2002. The hypothesis visits, telephone visits, emails) increased 8.3 percent was that incoming patient message volume would not following EHR implementation. A majority differ between sites using and not using patient Web of trends in Healthcare Effectiveness Data and messaging, and phone call volume would decrease at Information Set (HEDIS) scores for nine measures the site using Web messaging. of Kaiser’s commercial and Medicare populations The investigators documented that the case call were “favorable” over the course of the study period. volume averaged 18.2 percent less than that of the In addition, Kaiser member satisfaction ratings of control clinic (21.6 versus 26.4 calls per 1,000 panel overall visit satisfaction, level of interest and attention

10 | California He a l t h Ca r e Fo u n d a t i o n of their health care providers, and satisfaction with focused on these two chronic conditions because of telephone visits, remained unchanged over the study their high prevalence and high costs of care. period. Using regression analysis, the investigators determined that the use of secure patient-physician Patient-Physician Messaging and email was significantly associated with improved Visit/Phone Rates performance for all HEDIS measures. The In a study conducted in Kaiser’s Northwest region, proportion of patients whose measures improved Zhou and colleagues 54 documented the impact ranged from 4 percent to about 11 percent. of secure patient-physician messaging on primary Although the study did not determine how the use care office visit and telephone contact rates. The of patient-physician emailing might improve care, researchers used a retrospective cohort study and the researchers suggested three possible mechanisms: matched case-control study of continuously enrolled increased continuity of care, better patient-physician Kaiser members who used HealthConnect ™ for connectedness, and a greater focus on self- 13 months or longer and had accessed at least one management supports. feature. Pre/post analysis indicated a decrease in annual Patient-Physician Messaging and office visit rates of 9.7 percent visits per member Provider Productivity in the cohort study and a 6.7 percent net decrease In a study by Liederman, et al.,56 the investigators between users and controls of the matched-control compared the productivity of internal medicine and study. Also, the analysis indicated a 13.7 percent net family practice physicians in the case and control increase in annual documented telephone contact sites previously described. Intervention physicians rates between users and controls in the matched- averaged about 11 percent more visits per day control study. The investigators concluded that compared to the control group (i.e., 25 versus 23 electronic messaging “may provide a win-win-win visits per day). In addition, intervention physicians solution to pervasive efficiency and access issues from averaged about 10 percent more Relative Value Units the perspectives of patient, health care provider, and per day than controls (50 versus 45 RVUs per day). payer.” This translated into about $95 more per physician per day in the case site compared to the control site. Patient-Physician Messaging and The investigators concluded that email messaging Chronic Care improves provider productivity by freeing up time A comprehensive study conducted by Kaiser for additional patient visits and it increases patients’ documented significant improvements in care and access to care. operational efficiency among patients who use secure patient-physician messaging. Zhou et al.,55 studied Cost-Savings Estimates more than 35,000 Kaiser patients in Southern Gardner,57 in a March 2010 Health Data California with hypertension, diabetes, or both Management Magazine article, reported that some and documented an association between secure health care providers had savings of $0.63 for patient-physician emailing and more effective care, mailing costs for lab results, $17 for online billing as measured by HEDIS scores. The investigators questions (versus the telephone), and $7 for each

Measuring the Impact of Patient Portals: What the Literature Tells Us | 11 appointment scheduled online. Similarly, in a report from a presentation at the 2010 Northwest Medical Informatics Symposium,58 the secure messaging feature of the electronic medical record/patient portal could result in savings of $0.62 per appointment reminder, $1.75 per phone call to patients, and $2.69 for each lab result delivery. The figures “are based on industry averages for number of communications and typical office costs” according to the presenter, although references for these figures were unavailable. It is likely that more studies on return on investment will become available in the near future, since they represent natural follow-up studies to the more comprehensive investigations that have already documented operational efficiencies resulting from using patient portals in combination with EHRs.

