American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, February 24, 2014

Hospital patient IT portals are a nice idea, but ...

Patient portals are very much the future of health care. Having easy access to ones’ medical history, diagnoses, and test results, seems like such a natural thing that it’s hard to imagine that only a couple of decades ago medical information was regarded as private for the physician’s eyes only.

Of course, the Internet and a technology revolution have taken this concept to a whole new level. Health care organizations across the nation have been embracing “patient portals” to give patients online access to their records. The federal government’s Meaningful Use policy has provided significant financial incentives to do this.

Among the first to roll out the technology have been the larger multispecialty-type groups that are affiliated with established hospitals. Meaningful Use Stage 2 stipulates that at least 50% of patients must have timely online access to their records, and 5% of patients must transmit electronic health information to their provider. It remains to be seen whether imposing these targets will truly improve patient care (although the concept certainly sets the stage for doing so). But while increasing patient engagement via health care IT is an extremely useful idea for outpatient use, a debate is taking place as to how this should work for inpatient care.

Imagine the future scenario for a hospitalized patient. The doctor walks into the room, and the patient has already seen test results, whether on their own smart device or a flat screen at the end of the bed (now we really are talking about the future). Theoretically, this should make the doctor’s job easier in terms of explanation and implementing a strategy. The medical profession should welcome this model of patient-centeredness. The more engaged and informed the patient, the higher the likelihood of a better outcome.

Nevertheless, some hospital-based physicians are rather uncomfortable with the idea that hospitalized patients will be able to routinely access their results electronically. I must admit that the times I’ve walked into a patient’s room and heard them tell me what that morning’s blood test results are, it has thrown me off a bit! However, this has really only happened a handful of times, probably under half a dozen occasions in my 5-year career in hospital medicine, and typically it’s been a relative rather than the patient who has pulled up the information.

Despite the easy access that many patients now have, uptake of IT portals has been relatively slow when it comes to hospitals. Does the vision of the future involve patients rapidly accessing all of their test results while they are still lying in the hospital bed? Time will tell, but right now a number of barriers exist:
• The average age of a hospitalized medical patient is over 70 years old. Simply put, this population isn’t the tech-savvy generation that is comfortable using laptops and smart devices;
• People in hospital are often too sick to be scrolling around a screen and digesting complicated information on their own;
• Patients may not have ever used a health care IT portal before, and during their hospitalization is not really a good time to learn;
• In a significant number of hospitals, the technology isn’t yet available to enable patients to get real-time access to their results;
• Low health literacy and patient engagement. There has to be a reasonable baseline understanding of what the different test results mean. A large proportion of patients, especially those from socially disadvantaged backgrounds, are considerably less likely to use and embrace health care technology. And even for more highly educated patients, many seem comfortable putting their complete trust in the doctors and medical staff, and await their results and prognosis to be delivered to them in person rather than access it themselves.

These 5 points are important reasons why IT portal use has been limited among hospitalized patients. Another limitation is that unlike the outpatient setting, getting information in hospital is more complex and presents a whole new set of challenges, particularly when we’re talking about “real time” access to test results. Viewing laboratory values without waiting for the doctor is one thing, but what should the protocol be for getting imaging or pathology results? Or dictated consultation notes? Most of this other information needs to be “electronically signed”, which can take several hours or days. Having this information available to patients before it is reviewed and signed off could potentially result in serious consequences. And on a human level, if the patient was faced with a potentially devastating diagnosis, would it ever be better for them to have access to the result before the doctor had the chance to sit down and talk with them? Even in the ultimate patient-empowerment model, this is a difficult case to argue.

So while the future almost certainly involves hospital patients accessing results themselves, the implications of this need to be considered carefully. As patient portals become more common, health care organizations must decide how best to use them. The question is: how much real-time information is too much?

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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