A commonly voiced fear that patients will become overly persistent emailers and stalk their GPs around the clock if practices introduce patient portals has been dismissed by early research into the technology’s use in New Zealand.
Tom Love of health policy and analysis research firm Sapere Research Group told the Health Informatics New Zealand (HiNZ) conference in Christchurch yesterday that as well as dismissing fears about persistent emailers, the research showed that another concern – that patients would start bugging their GPs by emailing questions of a clinical nature – is also somewhat unfounded.
The NZ government and the National Health IT Board are keen to see patient portals being more widely used to both improve efficiency within practices and free up practitioners to spend more time with patients rather than paperwork, but also to provide more information to patients more easily.
While it was hoped that all patients would be able to access their GP-held medical information through a portal by last year, uptake of the technology by practices themselves has been much slower than hoped for. Health Minister Jonathan Coleman told the conference that 260 of the estimated 1000 primary care providers were now offering at least a partial portal through which patients can book appointments, request repeat scripts and correspond electronically.
Dr Love’s team was commissioned last year by health IT support organisation Patients First on behalf of the NHITB to do some financial modelling to look at how the introduction of patient portals would affect general practice costs and revenues.
Sapere and Patients First have since developed an interactive modelling tool that practices can use not just to model their bottom line but look at where savings can be made in terms of staffing, whether that be by redeploying admin or nursing staff or delaying employing new admin staff for longer.
(Patients First has also completed a review of the patient portal market in NZ, which includes information on the portals available from GP desktop vendors but also what consumers would like to see offered through the technology.)
However, before the modelling was started Sapere did some primary research, interviewing a number of practices that were using portals to gauge their fears and concerns before proceeding.
“We asked them questions about what had the discussion been like when they made the decision to get a portal, what were they concerned about, and we asked them a bit about their experience with their portal,” Dr Love said. “What had happened? Did they have lots of emails coming through in the middle of the night which they struggled to cope with?”
Dr Love said increased workload was a big worry for GPs. “They could see more work coming but they couldn’t see where the work was going to go, particularly the issue about persistent emailers,” he said.
“There is a lot of concern that you are going to be stalked by patients, although there was one GP who pointed out that you get a lot of frequent consulters anyway and if you are going to be stalked by someone it is actually more convenient to be emailed than in person.”
He said legal liability was also a big concern, particularly around the notion of how to effectively do a consultation over the internet without doing a physical examination. However, Dr Love said most GPs realised they were still in control and retained the ability to tell the patient they had to come in for a face-to-face consultation.
There was also concern over patients sending emails in the middle of the night asking questions of a clinical nature. However, practices reported consistently that it was only about 1.5 clinical queries per patient per annum, he said.
“I was pleasantly surprised to see there was such a consistent number reported. How generalisable that is I think time will tell but it is an encouraging start.”
Practice efficiency
In addition to the primary research Sapere undertook, it also had a number of what Dr Love called ‘design assumptions’ about how a portal might work based on previous research done with integrated family health centres.
This data includes a number of detailed time diaries that tell you how much time it takes for a practice nurse or a receptionist or a doctor to do a lot of the daily tasks that happen in practices.
“We had some quite hard quantitative information on the impact that a portal might have if you were able to streamline some of those processes,” he said.
What the research found was that much of the clear benefit of a portal arises from low-level tasks, particularly repeat scripts.
“It’s really interesting when you start getting into the detailed numbers about how much time is involved in general practices about producing repeat prescriptions,” he said. “How many phone calls between patients and a receptionist, between a receptionist and a nurse, how much that conversation goes around between different individuals in a practice before it gets to the GP who signs their name on the script. It is actually quite time consuming.
“Then you get the thorny question of doctor workload and substitution. Is a portal just going to be more work, … [or is it] going to start to substitute from the grind of your 32 consultations during the day?
“That’s very much open. It demonstrates the intimacy of a patient portal – it has to exist in the context of the model of care that the practice wants to run and the way you use it can be very different. It certainly enables you to substitute certain elements of doctor workload if that’s something you want to pursue as a practice and increasingly many practices do.”
Financial gains
Dr Love said there was no doubt that the main financial gains to be made from patient portals was in releasing resources for other work, such as releasing practice nurses to run clinics or not being so resource-intensive in terms of admin staff.
Dr Love said this is a sensitive issue but it can involve hard, cold cash. “We had one practice that was growing very quickly, and for them an ePortal meant that they could delay employing an additional staff member by probably 18 months,” he said. “That’s real money and is very important to them.”
From the modelling, Dr Love’s team can show that if the work that is coming in from a portal does not substitute for existing GP work, then the portal will require more GP time.
“It’s not an enormous amount of GP time and we can work it out more or less in absolute terms for practices of different sizes,” he said.
“Where you see really good gains is with your nursing and administration staff. That is where you see quite significant reductions in the amount of time involved. For a large practice, you are talking two or three admin staff. That is quite substantial.
“If you start substituting some of the general practitioner workload activities, then you can have even bigger gains. There is also a better gain for bigger practices – the bigger you are, the more you will gain proportionately.”
However, he did warn that charging patients for the convenience of using a portal had, with a few exceptions, not worked very well for practices. The financial modelling shows that scale is important to get the gains, and charging might be counter-productive despite the financial investment that practices have to make in licensing portal software.
“We had a number of practices that had set up portals and had charged patients for that service, which, with a couple of exceptions, hadn’t worked that well and tended to be a barrier to uptake,” Dr Love said. “This in itself is a problem, because the scale of uptake is really important.
“We saw some of this when it gets to the modelling, but it also certainly comes through anecdotally from practices that the scale of uptake of a patient portal is really important. If you are running a portal for five per cent of your patients, you are running two systems and it is actually taking more resources to run than it is worth.
“If you are running 50, 60 or 70 per cent of your patients, [providing] repeat scripts, lab results, those sorts of things through a portal, then you are really starting to see gains from it. Scale of uptake is important and that’s really where the [issue of] charges is a tricky one. If you are going to reduce the uptake by imposing a charge then you might be cutting off your nose to spite your face.”