12 | California He a l t h Ca r e Fo u n d a t i o n V. Conclusions

Pa t i e n t -l e v e l m e a s u r e s c o m m o n l y use and care), clinical outcomes, and operational documented by published studies and reports focus efficiency. on general use statistics of patient portals (mostly A number of external factors will likely accelerate use of portal features), patient demographics (with uptake and more widespread use of measurement possible comparisons between portal users and non- strategies that incorporate impact assessment. users), patient engagement, and overall satisfaction They include: (1) the need to meet meaningful use with the portal. Most of these measures have been requirements; (2) a greater focus on patient- and used to improve the functionality and reach of family-centered care; and (3) increased patient patient portals. Importantly, they have been used demand for health information technology. All of across different types of health care delivery systems these factors point to the importance of seeking and with different patient populations, including regular feedback from patients on portal features as a patients with chronic illnesses and medically mechanism to improve and expand capabilities and underserved populations. increase overall access. A limited number of studies bridge the gap between patient-level measures and long-term outcome measures, including health care quality indicators and operational efficiency. There is scant research on cost-savings resulting from the implementation of patient portals. However, with patient-level measures in place — and with appropriate integration with an EHR and links to other sources of administrative data — it will be possible for many clinics that adopt patient portals to eventually link this information to long-term health outcomes, operational efficiency measures, and cost- effectiveness. Portals offer a number of potential benefits to providers, including administrative efficiencies (e.g., reduced call volume), improved responsiveness to patients’ needs, decreased utilization of health services, more effective care, and cost savings. To be successful, they should be assessed using measures that span across improvements in patient and family engagement (e.g., overall use and satisfaction with

Measuring the Impact of Patient Portals: What the Literature Tells Us | 13 Appendix: Summary of Study Findings

Type of Health Domain Care System Portal and Functions Measures Reported/Findings† Patient Level Measures

Bergman, Portal usability; Multispecialty PAMFOnline (Epic Systems): Focus groups of teens and parents et al. adolescent group practice Secure messaging, view PHR, indicated that: teens were concerned (2008) population; health information resources, about confidentiality while parents provider-patient appointments, lab results, felt they would be ‘out of the loop’; relationship prescriptions, billing also, the portal could improve communications with providers

Bourgeois, Portal usability; Pediatric tertiary MyChildren’s (Indivo open source PCHR, Trends in use; portal features used; et al. pediatric and care center Children’s Hospital Boston): feedback survey to evaluate user (2009) adolescent PHR, secure messaging, satisfaction, ease of use, and impact population appointments, billing, information on access to and communication of sharing health information

Chou, et al. Provider-patient Primary care My Wellness Portal (University of Portal features used; only 60 percent (2010)* relationship practices Oklahoma Health Sciences Center): of field test participants believed it Secure messaging, lab results, improved patient-provider interactions preventive services, risk factors, symptoms tracking, health education, health tracking, appointment tracking, update PHR, symptom diary

Gardner Characteristics Integrated myGeisinger (Epic Systems): Trends in enrollment; portal features (2010) of portal users PHR, lab results, billing, health and used; 3 clusters of users: young fitness data, prescription renewal, parents; family members caring for appointments, secure messaging elderly parents; patients with chronic illnesses

Kanaan Portal usability; Primary care clinic; Healthcare Evaluation Record Periodic feedback from patients on (2009) disease outpatient primary Organizer (HERO)/MyHERO (UCSF): key features; portal features used management and specialty HIV/ PHR, prescriptions, lab results, AIDS care health information resources

Rockoff Portal usability Primary care MyChart-MyHealth (Epic Systems): Trends in enrollment; portal features (2010) centers Secure messaging, appointments, used; focus groups indicated patients billing, health education, were not as concerned about privacy administrative requests, and confidentiality as anticipated, but prescriptions, problem lists, concerned that portal might actually medication lists, lab results hinder communication with providers

Ross, et al. Portal usability; Primary care clinics Diabetes-STAR: Trends in use; portal features used; (2006) disease Personalized diabetes personalized and interactive content management self-management information; goal resulted in more sustained use setting; lab results; clinical notes compared with generic content

*Pilot study. †Studies that report on portal features used are noted, although specific features are not reported for each of these studies. In general, the most frequently used patient portal features are similar across studies, patient populations, and type of health care delivery system. The most frequently accessed portal features for regular users include viewing laboratory results, scheduling appointments, secure messaging with providers, and prescription refills.

