Online portals have become increasingly pervasive tools for practices wanting to better communicate with patients.¹ A common feature of electronic health record (EHR) systems, portals expand the reach of medical practices, enabling patients to make appointments, request medication refills, check the results of lab tests, view and pay medical bills, or even ask their physicians directly for medical information or advice.

One of the leading drivers of portal use is the Medicare EHR Incentive Program's meaningful use stage 2 requirements.² CMS will soon penalize providers unless they can show the following:

• More than half of their patients can view, download, or transmit to a third party their health record within four business days of being updated,

• At least 5 percent of patients actually view, download, or transmit their information,

• More than 5 percent of patients actually send secure messages through the portal.

Predicted increases in demand for health care services may also stimulate portal use, as meeting the needs of the growing insured and aging populations will require adopting methods that increase efficiency and capacity. In addition, the ability to provide patient-centered care how and when patients want it are strong motivators for some physicians to embrace portals.

But this technology is far from widespread,^1,3 and physicians who want to exploit the benefits of portals must get around a number of obstacles currently limiting their use.

Obstacle 1: The physicians themselves

Although proponents and studies say portals can make interacting with and treating patients easier,^4,5 some physicians are not yet sold on their value or have questions and concerns about the technology. One of the physician's first challenges is learning enough about portals to determine whether adopting one is worth his or her time.

In addition to offering commonly used features such as appointment scheduling and refill requests, many portals also include secure messaging, which allows patients and physicians to communicate electronically without running afoul of HIPAA rules and playing phone tag. Whether to use secure messaging is a topic of much debate among many physicians, even those who have implemented a portal. Advocates of the feature say it decreases disruptions throughout the day and reduces confusion from messages relayed through nurses, assistants, or other staff.

Daniel Sands, MD, is a health information technology consultant and part-time primary care physician at Beth Israel Deaconess Medical Center in Boston. He says physicians should embrace messaging because the communication can be automatically appended to a patient's EHR, which prevents message slips or voice mails from going missing and serves as a valuable source of patient understanding and legal protection.

“We know from study after study, when patients leave the office or hang up the phone, they remember less than a third of what we say to them,” Sands says. “So that's going to lead to confusion, poor outcomes, frustration, and so on. Secure messaging is different because it has permanence to it. Patients can look at it. They can read it again. They can share it with their loved ones.”

Some physicians worry that patient email messages will swamp them.⁴ But Sands says the volume is typically much less than expected, and most messages can be dealt with in a couple of minutes or less. If the number gets unwieldy, he suggests having a nurse triage the messages and refer the more mundane ones, such as those for refills or appointments, to other team members.

Regardless, practices that adopt secure messaging will need to decide whether all messages will be added to the EHR and establish procedures for how to keep track of and respond to messages sent when a physician is out of town and how to terminate a patient's access to the portal when he or she leaves the practice or dies. The practice should also explain, whether in print or online, relevant portal policies to patients, such as when the portal should be used (for nonemergencies only), how quickly the practice will respond to portal messages (typically one to three business days), and how the practice will treat abusive or threatening messages.

Obstacle 2: The physician's bank account

There's no way around it: Other than receiving meaningful use incentive payments (and avoiding penalties), physicians typically won't get directly reimbursed for using a portal. In fact, some physicians fear that successfully answering patient questions through secure messaging might create additional appointment capacity that the practice would need to fill to avoid declining revenue.

Joseph R. Scherger, MD, vice president of primary care for Eisenhower Medical Center in Rancho Mirage, Calif., acknowledges that the predominately fee-for-service payment system must change to reward nontraditional practice, including non-face-to-face care, before portals see widespread adoption. But in the meantime, Scherger says, portals can still help a practice's efficiency and, potentially, its bottom line.

Scherger's organization operates both a traditional primary care practice as well as EPC365, a practice in which a membership fee covers all online communication and non-visit care while insurance covers the cost of visits. More than 90 percent of Scherger's patients are registered in the system's portal, mostly because it is a requirement. But Scherger says making the portal the practice's main point of connection with patients has generated savings in terms of lower staffing and telephone costs. Physicians in EPC365, on average, see 10 to 12 patients a day for 30-minute visits and can care for an additional 30 to 50 patients online.

“When you're in a prepaid model, a visit is a cost,” Scherger said. “If you can handle patients more efficiently, that makes a lot of sense.”

Greater efficiency also can help practices that have many patients covered by capitation. For example, using a portal message rather than a second visit to follow up with a patient recently seen for a chronic condition can create room in the schedule, provide greater convenience to the patient, and reduce the cost of care.

Other physicians using portals said visit volume has remained steady or even increased as patients, now able to get their questions answered faster, seem more willing to come in and discuss their health further.

Obstacle 3: The practice and its staff

Integrating a portal disrupts practices to varying degrees as it forces staff to manage the increased number of online messages, change how they perform scheduling and refills, and deal with other new ways of doing things. Motivating employees to help promote the portal to patients can be a challenge, particularly if staff view portal registration instructions as just one more page in a thick pile of paperwork they must go over with every patient in a short window of time.

But getting practice staff on board is beneficial. A recent study found practices achieved more success with their portals when office employees, and not just clinicians, helped explain the portal to patients.⁶

Physicians should emphasize to staff how portals can improve the patient experience and outcomes – and the ways that portals can make staff members' jobs easier. For instance, portals have a tendency to reduce the number of phone calls as patients express their needs online or message the physician directly with questions or concerns. Certain tasks, such as processing lab reports or scheduling appointments, can also be streamlined as a result of the portal.

Jennifer Brull, MD, a solo family physician in rural Plainville, Kan., says her practice had used a portal for several years but hadn't been able to get patient participation above 30 percent. But once she extended its use beyond the front desk to the nurses – and promised to treat them to a fancy dinner if the practice saw significant improvement – patient registration surged to 60 percent.

