Patient Portals: Healthcare In The Email Era

Interactive online portals where patients can exchange messages with their physicians, in addition to viewing test results, have been around for over a decade.  The Kaiser Permanente system established its MyChart patient portal (later renamed My Health Manager) in 2003.  In 2014, the Centers for Medicare and Medicaid Services (CMS) introduced an electronic health records (EHR) Incentive Program focused on Patient Electronic Access to reward providers who could demonstrate that at least 5% of their patients were accessing their health information online.  The 2015-2017 EHR Incentive Program increased the target to >50% for eligible physicians.
There are many intuitive benefits to soliciting patient engagement via an online portal, as evidenced by the Kaiser Permanente experience.  Patients like being able to email their providers, and this factors into patient satisfaction scores.  Clinic visits can be more rewarding and productive, because email exchanges have kept the provider and patient on the same page.  The use of secure email has been shown to boost some clinical outcomes such as improved glycemic, cholesterol and blood pressure control.  Observational studies noted that face-to-face visits per patient per year were slightly decreased in tandem with increased use of secure emails, suggesting that virtual check-ins can promote more effective healthcare utilization.  (On a related note, e-consults between primary care docs and specialists can avert up to 40% of unnecessary in-person referrals.)
I have certainly had positive patient interactions via email that have facilitated timely medication refills, avoided ER visits, and alleviated patient anxiety.  But in this era where the patient-doctor relationship transcends in-person encounters, challenging shortcomings related to healthcare-via-email have emerged.
        Symptoms acuity.  Patients may not realize the seriousness of their symptoms and resort to email instead of seeking immediate care.  If they send out an email, then sit back and wait for a response, this can result in treatment delay.  I once got an email from a patient describing chest pain radiating down her left arm.  (ER visit was not averted in this case.)
        Getting the message across.  The majority of patients will not know what to make of their test results.  Email messages can similarly be misconstrued.  I once sent a follow-up email to a patient to advise that blood counts and coagulation tests (routine CBC and PT/PTT) would be checked before an outpatient kidney biopsy.  She emailed back to thank me for ruling out blood clots in her kidneys as a cause of kidney failure…
        Unreimbursed provider time.  Unlike lawyers who bill by the minute for phone conversations, medical providers are expected to take on patient email as just another part of the job.  Physicians already spend a significant amount of time on the computer for charting, ordering and reviewing tests, sending prescriptions, etc.  As icing on the cake, after responding to a patient’s email we sometimes have to chart a note documenting that we sent an email…
        Disparities in access to e-health.  Some of my older patients never warmed up to the world-wide-web, and give me a dazed/confused look at the mention of “patient portal” and “internet”.  Other barriers to e-health include lack of access to technology, illiteracy, or if the patient’s preferred language is different from the EHR platform (perhaps Google Translate can help here).
        I will email my doctor at 11 am on a Sunday while she’s on vacation out of state.  [patient emails] [cell phones] = [the doctor is always in].  Sometimes it’s hard to hide behind the automated “away-from-office” message because you know your on-call colleague isn’t familiar with the patient’s history.  It’s like we’re all practicing concierge medicine at some level.
Some of the issues mentioned above can be fixed with a simple phone call.  The more complex challenges related to increasing demands on the busy provider and sometimes disparate patient expectations will be harder to resolve.
 Wei Ling Lau Headshot

Wei Ling Lau, MD is Assistant Professor in Nephrology at University of California-Irvine, where she studies vascular calcification and brain microbleeds in chronic kidney disease. She is currently funded by an AHA Innovative Research Grant, and has been a speaker for CardioRenal University and the American Society of Nephrology.