14 | California He a l t h Ca r e Fo u n d a t i o n Type of Health Domain Care System Portal and Functions Measures Reported/Findings†

Patient Level Measures, continued

Silvestre, Characteristics Integrated KP HealthConnect™ Online (Epic Trends in enrollment; portal features et al. of portal users Systems) and My Health Manager used; 60% female; mean age: 48; age (2009) (PHR): range: 13 to 95; based on Web survey, View medical record, lab results, half of sample reported annual income secure messaging, medications, of <$75K and nearly half without visit reminders, appointments, college degree prescriptions, proxy access, health education, account management

Tang and Provider-patient Multispecialty PAMFOnline (Epic Systems): Portal features used; qualitative Lansky relationship group practice Secure messaging, view PHR, feedback from a patient survey (2005) health information resources, indicated that users felt like a team appointments, lab results, member in their own care and more prescriptions connected to their providers

Weingart, Characteristics Hospital-based PatientSite (developed by Beth Israel Trends in enrollment; portal features et al. (2006)* of portal users primary care Deaconess Medical Center): used; compared to non-enrollees, practices Secure messaging, appointments, PatientSite enrollees more likely to be referrals, view PHR and add white, younger, healthier, less likely to comments, administrative requests, have Medicaid or Medicare insurance prescriptions, lab results

Zhou, et al. Characteristics Integrated KP HealthConnect™ Online Trends in enrollment; portal features (2007) of portal users (Epic Systems): used; older patients; members with PHR, administrative requests, diabetes appointments, after-visit summary, secure messaging

Zickmund, Provider-patient Primary care HealthTrak (University of Pittsburgh Focus groups indicated that interest et al. (2007); relationship practices Medical Center): in portal use appeared to be linked also see Secure messaging, online to dissatisfaction with the patient- Hess, et al. information, lab results, diabetes provider relationship; and disinterest (2006) self-management in portal use appeared to be linked to satisfaction with the relationship

Clinical Outcomes and Operational Efficiency

Chen, et al. Administrative Integrated KP HealthConnect™ Online Retrospective study using (2009) efficiency (Epic Systems): administrative data, 2004 – 2007: ➡ PHR, secure messaging • Office visits: 26%

• Telephone visits: ➡ 9-fold

• Online messaging: ➡ 0.03 to 0.23 (messages/member)

Measuring the Impact of Patient Portals: What the Literature Tells Us | 15 Type of Health Domain Care System Portal and Functions Measures Reported/Findings†

Clinical Outcomes and Operational Efficiency, continued

Liederman, Administrative UC-Davis Primary University of California Davis Trends in patients enrolled; telephone et al. efficiency Care Network Health System web messaging and message volume and types (2005) system (RelayHealth Corp.): Retrospective case-control study: Prescription refills, appointments, • Case call volume: 22 vs. 26 (case vs. test results control clinic calls / 1,000 patients / workday)

• Case message volume (web and call): ➡ averaged 14% in case clinic and ➡ six times faster than control clinic • Conclusion: Web messaging may have enhanced efficiency of non-visit care

Liederman, Administrative UC-Davis Primary University of California Davis Case-control study et al. efficiency; Care Network Health System web messaging (i.e., Web messaging vs. not) (2005) physician system (RelayHealth Corp.): Compared productivity of physicians: productivity Prescription refills, appointments, • Visits/day: 25 vs. 23 test results (case vs. control clinic)

• RVUs/day: 50 vs. 45 (case vs. control clinic)

• Net ➡ $95/physician/day (case clinic)

Zhou, et al. Administrative Integrated KP HealthConnect™ Online Retrospective cohort and matched (2007) efficiency (Epic Systems): case-control study: ➡ View medical record, lab results, • Annual office visit rates: 9.7% ➡ secure messaging, medications, visits/member in cohort; 6.7% net visit reminders, appointments, between users and controls prescriptions, proxy access, health • Annual telephone contacts between education, account management

users and controls: 13.7% net ➡

Zhou, et al. Quality of Integrated KP HealthConnect™ Online Retrospective longitudinal and (2010) care; disease (Epic Systems): observational study: management View medical record, lab results, • 35,000 patients with diabetes, secure messaging, medications, hypertension, or both visit reminders, appointments, • Use of secure patient-physician prescriptions, proxy access, health email was associated with improved education, account management performance on HEDIS measures • Proportion of patients whose HEDIS measures improved ranged from 4 to 11 percent • Email messaging may have improved care through increased continuity of care, better physician- patient connectedness, or a greater focus on self-management supports

