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.


So I Want To Be A #cardiopreneur

As many of you may know, I recently joined twitter and am enjoying the challenge of learning a new (to me) social media tool. I must say, however, that I am always forgetting the hashtags on my tweets. So, I decided that there is no better way to remind myself than to make my own hashtag. Hence, the term #cardiopreneur. More on this to come, I promise. It will all connect in the end… keep reading on. 

Today, as an attendee and blogger at the HealthTech Summit, I couldn’t help but feel like I was witnessing the birth of a new era with the intertwining of technology and healthcare. In the past, there has been ambivalence among members of the medical community with respect to embracing a role for technology. Perhaps this may have been related to fear of the unknown or thought that care may be less personalized with implementation of technology. 

Some of the difficulties behind incorporating technology into healthcare have surrounded the standard practice in entrepreneurship thus far: 1. Come up with an idea for a device 2. Figure out how people can use said device.  In healthcare, we need to employ end-user development in conjunction with our engineers and entrepreneurs to recognize the patient needs which are of utmost importance and then develop a device to meet this need.  

When we connect systems of health record with systems of intelligence, engagement and networks for collaboration and work flow we will we be able to create change that will be accurate, precise, and scalable to a larger population. In the words of Dr. Jessica Mega, Chief Medical Officer at Verily Life Sciences, “Unless we understand how to apply artificial intelligence and automation, we will end up down the wrong road.” Our technology is only as good as the human who designs it and understands it. How do we create an infrastructure to support new disease insights through use of machine learning and artificial intelligence? Collaboration, organization, and action!

How do we best utilize a deep learning model that is both adaptable and good for complex, nonlinear data? Research presented by Dr. Rima Arnaout from UCSF showed that a deep learning model can be trained to classify among 15 standard transthoracic echo views, with the model taking just 21 milliseconds to classify each image. The model had a 91.7% accuracy on images compared with board certified echocardiographers who had 70.1-84% accuracy. Including video instead of still frames increased the accuracy of the model to 97.8%. Combining human ingenuity and understanding with machine learning and artificial intelligence will allow us to create rapid fire innovation to better serve the needs of our patients. 

I had the chance to speak with David He, also of Verily Life Sciences, who demonstrated the Verily Study Watch with multiple physiological and environmental sensors about adaptation of these devices to my patients with adult congenital heart disease, left ventricular assist devices, and transplants. There is a need for creation of novel wearables for use in these most vulnerable patients. They stand to benefit the most from these types of innovations, underscoring the need for cardiologists as myself to keep this momentum moving. 

So, back to #cardiopreneur… what does it mean? It’s a novel term (yes, I made it up… innovation starts small!), to reference cardiologists like me who are committed to innovation, entrepreneurship, and collaboration to advance healthcare technology in a way that has never been seen before. So, join me in starting the #cardiopreneur movement and embracing change… our patients will thank us for it!

Megan Kamath Headshot

Megan Kamath is a Fellow in Advanced Heart Failure and Transplant Cardiology at the University of California, Los Angeles. Her research interests include outcomes in advanced heart failure, decision making and relational medicine, and utilizing technology in healthcare. She is now tweeting @MeganKamath, so follow her on there!