Patient Portals: If You Build It, Will They Come?

With the advent of meaningful use (MU) came the increased, and required, use of patient portals. These portals were meant to be a tool to assist in achieving the goals of the Institute for Healthcare Improvement’s (IHI) Triple Aim Initiative (Triple Aim): improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of healthcare. The premise behind the Triple Aim was that if patients had better access to information about their health, along with the ability to schedule appointments and better communicate with their providers, their satisfaction and outcomes, and thus costs, would improve. The portal was always an intent since the initiation of MU in 2011, and became required for those participants attesting to Stage 2 by 2014. Six years after MU inception, portal use remains less than optimal.

A recent study conducted by the U.S. Government Accountability Office (GAO), based on data from patients of 2015 Medicare EHR Program Participating Providers, found that while almost 90 percent of hospitals offer patients portal access, only 15 percent of patients are leveraging this technology.¹ This paper explores some of the factors affecting patient portal adoption rates of U.S. provider organizations and shares some best practice strategies for improving portal use.

A Moving Target: Required Adoption Standards

The MU Objective scores for actual patient “use” of their personal portal varied tremendously based on the system, how the portal was promoted and rolled out, and patient population demographics. CMS initially set the adoption bar very low—only 5 percent—and then bumped the requirement down further to only require one patient view, download, or transmit (final rule release for Modified Stage 2 on October 6, 2016). With an already low standard, this further decline to almost no necessary adoption all but diminished market momentum.

Prior to this reduction in what CMS defined as “adoption,” adoption ranges covered a broad spectrum—from as low <1 percent to an average of 7.5-12 percent, with a few select organization reporting as high as 30-40 percent. In light of these new CMS requirements, many organizations chose to adopt a “check-off-the-box” approach, implementing a portal with minimal functionality, and easily achieved the minimum requirements with little to no effort to encourage patient adoption. Once MU was achieved, adoption rates in many organizations further declined.

What Factors Impact Portal Adoption? 

Adoption rates can vary for many reasons, from the vendor system chosen by the provider, to patient socioeconomic demographics, patient health, how the organization goes about encouraging patient adoption, and more.

Some reports suggest that a large part of the battle is simply choosing the right vendor. Although most portal technologies have the same basic functions, some vendors offer additional features that make access more beneficial and appealing to patients. Definitive Healthcare found that top portal vendors include Allscripts, athenahealth, Cerner, and Epic.² Some of the special features these vendors offer are mobile apps, appointment scheduling, secure submission of medical questions, prescription renewal, and more.

The GAO study found that providers in rural, high-poverty areas or areas with a smaller senior population, as well as smaller practices with 50 or fewer members, saw lower patient portal adoption. In addition, subspecialists had lower adoption rates than general and specialty providers (i.e., dentistry).³  

A 2015 presentation by the Center for Health Care Research and Policy, The MetroHealth System, and Case Western Reserve University also supports the socioeconomic disparity when it comes to portal use. The presentation showed that only about 20 percent of the MetroHealth System’s Medicaid-covered patients had logged in, compared to 36 percent of commercially-insured patients.4 They also found that of the users who engaged in what the report called “Common PHR (personal health record) Activities” (i.e., reading messages, viewing lab results, checking allergies, and requesting advice), “males, racial and ethnic minorities, patients age 80+, and Medicaid and uninsured patients had lower levels of use across all categories.” A blog authored by Bill Callahan reports that, “The researchers characterize this pattern as ‘an emerging inequality.’”5 This blog further states that researchers reported that, “Differences in the uptake and use of PHRs could increase or exacerbate health disparities.” As we move to value-based care, the need to engage patients in their care becomes more and more important, and subsequently, the use of portals more critical.

The GAO study also found that patients were most likely to use a patient portal before or after an appointment to send information to their provider or view test results, or if they have a chronic disease that makes monitoring health information regularly important.6 The study posited that adoption rates are low because many patients—especially those who are young and generally healthy—don’t have a reason to access their health information on a regular basis. Another reason for poor buy-in from patients may be a limited ability to view all of their healthcare data, from various providers and specialists, all in one place.

Adoption rates remain low despite a concerted effort from providers to encourage patient portals use. The study found that most providers offer educational materials, in-office computer access, reminder emails, procedure discounts, and other resources to generate more interest in portal adoption.