16 | California He a l t h Ca r e Fo u n d a t i o n Endnotes

1. “Patient Portals in the Safety Net – Implementation 12. Seidman, J., and T. Eytan. “Helping Patients Plug In: Planning.” California HealthCare Foundation. December Lessons in the Adoption of Online Consumer Tools.” 2010 (internal document). California HealthCare Foundation. Oakland, CA: June 2008. 2. Kanaan, S.B. “Safety Net Providers Bring Patients Online: Lessons from Early Adopters.” California 13. American Academy of Family Physicians, American HealthCare Foundation. Oakland, CA: April 2009 Academy of Pediatrics, American College of Physicians, (www.chcf.org). American Osteopathic Association. “Joint Principles of the Patient-Centered Medical Home.” February 2007 3. California HealthCare Foundation-funded survey by Lake (www.pcpcc.net). Research Partners, “Consumers and Health Information Technology: A National Survey” (www.chcf.org). 14. “Patient-Centered Medical Homes,” Health Affairs, September 14, 2010 (www.healthaffairs.org). 4. Wunder, S.S. “Pursuing the Promise of Patient Portals.” Healthcare Financial Management Association. May 15. Bates, D.W., and A. Bitton. 2010. “The Future of Health 2009 (www.hfma.org). Information Technology in the Patient-Centered Medical Home.” Health Affairs 29(4); 614 – 621. 5. Zaroukian, M.H. “Patient Web Portals, Clinical Messaging, and E-visits.” HIMSS Enterprise Integration 16. Cohen, S.B., K.D. Grote, W.E. Pietraszek, and F. Task Force Conference Call/Meeting. June 12, 2008 Laflamme. 2010. “Increasing Consumerism in Healthcare (www.himss.org). Through Intelligent Information Technology.” The American Journal of Managed Care 16; SP37– SP43. 6. Weingart, S.N., D. Rind, Z. Tofias, and D.Z. Sands. 2006. “Who Uses the Patient Internet Portal? The 17. Intuit, Press Releases (www.about.intuit.com). PatientSite Experience.” Journal of the American Medical 18. Department of Health and Human Services, Centers for Informatics Association 13(1); 91– 95. Medicare & Medicaid Services, “Medicare and Medicaid 7. Kushinka, S.A. “Making a Connection: Clinics Programs; Electronic Health Record Incentive Program — Collaborate on EHR Deployment.” California Final Rule,” Federal Register, 75, no. 144 (Wednesday, HealthCare Foundation. Oakland, CA: December 2009 July 28, 2010). (www.chcf.org). 19. Blumenthal, D., and M. Tavenner. 2010. “The 8. Murchinson, J.V., J.D. Ray, and C.E. Sison. “EHR ‘Meaningful Use’ Regulation for Electronic Health Networks in the Safety Net” California HealthCare Records.” New England Journal of Medicine 363 (6); Foundation. Oakland, CA: March 2008. 501 – 504. 9. See note 7. 20. Chen, C., T. Garrido, D. Chock, G. Okawa, and L. Liang. 2009. “The Kaiser Permanente Electronic Health 10. “Snapshot: The State of Health Information Technology Record: Transforming and Streamlining Modalities of in California.” California HealthCare Foundation: 2008 Care.” Health Affairs 28(2); 323 – 333. (www.chcf.org). 21. Zhou, Y.Y., T. Garrido, H.L. Chin, A.M. Wiesenthal, and 11. Woodcock, E.W. “How Patient Portals Create Value for L.L. Liang. 2007. “Patient Access to an Electronic Health Patients — and Fulfill Meaningful Use Requirements.” Record with Secure Messaging: Impact on Primary Care Intuit Health. 2010 (www.medfusion.net). Utilization.” American Journal of Managed Care 13(7); 418 – 424.

