Stage 2 of the government's Meaningful Use Program requires that at least 5 percent of patients view, download, and transmit their health information and send a secure electronic message to their provider. The CMS lowered this objective from 10 percent to 5 percent when it published its Stage 2 final rule.
With the transition to Stage 2 starting in 2014, even the lowered objective spurred anxiety in the healthcare community over whether achieving the goal of patient engagement is even possible.
"I think it's going to be a rocky transition," said Zachary Landman, MD, and CMO at DoctorBase, "There really aren't too many people that are doing effective patient engagement"
Providers have, for the most part, struggled with adopting patient portal technology. But these struggles stem, in part, from a simplistic understanding of the technology.
"The idea was that if you just created it, it was a checked box: We have a portal, check" said Landman.
A common thread throughout the current discussion about patient portal technology is that having a portal does not guarantee patient engagement. This stance, in Landman's view, is in reaction to this check-box idea of portals. It reflects a conservative view of patient engagement, one that views patients as uninterested in managing their own care when they are away from a doctor's office.
This misconception of patients has, it seems, hindered the development of patient portals as the meaningful tools many expected them to be - and still believe they can be - in the healthcare industry.
"There is this latent belief in the healthcare industry that it's too complicated, patients won't understand it, they're not going to do it," Joanne Rohde, CEO of Axial Exchange, told Healthcare IT News. "And our view is that's simply not true. Most people want to be well and most people want to understand what's going on in their bodies. And if it's complicated, but it pertains to them, they're going to learn about it."
While Rohde acknowledged that some patients might be disinterested, they are a minority. And, The healthcare industry, by focusing on this patient segment, has done a great disservice to those interested in educating themselves on their own health.
Not about the technology
Steve Wilkins wrote in "Patient Engagement Is A Physician-Patient Communication Challenge...Not A Health Information Technology Challenge" for his blog Mind the Gap, "People who show up for a doctor's appointment are already engaged" since their very presence indicates that they wish to better understand how to be healthy. When a patient shows up, he said, "they have to believe that the need or reason merits seeing the doctor vs. taking care of it at home themselves - this generally implies cognition and doing research, i.e., talking with friends, going on line, etc"
In other words, a patient's decision to see his doctor can be motivated by learning from the information he gathered he requires treatment. The doctor, then, is not the primary source of health information for the patient, but assesses the information the patient brings to the encounter.
When patients educate themselves, they bring more information, making the encounters easier for the doctor and thus more productive.
Wilkins' reasoning points to an issue at the heart of the confusion surrounding patient portals: vendors and providers have been developing technology for influencing patient behavior away from points of care without knowing how patients behave, regarding their health, in between visits.
"We also have to teach the hospitals things about their patients," said Rohde, "One of the reasons in my opinion for that misconception that patients aren't concerned with their own health is people don't actually know what you do when you leave the hospital."
For example, Axial's research has found that many patients record their mood, a finding that both surprised and gladdened practitioners. The issue is that no one knew that a mood tracker was a sought-after feature among patients. Becoming more attuned with what information patients wish to monitor could facilitate improved, or patient-centered, patient portal development.
Patient-centered means patients determine their own portal experience. They can use a portal application to engage with the information most relevant to them. Axial's apps feature access to the Mayo Clinic medical library and numerous health trackers, including one for mood along with blood pressure, glucose, migraines, and several others.
"If you've got a condition, we're going to help you through it," said Rohde, "we're going to teach you about your disease and we're going to teach you how to take care of yourself. And that's the huge distinction in my mind between best practice and checking the box."
Landman offered his take on patient portal best practices, complementing Rohde's insofar as he argued for a patient-centered philosophy. He focused on a different misconception of patients, though, dispelling the idea that as a patient, when engaging with a difficult-to-use portal, "you're willing to overcome all that amount of activation energy, because you're so motivated to communicate with your doctor and take care of your health."
For Landman, a patient-centered portal will not hinder patients' pre-existing efforts to engage with their health, but will give them an easy-to-use platform that can simplify and hopefully enhance them.
This last point highlights that the stakes for developing a patient portal are not just failing to get patients to use the new technology and missing out on meaningful use incentives. A portal that is difficult to use or only offers clerical functions, such as bill paying, refill requests, and appointment scheduling could turn out to be ignored, even maligned.
"That's a huge PR disaster," said Landman, "Not only did you create a rushed app maybe no one uses. You just created everyone hating you."
If getting it wrong, even the first time, means a ruined public image along with a failed IT investment, understanding the best practices for developing patient portals is a pivotal issue in the healthcare IT industry
How HIT professionals amend their approach to portal technology stands to have tremendously beneficial implications for the healthcare industry.
For Rohde, this change to a more consumer-focused mindset is already happening, "but it's going to happen a lot in the next three to five years. And in the next three to five years, patients are going to find that they can have a lot of these things they need to help themselves...and I think that's what's finally going to bend the cost curve for healthcare in this country."
The transition to Stage 2 might be rough, but there's reason enough for at least cautious optimism that healthcare organizations will rise to the challenge.

Zachary Landman, MD lists four best practices for portals:
Branding He encouraged marketing for portals that is "clear and concise...consistent through all your platforms." Allow patients to access portal download in three clicks or less on your website.
Usability Usability is "reducing the activation energy as much as possible". Portals should be easily accessible and navigable. Landman gave integrating your portal with preexisting social media platforms such as Facebook and making your portal easy to find on Google as two good strategies for making a portal more easy to use.
Functionality The key functionality is offering fast, easy, and informative communication between patients and physicians. For example, enable the portal to allow patients to send photos and pdf files in messages to doctors. Patients must feel assured they will get a response, so "is it easy and quick for doctors to use it?"
Reliability Make sure your application doesn't lose information or crash. Users will doubt that their information is secure on an unreliable portal.