Keys to Adoption Success

Feedback from patients and CTG’s observations from the field show that organizations who embraced the use of portals from the beginning and who made a commitment to view the implementation of MU as a vehicle to improve overall quality and outcomes, fared better. In CTG’s experience, barriers to portal adoption post-implementation include limited functionality and the use of multiple portals, with multiple log-in requirements, from the same hospital system. CTG recently found one organization with five different portals in use, ranging from the EHR, OB, Oncology, to multiple physician offices with different EHRs. Data was frequently found to be missing or entered late and each of the five portals had limited functionality, which resulted in a high degree of patient dissatisfaction and low portal adoption.

Additionally, we found that portals built for “true” functionality had higher adoption rates, while those built simply to achieve the minimum MU requirements did not create loyalty or the desire for patients to return to the portal. Some examples of this “check-the-box” implementation included patients being directed to a scheduling request form or shown a listing of numbers to call after they logged in. This absence of automation has a significant impact on adoption.

CTG’s experience shows that most patients will make a determination of whether the portal is worth their time and use based on the first, at the most two, log-in activities. In order to maximize engagement, it is critical to have key, user-facing functionality available from day one. When there is perceived value by the user, adoption occurs. Further, it is critical to have a clearly defined communication plan in place that provides ongoing education to patient users when significant portal changes are made. PHRs, PHPs (personal health platforms), patient portals, etc., are certainly a technology, which, when well-designed and implemented, can deliver significant value and subsequently produce high adoption rates.

Despite a general low rate of patient portal adoption, organizations like KaiserPermanente have reported adoption rates much higher than the ranges reported by other organizations—up to 45 percent.7 So how does an organization learn from those who have achieved better-than-average adoption rates?

Embracing a set of key guiding principles should be considered:

• Adoption begins at the top, with a focus and commitment on embracing the technology as a driver to increase quality and improve outcomes. This must be communicated clearly and people must understand the “why.”

• The use of physician/provider champions who understand the technology and can share their knowledge and passion with others, is a key driver to success. Assign a portal leader and turn physicians into portal advocates.

• Design of the portal, with access to the entire network of providers is key. No patient wants to go to multiple portals to manage their care, thus, a seamless view across the system is critical.

• Progressive organizations are involving patients in the design and feedback process for patient portals.

• Functionality must be robust. Patients want to have secure messaging to contact their providers, the ability to schedule online in a seamless fashion, and the ability to view meaningful data that will allow them to take ownership of their care. Features such as online review, bill scheduling, and family access have added benefit.

• Data must be entered in a timely manner. Metrics for data submission should be set, and this should be monitored, along with expectations set for compliance.

• The use of patient self-monitoring tools such as downloads for blood sugar, blood pressure, weight, and other key metrics support active patient engagement and two-way communication between patient and provider that can reduce hospital admissions and improve outcomes.

In summary, MU introduced an opportunity for organizations to embrace a technology that can empower patients to take ownership of their care. While adoption rates for hospitals average 15 percent, high-performing organizations have reported rates upwards of 40 percent. The move to value-based care makes the business case for improving portal use an imperative. Understand your organization’s adoption rates, analyze your portal design as well as the needs of your patient population, and utilize this time to embrace lessons learned from high-performing organizations.

1 U.S. Government Accountability Office. 2017. “Health Information Technology: HHS Should Assess the Effectiveness of Its Efforts to Enhance Patient Access to and Use of Electronic Health Information.” U.S. Government Accountability Office (GAO). Accessed July 24, 2017.
2 Monica, Kate. 2017.”Top Hospital Patient Portal Vendors by Implementations.” PatientEngagementHIT. Accessed July 24, 2017.
3 U.S. Government Accountability Office 2017
4 Perzynski, Adam T., Mary Jo Roach, Douglas Einstadter, Douglas Gunzler and Bill Callahan. 2015. “Emerging Inequality in Adoption and Use of the Personal Health Record at a Large Urban Safety Net Care System.” Accessed June 21, 2016.
5 Callahan, Bill. 2015. “Lifeline Comments: Maximize Impact Of Lifeline Broadband On Personal Health Record Adoption.” National Digital Inclusion Alliance. Accessed June 21, 2016.
6 U.S. Government Accountability Office 2017
7 Geyer, Sherree. 2015. “Patient Portals More Useful than Many Realize.” Healthcare News. Accessed July 24, 2017.

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Joseph Esdale, Client Support Manager, Health Solutions
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