“My nurses said, ‘Oh my gosh, this is awesome! We don't have to do lab letters. We don't have to call patients.’ They were spontaneously telling patients, ‘No, you need to use the portal,’” she says.

Obstacle 4: Patient resistance

Patients are increasingly interested in online communication regarding their health care. A 2013 survey of patients showed that a third of respondents who were already online said they were open to asking their physicians questions, making appointments, and getting lab results through their smartphone or tablet.⁷ However, many haven't heard about portals or don't want to change how they communicate with their physician. Those who have spent a lifetime communicating with their doctor's office on the phone may find it a hard habit to break.

Practices have found that effective marketing is the key to getting patients to use the portal – explaining the value of the portal and making patients curious to try it. One suggestion is studying the most common ways and reasons why patients contact the practice currently – for example, calling to make appointments – and start your marketing there. Physicians have suggested promoting the portal using waiting room posters, a flyer in new patient packets, information on the practice website, and on-hold messaging. The latter has the benefit of selling the portal's convenience at a time when patients might be feeling inconvenienced while waiting to make an appointment or calling about a refill.

The most effective time to persuade patients is during the office visit itself. Although the physician's encouragement may be the most influential, patients should hear about the portal at every step of their visit, from the front desk clerk (“You can also fill out your information online”) to the nurse (“Our portal lets you request refills”) to the physician (“You can email me questions anytime” and “You can view these results on the portal”) to the checkout desk (“You can schedule your next appointment online”). Repetition can breed familiarity and, hopefully, greater acceptance.

When simply telling patients about the portal and relying on them to register and use it does not yield the desired results, practices have used more direct tactics. For example, James Williams, MD, a family physician in Lexington, S.C., says that he or a nurse will walk new patients to the checkout desk at the end of a visit and ask the clerk right then to sign up the patient for the portal. Williams also encourages portal use by sending all lab results electronically. Other practices advise sending a test message and asking patients to check their message boxes to make sure the connection works. “If patients do it once, they're hooked,” Williams says, adding that about a third of his patients are on the portal and half of those use it regularly.

Another practice has a laptop at the check-out counter that always displays the login page of its portal. Upon checkout, staff ask patients who haven't yet signed up for the portal to log in using a temporary ID/password and to confirm their contact information. That process initiates a request to establish permanent login credentials.

Gerry Tolbert, MD, is part of CareHere, a corporate health care system that oversees 1,300 public employees and family members in Kenton County and Covington, Ky. The system requires patients to make all appointments, submit refill requests, and conduct many interactions with physicians through the portal only.

Tolbert says he regularly advises practices to make their own portals as mandatory as possible to keep their new technology from becoming just an expensive add-on.

He also recommends that practices do as much as they can to improve the portal's user interface for patients. Many physicians are stuck with whatever portal came with their EHR, which they may have had no input on choosing. If a physician can choose the portal, or has some say in its customization, Tolbert advises making sure that the portal provides users a simple experience with little guesswork.

“People need to be able to recognize exactly what they're looking at without having to think too hard,” he says. “If you add more than one or two steps to what they would normally do, it's just not going to happen.”

Obstacle 5: Patient limitations

Sometimes demographics, such as age, income, or language, prevent patients from using a portal. Some patients often have a harder time embracing technology or may be too frail or cognitively compromised to adequately use a portal for their care. Others may not be able to afford a computer or may lack Internet access at home. Some portal programs aren't friendly to users for whom English is a second language.

Of course, these are generalizations. Some physicians said they have numerous retired patients who like communicating with their doctor online, while younger patients may resist the portal because it isn't mobile-device-friendly. But statistics show that older patients generally prefer scheduling appointments and being contacted by their physicians by phone, not online.³

What if the patient's health is what keeps him or her from using the portal? Karen Smith, MD, a solo family physician in Raeford, N.C., says she typically looks for a family member or other caregiver to serve as the patient's representative in the portal.

“Those are the individuals who are already expending time to get the patients in and out of the office, and they are really liking the access,” Smith says, adding that 10 percent of her patients are using the portal.

Practices that allow third parties to use a portal on behalf of another patient will obviously need policies in place to protect privacy.

Patients who lack computer access at home but still want to use the portal may sacrifice some level of privacy to do so. For example, Smith says she has had patients access their portal accounts through work or even the public library. The situation is far from ideal, and she says physicians should advise patients of the privacy danger and how to be as careful as possible.

Obstacle 6: Security and privacy concerns

Given the frequent news stories of cyber-criminals breaking into the computer networks of retail chains, government databases, and even health care organizations, it's no wonder that some patients are less than willing to access their health records or discuss sensitive matters online.

When discussing portals with their patients, physicians should detail the many technological defenses built into them and EHRs in general. For example, physicians might explain that although physician-patient messages sent through the portal may resemble standard emails, they never leave the confines of the portal.

Rachel Franklin, MD, medical director of the University of Oklahoma Department of Family and Preventive Medicine in Oklahoma City and a part-time practicing physician, says her practice informs patients about portal security from the moment they register. In fact, her office requires patients to be physically present in the office to receive a personal identification number that they can use within a limited time to set up an account on their own.

Despite having these safeguards, Franklin said she still has patients who choose not to use the portal. She said she also has some patients who won't use the portal because they say the security procedures are too onerous.

Some patients may avoid the portal thinking this will keep their records secure. But Sands says that with a majority of offices and health systems using EHRs, patients should understand that their information is online regardless, and they must decide if they want to take advantage of the potential benefits.

As with any new tool, physicians are trying to figure out how portals fit into their particular toolboxes. Identifying and explaining the portal's value is worthwhile if they wish to smooth a path to increased use and efficiency.