How to Evaluate Patient Portal Efficiency

When Riverside Health System implemented its EMR in 1996, the idea was that it would be able to use the data to help drive improvements in care.

"We thought we'd have all of the data fields in our notes," says Charles Frazier, MD, vice president of innovation. "Everybody thinks we'll get all this data and be able to do all of this stuff with it, but it is a difficult thing."

After 10 years, the VA-based health system—which consists of four acute care hospitals, rehabilitation and long-term care facilities, and the Riverside Medical Group, a 350-member multispecialty physician practice—was still working on problem lists, lab values, medications, and elements such as gender and age. Today, the health system is still continually trying to improve how it puts information into the EMR, Frazier says.

Riverside developed a patient portal in 2003 to improve communication with patients and provide guidance on preventive care. But after several years, only 20,000 of the health system's some 350,000 active patients were using the portal. 

"When you have such a small percentage connected on the Web, you have to think of something else, and most everybody has telephones," says Frazier. 

So Riverside implemented Dallas-based software vendor Phytel, Inc.'s proactive patient outreach solution to help it follow up with patients—especially those who are out of compliance and in need of recommended care.

The technology captures data from practice management, scheduling, billing, and/or clinical information systems such as EMRs. It then creates physician-specific registries and screens patients based on a couple hundred nationally recognized disease management and preventive health protocols.

The software searches for gaps in care, such as a diabetic patient who has not seen his or her physician in more than a year. It then sends an automated message—voice messaging, text, or e-mail—that is from the physician or medical group asking the patient to contact his or her doctor. Physicians pay a monthly subscription fee for the service, which is based on the number of physicians rather than patient volumes.

The technology looks for things that the physician has ordered that have not been done or for services that are recommended, says Steve Schelhammer, Phytel's CEO. "We find the patients that are out of compliance and [have] fallen off the radar screen, and we motivate those patients to get back into the healthcare system so that they can get the appropriate care."

Riverside, which began using the technology roughly 10 months ago, focused its efforts on patients with chronic conditions such as diabetes and hypertension. Currently, the software is only pulling data from Riverside's financial system, but the health system hopes to have data from its EMR and clinical systems included by the end of this year.  

Until then, Riverside is extracting data from its clinical system for Phytel to use. For example, Riverside shared mammography data that it pulls on a monthly basis for its physicians. The technology screened the data and sent automated messages to all the female patients aged 40—69 who had no record of a mammogram during the previous two years. 

Riverside set up a specific telephone number for the women to call so it could track how well the initiative was working. "We had more than 250 mammograms scheduled through that process," says Frazier, adding that they also identified patients whose EMR was incorrect and corrected the information.

Riverside is now working with the vendor to better communicate with its patients who have signed up for the health system's patient portal either electronically or via text message rather than by phone.

Similarly, The Iowa Clinic in Des Moines wanted to ensure that its patients were receiving appropriate follow-up care and screening services. "Even though we were putting an EMR in place, it didn't really have the right components to make sure we were reaching out and following up on certain aspects as it relates to the delivery of care," says CEO Ed Brown. "Phytel appeared to be at the time one of the solutions to that," he says, adding that some colleagues were having positive experiences using the technology.

The Clinic, which is an independent, physician-owned, multispecialty practice with 135 physicians serving more than 400,000 patients annually, started using the system with its internal medicine, cardiology, and OB patients. For internal medicine, the group focused on congestive heart failure, diabetes, hypertension, physical exam, and mammogram, says Julie Sanders, director of quality. "For cardiology it was very similar protocols as far as disease states, and we look at heart failure, hypertension, and coronary artery disease. For OB, we reached out to those [patients] who have not had the HPV vaccine, [those with] abnormal pap smears, and those who needed a wellness screening.

"We have definitely had patients come in who have been delinquent for care," says Sanders, who was somewhat skeptical at first regarding how many patients were really out of compliance and in need of this type of outreach.

Implementation process
Riverside chose 50 primary care doctors to test the technology, based on physician capacity, says Frazier. The health system didn't want to reach out to a patient for follow-up care with a physician who was extremely busy and would be unavailable for three to six months, he explains.

