On a Saturday morning not long ago, I received a phone call from a patient of one of my partners. As a primary care physician, this is typical. Roughly every five weekends, I take calls, fielding questions and assisting with medical concerns for any patient of my office. What was novel was the genesis of this call.
An otherwise healthy thirty-four year old woman had recently undergone routine lab work ahead of her annual physical. It used to be the case that lab results would not be posted to our practice’s electronic “patient portal” until after the ordering physician had had a chance to review them. This way, any abnormal results could be preceded by a communication from the physician to the patient. But last spring, in accordance with new U.S. federal regulations, our electronic medical record vendor changed our system, and patients can now see lab results as soon as they come in.
This healthy young person, who felt entirely well, saw that one of her lab results was listed as being slightly abnormal. I took the call, reviewed the labs, and explained that the abnormal result was not of any significance and could be safely ignored. She hung up reassured. I hung up frustrated.
If this were the first such call, I’d write it off as a blip. But it wasn’t. The night before the above interaction, I was paged by another patient who had seen online that a radiologist read her mammogram as inconclusive and was suggesting a breast ultrasound to take a better look at one spot of concern. This is a common scenario (and fortunately usually leads to benign findings). Understandably though it can be nerve wracking for a patient.

In the “old days” — prior to last spring — the patient’s physician would have reviewed the mammogram, and called her to explain the significance of the results, offering some much needed reassurance as well. Instead, the result was made accessible to her on a Friday evening, before her (then off-duty) doctor had seen the mammogram report. It fell to me to return her call and do the above, rather than her hearing it directly from the doctor with whom she has spent years building a trusted relationship.
None of this surprises me. My partners and I all groaned when we were informed of the regulatory change, and predicted that our already crushing workload was about to be drastically increased, as the volume of calls from anxious patients over non-urgent or minor issues would go up exponentially. I wish we had been wrong, but so far experience suggests otherwise.
Of greater concern, however, is that, sooner or later, a patient is going to see a truly terrifying result before I do. It is never good to receive a diagnosis of, say, lung cancer. But I believe that a patient will be better off hearing it directly from a medical professional’s mouth. We have experience delivering this kind of news, and can be there to answer the inevitable flood of questions that follow. Reading shocking results in incomprehensible medical jargon online, alone, isn’t good for anyone’s health.
Nobody in the U.S. government seems to have considered this possibility when devising this new set of regulations. Instead, the push toward ever greater transparency — seemingly an end in and of itself, rather than a means toward improving healthcare — has prevailed.
But allow me to back up a bit.
In the Beginning
As part of the 2008-2009 stimulus package to combat the Great Recession, the U.S. congress passed the “HITECH” act. (That’s an acronym for Health Information Technology for Economic and Clinical Health.) This act offered both carrots (financial incentives) and sticks (penalties for non-compliance) to medical practices that adopt electronic medical records and demonstrate that they engage in “meaningful use” of such records. In other words, medical practices could not havean electronic medical record only as a form of mere window dressing. Rather, they had to demonstrate that they actually use it day to day in the care of patients.
The hasty implementation of these records has led to extreme frustration on the part of doctors. But to focus on one aspect of the “meaningful use” requirement: these records had to have a patient portal. And, over time, practices had to demonstrate that they were using this portal more and more for interactions with patients.
Dear Ms _____
We are running a test of our patient portal and want to make sure you received this message. If you could, kindly click reply and type the word “yes.”
— Doctor Bittermilk
Most of my patients probably assumed that the above message was sent in a good faith effort to ensure that our portal was working correctly. But the reality was we had a deadline approaching: we had to demonstrate to Medicare and the insurers that at least 10% of our patients had sent a message at least once during the year. Several thousand “yeses” later, we qualified for the next set of “meaningful use” incentive money.
Meaningful to me or my patients? No.
A true improvement in healthcare? No.
Meaningful to my practice’s bottom line? Hell yes.
Regardless of the above shenanigans, a decade plus of pursuing “meaningful use” measures has indeed meaningfully changed my patient’s use of the portal. A substantial number of them now use it to write me, review their lab work, schedule appointments, request refills, and otherwise conduct their business.
And that’s a problem.
Now, in addition to caring for patients, fielding phone calls, filling out paperwork, and reviewing reams of lab results and reports that come in on my patients each day, I’m also expected to answer all of the above messages arriving via the portal, including some that are medically complex. None of this work is compensated in any way by the insurers, so it sometimes adds up to an hour or more of essentially free labor extracted out of me on a given day. And it’s not at all clear that by fielding such messages I’m saving work that would otherwise have to be done elsewhere, say during a patient visit. Rather, many patients now have the sense that, since they can easily write to me anytime of day, they can go ahead and ask me trivial questions that they maybe wouldn’t have bothered asking in a prior era, such as my reaction to some healthcare-related story on the news.
A decade plus of pursuing “meaningful use” measures has indeed meaningfully changed my patient’s use of the portal. And that’s a problem.
In sum then, patient portals were implemented not via an organic process in which their value to both patients and healthcare workers was demonstrated, but by federal dictate, on the assumption that making your doctor’s office more closely resemble an e-commerce site would magically improve healthcare quality and costs. Instead, while portals certainly have brought some helpful features to our healthcare system, they have created a lot of extra anxiety for patients and work for doctors.
Could we design a better patient portal?
What the Portal Should Be
It’s easy to complain about large government programs with unintended consequences, such as the way that patient portals were implemented in this country. But patient portals haven’t been all bad. They can and should play a role in our healthcare system moving forward.
Current patient portals allow patients to see both their medical history (results of prior labs and x-rays, for example) as well as their present (current results, and the generation of email messages with their doctor). The former is truly useful; the latter is where problems lie.
Access to prior results can be very empowering. For example, a patient might be able to see how their cholesterol compared in two different years, or note when they last had a mammogram. This sort of information can help patients to stay on top of their health.
By contrast, patient visibility of current lab results — that is, results that are “hot off the press” and that perhaps have not even yet been seen by their doctor — doesn’t make a lot of sense. Doctors spend years training to be able to interpret lab results, and even then there can be a lot of nuance and integration of patient factors such as age, medical conditions, medications, and so forth, in understanding what a result signifies and when it is truly worrisome. It simply isn’t realistic to expect most patients to be able to do this for themselves; offering patients access to results that they can hardly understand can only sow fear and confusion.
Your Past, Not Your Present
Similarly, there’s certainly nothing wrong with letting patients send their doctor’s office a quick message about something via an email-like interface, and features like being able to request refills or schedule appointments online are clearly a useful convenience. But it’s neither fair nor realistic to expect doctors to take on large amounts of extra, entirely uncompensated work in the form of responding to a constant barrage of long and complex medical questions sent via the portal.
With almost fifteen years of widespread use under our belt, we now have the experience to revise and scale back. The patient portal should be a central location for housing prior reports and patient history, with doctor-patient communication features primarily around scheduling or refill logistics. If we focus the features of patient portals into the areas where they can be most helpful, doctors and nurses can get back to focusing on patients.
This is one of an ongoing series from Dr. Bittermilk, offering solutions to a variety of issues surrounding the U.S. medical system.
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Dr Reginald Bittermilk