Patient portals have evolved from offering self-service tools for clerical tasks such as bill paying and appointment setting, to more clinical applications such as entering remote physiological monitoring data and filling out intake questionnaires.
In the process, portals have empowered patients to “transform their role from a recipient of health care to a partner in health care,” according to an AMA STEPS Forward® toolkit, “Patient Portal Optimization.”
But there has been a downside.
“I could fill my entire day just responding to patient messages and never actually examine anyone,” wrote Michael Stillman, MD, in a JAMA® “A Piece of My Mind” essay referenced in the toolkit.
While some messages, such as routine prescription refills, could be responded to quickly, “many requests were higher order,” wrote Dr. Stillman, an internist in Philadelphia.
“Patients would write asking me to adjust their medication doses, to comment on consultants’ opinions, to review studies other physicians had ordered, and even to perform literature searches on novel therapies,” he added. “Several times a week, I would be hit with a page-long recitation of symptoms ending with the dreaded one-word paragraph, ‘Thoughts?’”
The toolkit further describes the experience that Dr. Stillman and many other physicians have gone through.
“The increasing use of patient portals and expectations around care team availability for asynchronous communication has also challenged physicians' work-life integration and contributed to professional burnout,” the toolkit says.
“Expectations” is a key word here.
The toolkit outlines a five-step process for engaging patients while also minimizing the burdens of the care team. One of these steps is to set the right patient expectations for portal use.
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Setting expectations
The toolkit recommends providing new patients with a printed handout that outlines reasonable expectations for responses and guidelines for portal use.
A sample document is provided and suggested content includes:
- Communicating the expected response time to patient messages.
- Setting character limits for portal messages.
- Restricting the ability to send messages to patients who have seen the physician within a certain timeframe such as the past one to two years or if they have an upcoming visit scheduled.
- Alerting patients that they could be charged for patient portal messages that require clinical decision-making.
Physicians are also encouraged to:
- Send a message or provide a handout to patients describing their personal preferences for patient portal use.
- Remind patients during their visits about the workflows in place, and refrain from making exceptions to those rules.
- Be open and honest with patients if they are sending too many messages. It may be helpful to set boundaries with them for patient portal use and instead schedule more regular in-person follow-up appointments.
Experts agree on the importance of this step.
“We’ve worked hard to set expectations on appropriate portal use for patients, physicians and staff,” C. Becket Mahnke, MD, the chief medical officer for North Central Washington State-based Confluence Health, wrote in an essay for the AMA.
“We no longer speak of ‘messaging your doctor.’ but have changed this language to ‘message your physician’s office’ to ensure a team-based focus,” Dr. Mahnke added.
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Matthew Sakumoto, MD, chief medical information officer for Sutter West Bay Region in San Francisco, stressed the importance of setting clear and consistent expectations on patient portal response times.
This includes providing guidance on the clinical appropriateness of what can—and cannot—be handled via message and that relaying some information may require a virtual or in-person visit.
Patients should know upfront that you usually will not resolve their question within seconds or even within hours. If a clinic has the capacity, it could be by the end of the day, but there could be instances where it takes three to five days.
“Setting those clear timelines and acknowledging receipt, that has helped to really knock down the amount of repeat messages that we'll get from patients,” Dr. Sakumoto said in an AMA webinar that is available on demand.
Sutter Health and Confluence Health are members of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Christine Sinsky, MD, vice president of professional satisfaction for the AMA, offered similar advice on taming the EHR inbox.
In an AMA STEPS Forward® webinar (registration required) that focused on a system-level approach to EHR inbox reduction, Dr. Sinsky noted the need to set proper boundaries on patient portal use.
“At the individual physician level, it’s important to recognize that the inbox is not the place for patients to access care for urgent needs,” Dr. Sinsky said. “Physicians should communicate that through standard information given to patients about the portal when they sign into it.”
Additionally, patients should be informed “that the team will answer their questions during normal business hours,” she said. “And then physicians can reinforce that by responding only during business hours.”
The AMA toolkit has downloadable guidelines for patients on portal use as well as an example letter to send patients about electronic messages.