Measuring the Impact of Patient Portals: What the Literature Tells Us | 17 22. Bernstein, W.S., H.R. Pfister, and S.R. Ingargiola. 38. Lobach, D.F., J.M. Willis, J.M. Macri, J. Simo, and “HITECH Revisited.” Manatt Health Solutions. New K.J. Anstrom. “Perceptions of Medicaid Beneficiaries York, NY: June 2010 (www.manatt.com). Regarding the Usefulness of Accessing Personal Health Information and Services through a Patient Internet 23. See note 7. Portal,” in AMIA 2006 Symposium Proceedings, 509 24. Gardner, E. “Will Patient Portals Open the Door to (presentation). Better Care?” Health Data Management Magazine, 39. Rockoff, M.L. “MyChart MyHealth: The Institute March 1, 2010 (www.healthdatamanagement.com). for Family Health’s Implementation of Epic’s Patient 25. Zhou, Y.Y., M.H. Kanter, J.J. Wang, and T. Garrido. Portal.” Presentation, MLA 2010 E-Patients Symposium, 2010. “Improved Quality at Kaiser Permanente through Washington, DC, May 22, 2010. E-mail Between Physicians and Patients.” Health Affairs 40. See note 2. 29(7); 1370 – 1375. 41. Rockoff, M.L. “MyChart MyHealth: The Institute for 26. Silvestre, A., V.M. Sue, and J.Y. Allen. 2009. “If You Family Health’s Implementation of Epic’s Patient Portal.” Build It, Will They Come? The Kaiser Permanente Model (www.nnlm.gov). of Online Health Care.” Health Affairs 28(2); 334 – 344. 42. Chou, A.F., Z. Nagykaldi, C.B. Aspy, and J.W. Mold. 27. See note 21. 2010. “Promoting Patient-Centered Preventive Care 28. Kaiser’s system was fully implemented for all members in Using a Wellness Portal: Preliminary Findings.” Journal of 2010. Primary Care & Community Health 1(2); 88 – 92. 29. See note 26. 43. Tang, P.C., and D. Lansky. 2005. “The Missing Link: 30. See note 25. Bridging the Patient-Provider Health Information Gap.” Health Affairs 24(5); 1290 – 1295. 31. “Use of Health Information Technology Leads to Improved Care Quality.” Kaiser Permanente News 44. See note 16. Center. July 7, 2010 (xnet.kp.org). 45. Zickmund, S.L., R. Hess, C.L. Bryce, K. McTigue, 32. See note 26. E. Olshansky, K. Fitzgerald, and G.S. Fischer. 2007. “Interest in the Use of Computerized Patient Portals: Role 33. My HealtheVet. United States Department of Veterans of the Provider-Patient Relationship.” Journal of General Affairs (www.myhealth.va.gov). Internal Medicine 23(Suppl 1); 20 – 26. 34. Nazi, K.M., T.P. Hogan, T.H. Wagner, D.K. McInnes, 46. Hess, R., C.L. Bryce, K. McTigue, K. Fitzgerald, S. B.M. Smith, D. Haggstrom, N.R. Chumbler, A.L. Zickmund, E. Olshansky, and G. Fischer. 2006. “The Gifford, K.G. Charters, J.J. Saleem, K.R. Weingardt, L.F. Diabetes Patient Portal: Patient Perspectives on Structure Fischetti, and F.M. Weaver. 2009. “Embracing a Health and Delivery.” Diabetes Spectrum 19(2); 106 – 110. Services Research Perspective on Personal Health Records: Lessons Learned from the VA My HealtheVet System.” 47. Adler, K. 2008. “Making a Case for Online Physician- Journal of General Internal Medicine 25(Suppl 1); 62 – 67. Patient Communication.” Family Practice Management May; A3 – A6. 35. My HealtheVet: Personal Health Records. United States Department of Veteran Affairs. (www.cms.gov). 48. See note 2. 36. Greenhalgh, T., S. Hinder, K. Stramer, T. Bratan, 49. Ross, S.E., L.M. Haverhals, D.S. Main, S.S. Bull, K. and J. Russell. 2010. “Adoption, Nonadoption, and Pratte, and C.T. Lin. “Adoption and Use of an Online Abandonment of a Personal Electronic Health Record: Patient Portal for Diabetes (Diabetes-STAR),” in AMIA Case Study of HealthSpace.” BMJ 341; c5814. Symposium 2006 Proceedings, 1080 (presentation). 37. See note 6.

18 | California He a l t h Ca r e Fo u n d a t i o n 50. Bourgeois, F.C., K.D. Mandl, D, Shaw, D. Flemming, and D.J. Nigrin. “MyChildren’s: Integration of a Personally Controlled Health Record with a Tethered Patient Portal for a Pediatric and Adolescent Population,” in AMIA 2009 Symposium Proceedings, 65 (presentation). 51. Bergman, D.A., N.L. Brown, and S. Wilson. 2008. “Teen Use of a Patient Portal: A Qualitative Study of Parent and Teen Attitudes.” Perspectives in Health Information Management 5(Fall); 13. 52. Liederman, E.M., J.C. Lee, V.H. Baquero, and P.G. Seites. 2005. “Patient-Physician Web Messaging: The Impact on Message Volume and Satisfaction.” Journal of General Internal Medicine 20; 52 – 57. 53. See note 20. 54. See note 21. 55. See note 25. 56. Liederman, E.M., J.C. Lee, V.H. Baquero, and P.G. Seites. 2005. “The Impact of Patient — Physician Web Messaging on Provider Productivity.” Journal of Healthcare Information Management 19; 81– 86. 57. See note 24. 58. “Centricity EMR Clinical Messenger/Patient Portal” by Northwest Medical Informatics Symposium in partnership with eHealth Initiative.

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