Digital Communication - the Patient Portal

“I got the results back from my lung scan. Actually, well, I read it on that online chart thing. I don’t really know what I’m looking at, but it says the mass in my lung is growing. But, my doctor wrote a little note that he isn’t concerned so he will see me in 3 months.” My patient and I made eye contact, and I would bet any amount of money that we were both grimacing under our masks. I finally asked, “Will you be able to talk to him about your results before that appointment? Did he say why he isn’t concerned?” My patient blinked several times. “He said he wasn’t concerned because of...something about margins, and edges, and lymph nodes. I’ll be able to talk to him at that 3 month appointment. But, if he isn’t concerned, then I guess I shouldn’t be. Although I do feel confused that he isn't concerned about a mass that is growing.” Honestly, I would also be concerned if someone told me a mass in my lung was growing but that I shouldn’t worry about it.

There seems to be a trend where patients receive really important test results over an online chart service, and no one follows up to discuss or interpret the results. I’m not sure if it’s a change since covid, or if covid just accelerated a move toward the all digital interaction, but it’s alarming. Patients are being provided with information that they don’t understand, or that they understand partially, without the benefit of a clarifying conversation with a health care provider. One person told me that, when she called to make an appointment to discuss imaging results and next steps for treatment of her condition, she was informed that the practice did not conduct visits to discuss information that was available via the patient portal. She was left wondering what to do with the information she received and not knowing what steps to take next to manage her condition. She would have to wait months for her next scheduled appointment with this physician.

After a certain number of conversations about this topic from a wide variety of people, I searched the available literature for information about patient portal use and effective communication. Interestingly, most of the studies I could find were centered on whether patients 1) set up their portal accounts, and 2) attempted to message a physician using such accounts. Neither of these metrics actually assesses whether effective communication occurs, since dumping test results without discussing them in context doesn’t actually empower patients to make informed health decisions. One study[1] did note that using a patient portal could impact clinical outcomes by improving continuity of care, patient convenience, activation of information, and patient insight into information. However, I think that all of these mechanisms of action presume that a patient has understood the information presented digitally and is in agreement with (or at least has no questions about) the provider’s recommended course of action.

For instance, in the example of my patient with a lung scan – he did gain insight into information, as he learned that his lung mass was continuing to grow. He did experience activation of the information, as he is following his provider’s suggestion to follow up in 3 months. He is experiencing continuity of care, as he is communicating with the same physician each time, and it is convenient for him to learn the results of his scan on the computer. However, none of these mechanisms of action lead to the hypothesized patient empowerment, because he does not understand why his physician isn’t concerned about a growing lung mass. He has major questions about the appropriate course of action for the phenomenon occurring inside of his body, and no one is available to address his questions because, according to this patient portal model of practice, the attempted communication has been deemed successful.

Perhaps, purely as a business model, this was a successful interaction. Information was provided to the patient, and he complied with the recommended treatment. However, I know my patient still felt uneasy and uncertain, which means that the model does not necessarily translate to real life. With studies demonstrating vastly improved outcomes after a 15 minute conversation[2] centered around addressing a patient’s questions and anxieties, it’s hard to imagine that communication via online portal WITHOUT the option for a virtual or in person discussion could be considered best practice. It's certainly not evidence based. But, in our current fee-for-service payment model, or even in the pay for value models that are being adopted in various scenarios, there is no real way to get paid for conversations that would lead to decreased pain, faster wound healing, improved function, less depression, and greater patient satisfaction. Yes, there is a patient education billing code, but it pays very minimally and providers are often discouraged from using it. It’s easy to see why, from a business standpoint, giving appointments to discuss information that is available online would be a less favorable use of overworked physicians.

Some patients do have enough health literacy that they might feel confident with just an online interaction via patient portal. Other patients might be receiving uncomplicated test results that do not change the course of action, and they might also be satisfied with online communication. However, medical information can be confusing, stressful, and complex. Not to mention that successful use of a patient portal requires stable internet access, a computer or smart phone, and literacy. An evidence based way to improve patient adherence and patient outcomes would be to offer a short telehealth visit to discuss results for those patients who wanted one. It's an actionable solution that does not require systemic change to accomplish, although it might require hiring an additional nurse to perform these visits. Providing evidence based, compassionate care CAN be compatible with using digital technology to share information, but only if people's individual needs for communication are identified and accommodated.

[1] How outcomes are achieved through patient portals: a realist review. Terese Otte-Trojel, Antoinette de Bont, Thomas G Rundall, Joris van de Klundert.

[2] Preoperative Anxiety in Ambulatory Surgery: The impact of an empathetic patient-centered approach on psychological and clinical outcomes. https://www.sciencedirect.com/science/article/abs/pii/S0738399115301324?via%3Dihub