There was the initial data mapping work with Phytel, so that it knew where the data were coming out of the finance system. Riverside's quality committee then evaluated the vendor's protocols and made adjustments based on the data in the financial system. It eliminated some of the protocols and modified others altering age intervals or changing the protocol from six months to one year, for example. The last piece was training practice staff on what to do when patients called in.

The Clinic followed a similar process--data mapping and reviewing protocols. Aside from the standard glitches associated with deploying new technology, "it was a very easy rollout," says Beth McGinnis, director of administrative services, billing, and information technology.

"When we turned the protocols on, we did some tweaking--patients were being called who we didn't want to be called," says McGinnis. The technology does have an opt-out capability, so you can remove those patients from the system or note when calls should resume.

Closing the care loop

The technology also funnels the data back to the care team so when a patient calls in the clinicians are prepared.

Initially, the patient would call saying, "I got this call saying that I need to come back in for some reason," says Frazier. The clinical staff would go right to Phytel's website to determine why the patient was called, ask some questions, and make an appointment when appropriate. Now, however, when an outreach call goes out, there is a document that is sent to Riverside's EMR system explaining why a patient was called.

"Now our staff doesn't have to go to a different application or website, and they can stay in their primary application, which is the EMR," Frazier says.

Riverside is also working on more scripting for its staff. When a patient calls, the clinician will now say, "You were called because we believe you need follow-up for diabetes. Does Dr. Frazier see you for diabetes?" That may seem like an odd question, Frazier says, but say that patient sees an endocrinologist who is not in the Riverside family. But "our financial system says that they have diabetes and haven't been in to see me for six months," he explains. "So the staff member can catch that and say, 'We'll make sure not to call you for diabetes anymore,' and update the system."

Brown and Frazier agree that the benefits of the system and positive responses far outweigh the handful of patients who were called when they shouldn't have been.

Based on data from December to July, Riverside booked more than 13,400 appointments, and of those appointments, about 9,100 would not have been made without the intervention. In addition, those visits generated roughly $675,000.

Likewise, The Iowa Clinic, which went live with the system about nine months ago, successfully contacted more than 16,600 patients with gaps in care, and of those, roughly 8,500 appointments were made within 60 days. "We have also increased compliance with standards of performance that have been laid out for us by some of our payers for performance improvement," says Brown.
"It has a positive impact on the bottom line, but it is not disproportionately out of line with what it would have been before because those openings would have been filled by other services," says Brown. "But we are making sure that patients are getting more appropriate care for their needs."

Managing patient populations

Providers are still determining what accountable care organizations (ACO) are exactly and how they will be structured. But one thing is certain­?technology will play a key role in helping organizations better manage populations of patients.

Today, when a physician tells a patient, "I want to see you back in so many months for follow-up labs," the responsibility rests with the patient, says Ed Brown, CEO of The Iowa Clinic.

But with so much emphasis being placed on patient-centered medical homes, P4P, meaningful use, and ACOs, "the bar is being raised so that there is responsibility on the provider to maximize the outcome of that patient's health," Brown says.

"That is the transition from a fee-for-service-based payment system to a global payment system," says Steve Schelhammer, CEO of Phytel, Inc. "To be successful, providers have to have capabilities to help them manage the entire population, not just the population that is actively seeking healthcare."

The idea of ACOs and complying with protocols that are set internally or externally will be enhanced by technology, agrees Brown. "As we establish protocols for various disease processes, we'll have within our demographics in our EMR the patient population that qualifies for the protocols," he says. Those patients need to be tracked closely, and "technology will enhance our ability to perform up to a high level of care based on the protocols that have been established." 

In the future, Charles Frazier, MD, vice president of innovation at Riverside Health System, envisions technology solutions like Phytel enabling nurses to coordinate patient care more effectively.  Rather than having patients call their physician practice, they can call a central number where nurses looking at the EMR can say, "Yes, I see where you do need follow-up for diabetes, and by the way, can I go ahead and make your eye appointment and order lab work that Dr. Frazier will need when you come in?"

See also:

The Connected Patient

Behind the Wires