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Wednesday May 28, 2014

Patient Portals: Useful Resource But Expensive Mandate

To spend money on a patient portal, or not to spend money on a patient portal right now: That is my dilemma.

I am in a three-physician family medicine practice. We have no physician assistants or nurse practitioners. Our small practice held off on buying an electronic health record (EHR) system, waiting for the Veterans Administration to release VistA (Veterans Health Information Systems and Technology Architecture) to the public domain. That system initially won many awards when fully supported, but licensing of proprietary modules is required for it to function correctly. Thus, we were forced into the commercial marketplace. 

Our path took us to the EHR system that we have used for the past eight years. These have been expensive and emotionally taxing years. Our original trainer, sent by the vendor prior to implementation, gave us some bad information and advice. (Although the company eventually fired him, they still charged us for all the time he spent "helping" us.)

Last year, our server was hacked, causing it to crash. Three weeks and tens of thousands of dollars later, we were back up and running.

We have worked hard and diligently to do the right things. Before the words “meaningful use” even entered our lexicon, we participated with our local Medicare Quality Improvement Organization on a project involving colonoscopy, Pneumovax administration, mammography and flu vaccinations in our patient population. We finished either first or second among the practices for meeting goals set by Medicare.

Meaningful use stage one was our next project, and we successfully fulfilled that government mandate. Meaningful use stages two and three, as well as National Committee for Quality Assurance recognition for transforming to a patient-centered medical home, will be our next projects. All three require upgraded hardware and software, which we acquired after our server crash pushed us in that direction.

We also are considering the addition of a patient portal, which is a requirement of meaningful use stage two. I understand the importance of fluid patient communication, but the cost of complying with this requirement seems steep.

Initially, our vendor was going to charge $5,000 per physician, plus training and a per-use fee. A "use" could include an email, an appointment or a payment received through the portal, and there would be no way for us to limit a patient from inundating us at our expense. That price -- before the server crash, at least -- seemed unfathomable.

The vendor later decreased its asking price by roughly $8,000 to initiate, but the per-use fee and training costs still remain.

What to do? Could we run a parallel program on a free EHR with a free patient portal? Should we spend the kind of money that the vendor is charging? A patient portal has the potential to reduce the number of phone calls we handle, but it also could result in more electronic messages that require responses. Can we, and should we, charge our patients for electronic access to help defer the cost?

What is the return on investment of implementing a patient portal? A Kaiser Permanente study showed that outcomes for patients with diabetes and/or hypertension improved within two months with the use of secure patient-physician email. Another study involving Kaiser patients showed that those who enroll in a patient portal that allows secure messaging with physicians, access to clinical data and self-service transactions are more than two times more likely to stay with a practice than patients who do not use such online resources.

A study in JAMA: The Journal of the American Medical Association found that patients with online access to their medical records increase their use of clinical services.

Still, I'd like to hear from my fellow small-practice physicians on this issue. I'd like to hear about your experiences in this brave new world of constant access and costs associated with electronic data. I look forward to learning people’s thoughts and, hopefully, coming to peace with a definitive decision.

Have patient portals helped your practice, and have they been worth the expense?

Rebecca Jaffe, M.D., M.P.H., is a member of the AAFP Board of Directors.


Of all the meaningless things in MU, I really thought the patient clinical summary and portal had the most potential benefit. Unfortunately, both are currently "add-ons" to my primary software and clunky to integrate into the existing workflow. For a portal, I would not sign on to any "per use" fees, that seems wrong. In my rural solo practice, I have had few patients interested in the portal, those that are, are. I think it could be a great time saver in getting results out to people and wish more did use it, but don't like the threat of BIg Government mandating that we have to use it. If its so great, then we will do it in our own time. MU started as an economic stimulus project but we should have known to be wary of Federal money that always comes with strings attached.

Posted by Jeff Harwood, MD on May 29, 2014 at 11:14 AM CDT #

When I opened my solo practice in 1986, I gave every new family a notebook to keep copies of their lab work and office visits. (This was before the personal computer was invented). I see about 25 patients a day, of whom around half will generate lab work or other studies. We get the stuff back the next working day or the day after, and call them all, answering follow-up questions at that time. My phone number is in the book, and my beeper is near my body 24/7, because I do obstetrics. But they don't call me, because our highly efficient office keeps up with our work every day, and same day appointments are always available. S0-- who needs a portal? For that matter, who needs an EMR (except I love my nearly free eprescribe program, the only part of the EMR which increases productivity)? I've never been hacked. I've never been unable to access my records. My IT needs are minimal. My income is twice the FP average. I must be missing something.

Posted by Doug Iliff, MD, FAAFP on May 29, 2014 at 12:59 PM CDT #

I find it ironic that my computer balks at the Leader Blogs, which are frequently about something related to computer technology, and I can only enter text in a most unfriendly manner. Anyways back to the main point. You asked for our experience with patient portals. The short answer I would give is to not waste your time, energy, or money. Here goes the longer answer. Over the past 3+ years I have spent half my time working with an "informatics" team in an integrated community hospital setting and the other half practicing. My wife asks what I do in the mornings and I say I teach highly educated people how to press buttons on a box (basically true). In addition to helping institute EMR and all it entails I also work with a PCMH team. The catch-22 with EMR and the patient portal is that it is required for meaningful use. Here are the negatives for a patient portal. It requires time. You will have to train your entire staff on this topic and it will give them more things they need to remember and do - continually - it's a never ending process. After a huge system wide push to try to get people to sign up for the service we see very little usage by the patients. It's a constant worry if we have enough patients "with access" and being able to prove the "have access" (i.e. meaningful use) and it's going to be even more of a worry that the arbitrary 5% actually view, download, or transmit data via the portal but if you go for meaningful use the portal will be required. Stage 2 MU criteria is onerous. Based upon my interactions with a lot of providers there are a few that like it, a few that do not like it, and most are neutral about the portal. My personal experience is that I can remember about 4 patients the past year in which I remarked to myself that the patient portal was a useful tool. On the other hand I have about 4 patients that seem to have figured out their messages essentially come straight to me and they use the portal almost every single day. Overall I am not impressed with a patient portal over and above other forms of communication. At best I would grade a portal as just another way to communicate - just a lateral move. Based upon my response you might think I'm anti-technology but that would be incorrect. One day one when I opened my solo rural practice in 1991 I was using a computer on the business end for appointments, electronic billing, and implementing RVU's as a billing tool. I have been personally using computer for 25+ years. I am not anti-technology. I am anti-bureaucratic mandates regarding technology. Three years into EMR with MU it is looking more like a bureaucratic mess than a useful tool. Please forgive any errors or poor grammar. There is an unexplained glitch on this web page and I cannot easily go back and correct problems.

Posted by John Sherard on June 05, 2014 at 08:18 PM CDT #

Posted by on June 13, 2014 at 12:47 AM CDT #

I appreciate the thoughtful comments. It is the secure communication piece that I would like to have--- and to try and do the right thing... and to continue to attract a younger tech based patient population but the financial cost and obligation is our stumbling block. Our patients can already retrieve their lab work directly from the lab, and we add that they should get it by mail as well-- that is already happening. We are working with our local (state) information network on two way communication with specialists-- without the add on. Ironically, since writing this piece I learned that there was a free add on-- but a week later the EHR vendor discontinued the free patient portal access. Now the portal is one fee and the MU2 piece is a second fee that needs to be bought together-- more financial barriers-- The other alternative is to charge the patients for access to the portal-- anyone doing this and if so, how much are you charging for the access? Thanks to all. Becky

Posted by Rebecca Jaffe on June 30, 2014 at 08:26 AM CDT #

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