Patient Portals Move Toward Widespread Use

Eliot Siegel, M.D. University of Maryland

While most hospitals have yet to make the transition to electronic health records (EHRs), Duke University Medical Center is not only giving patients online access to lab and X-ray results, but is also pursuing a plan to offer online radiologic images to patients.

Meanwhile, Memorial Sloan-Kettering Cancer Center in New York is configuring a new radiology system with the intention of offering patients online access to summaries of their radiologic reports.

They are not the first, but both facilities are at the forefront of a transformative new technology—the patient portal—that experts predict will become more prevalent as patient demand for health information increases and more hospitals make the transition to EHRs following the injection of $19 billion in government incentives to move healthcare toward full implementation of these records.

Only a fraction of the 3-4 percent of hospitals estimated to have EHRs are operating portals—a secure Web connection to health information, services and clinical care—and an even smaller percentage have sites with radiology-specific features, said Eliot Siegel, M.D., professor and vice-chair of information systems in the Department of Radiology at the University of Maryland School of Medicine and chief of radiology and nuclear medicine at the VA Maryland Healthcare System. Other early portal adopters include Kaiser Permanente in Oakland, Calif., and Beth Israel Deaconess Medical Center (BIDMC) in Boston.

"I would say that less than 1 percent of facilities have portals that offer radiology-specific services and none that I know of offers images, but that will change," said Dr. Siegel, a member of the RSNA Radiology Informatics Committee. "This has not had a major impact on the radiology community yet."

Nevertheless, some clinicians are concerned about the level of information to which patients could have access, said Lawrence Schwartz, M.D., vice-chair in the Department of Radiology and director of the Laboratory for Computational Image Analysis at Memorial Sloan-Kettering.

"Physicians are in favor of these portals in general because they educate patients and increase efficiency, but there is concern about the potential misunderstanding of data which could lead to increased patient concern and anxiety," said Dr. Schwartz.

Portals Tailored to Facility's Needs

A patient portal can be tailored to suit each facility's needs and can be created in-house or through an outside vendor. For example, the VA's portal, MyHealtheVet, was created in 2005 by the multihospital VA network, said Dr. Siegel.

At a minimum, most portals offer billing, prescription refills, educational tools, appointment scheduling and insurance and admittance forms, while more robust sites offer features like lab results and e-messaging. Patients must register and sign on with a secure password and portals are required to be Health Insurance Portability and Accountability Act (HIPAA) compliant, according to Dr. Siegel. Once a facility creates a site, it is assumed that all physicians will participate, he said.

A patient portal is different than a patient health record (PHR), which is a lifelong, electronic resource of health information owned by the individual and maintained in a secure, private environment such as sites hosted by Google™ and Microsoft®, said Dr. Schwartz. "Unless a person is at the same institution from birth to death, a patient portal contains only part of a person's PHR," he said.

At Memorial Sloan-Kettering, which launched its MYMSKCC patient portal about two years ago, the most popular features among its 7,000 users are scheduling, test preparation information and e-messaging, said David Artz, M.D., medical director of information systems. "Patients preparing for a CT scan can find out exactly what procedure they need to follow before they come in," he said. E-messages, which are used for everything from general questions to appointments, are routed to the appropriate administrative or nursing staff based on the message topic chosen by the patient from a pre-defined list. With the click of a button, the message becomes part of the patient's EHR, said Dr. Artz.

Prescriptions are the most common search on MyHealtheVet, which has 500,000 registered users, said Dr. Siegel.

At Duke, which has shared a quarter of a million test results with patients since launching its HealthView portal in January 2008, some physicians are doing online consultations in a secure, limited fashion, according to Asif Ahmad, vice-president and CIO for the Duke University Health System in Durham, N.C. "This is happening on a voluntary basis and doctors are not billing for e-consultations so far," said Ahmad.

Radiologists are preparing to contribute imaging information to online patient portals, which at some institutions already give patients access to lab and X-ray results, prescription refills, appointment scheduling and other information. Some portals already developed include (from top) MyHealtheVet (U.S. Department of Veterans Affairs), MYMSKCC (Memorial Sloan-Kettering Cancer Center) and HealthView (Duke University Health System).

Although facilities already offer CDs of radiologic images and send copies of clinical test results in the mail, features like e-mails, online consultations and sharing clinical report summaries has made some physicians anxious about taking on a new level of responsibility, according to Paul Chang, M.D., a professor and vice-chair of radiology informatics and medical director of pathology informatics at the University of Chicago School of Medicine. "But the technology is here and we are going to have to learn to incorporate it into our practices," he said. "We're going to see more and more use of e-mail, Twitter and those kinds of tools. A lot of medical practices have a blog."

Facilities planning portals can learn from portal pioneers such as BIDMC, which has offered the technology for several years, according to Jonathan B. Kruskal, M.D., Ph.D., radiologist-in-chief and chair of the Department of Radiology. "First, reports should only be made available to patients once approved by an attending physician, since blanks and spelling errors send the wrong message and cause unnecessary patient concern and loss of confidence in the interpreting radiologist," said Dr. Kruskal, a member of the RSNA News Editorial Board.

When it comes to posting more detailed information like report summaries, physicians currently participating in portals are taking time to explain the medical jargon that could otherwise confuse or harm the patient, said Dr. Chang. "It's critical that patients have control over their own healthcare information, but on the other hand, we don't want to pass on information that is potentially harmful if it's misunderstood," said Dr. Chang.

At BIDMC, the entire report summary structure has been modified with the patient in mind, said Dr. Kruskal. "For example, patients become very concerned when they read they may have a cancer and radiologists frequently will include this diagnosis in a list of differential possibilities," he said. "Summaries should be kept short and practical, with full knowledge that these may be read by the patient."

While in the planning stages of adding radiology summaries, Memorial Sloan-Kettering continues to take a balanced—but cautious—approach to its portal content, said Dr. Artz. "We're being as generous as possible with information while still being aware of any concerns from practitioners about what we display," he said.

Interoperability Standards Necessary

Along with the transition to EHRs, the widespread adoption of portals is also being hindered by the lack of national interoperability standards. At Duke, for example, the plan to offer radiologic images online is contingent on federal funding and development of national standards due to the large size of the images and the proprietary nature of PACS, said Ahmad. "We're planning on image sharing, but these systems have to be able to interface with each other and right now they can't," he said.

To that end, RSNA's Integrating the Healthcare Enterprise (IHE®) has defined a method of exchanging medical documents and images that enables the interface of information by networks of healthcare sites. A goal of RSNA's new Radiology Reporting Committee is to make radiology reports compatible with this same architecture.

Considering the major transition ahead, patient portals won't become commonplace overnight, said Dr. Schwartz. However, as early portal adopters expand their sites and share their successes, it is likely that most facilities will have adopted some form of portal in the next five years, he said.

"I think most facilities will have some flavor of portal in place in the near future," he said. "Then again, I thought most doctors would be computerized by now."