Here we take a deep dive into patient portals, exploring the current stats around coverage and functionality, the benefits highlighted in a case study from Hull University Teaching Hospitals, and recent research into the topic.
In March, at HETT North, the NHS’s national director of transformation at the time, Tim Ferris said there are 40 trusts with patient experience portals in place. He added: “We are going to have a very aggressive campaign to sign up all secondary care systems with these portals in the next six months. For many CIOs, there will be a letter going out soon which details the changes we are hoping to make to expand digital innovation.”
In the letter to NHS directors, sent out last month, chief operating officer Sir David Sloman and national director for digital channels Joe Harrison confirm that additional investment will be put in place to extend the coverage of patient portals in the new financial year. The letter notes that the investment aims to “extend the coverage and expand the functionality and impact of patient portals in 2023/24, both for the benefit of patients and to support your systems’ elective care recovery and transformation plans.”
The letters highlights an expectation to deploy a “minimum level of functionality in support of elective recovery and work with the NHS England Wayfinder team to surface their portal through the NHS App.”
The minimum functionality requirements set by the NHS include portals enabling patients to view their outpatient appointments; enabling trusts to send a waiting list validation questionnaire to patients; providing patients with a single point of access to contact the provider; and enabling patients to access their correspondence through it.
Further functionality through the NHS App is to include booking capability, eForms for pre-operative screening, eForms and messaging for waitlist validation, eForms and booking capability to support clinician and patient initiated follow up, and access for all pathways for patients to confirm that they wish to take up their appointment at 12, 18, 26 and 52 weeks.
So what does patient portal coverage look like so far?
Patient portal coverage
Currently, NHSE statistics indicate that 84 trusts have a patient portal at differing levels of functionality and use cases, with 19 in active procurement. 26 organisations have already integrated their portal with the NHS App, whilst a further 22 are on the roadmap to follow suit.
In terms of NHS trusts in England meeting the minimum functionality level, 24 have reached this level, the data captured in March highlights.
In North East and Yorkshire, eight trusts in the region have a patient portal in place at this level: Doncaster And Bassetlaw Teaching Hospitals NHS Foundation Trust, Hull University Teaching Hospitals NHS Trust, Leeds Teaching Hospitals NHS Trust, Mid Yorkshire Hospitals NHS Trust, Northern Lincolnshire And Goole NHS Foundation Trust, The Rotherham NHS Foundation Trust, York And Scarborough Teaching Hospitals NHS Foundation Trust and The Newcastle Upon Tyne Hospitals NHS Foundation Trust.
The South East region, Hampshire Hospitals NHS Foundation Trust and Royal Berkshire NHS Foundation Trust meet the minimum functionality level.
Then there is the South West, where Great Western Great Western Hospitals NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust are noted.
In the East of England region; Milton Keynes University Hospital NHS Foundation Trust, North West Anglia NHS Foundation Trust and West Suffolk NHS Foundation Trust.
London follows, including St George’s University Hospitals NHS Foundation Trust and Croydon Health Services NHS Trust at this level.
Meeting the minimum functionality level in the Midlands: Chesterfield Royal Hospital NHS Foundation Trust, Nottingham University Hospitals NHS Trust, Sherwood Forest Hospitals NHS Foundation Trust, South Warwickshire NHS Foundation Trust and University Hospitals Birmingham NHS Foundation Trust.
Finally, the North West includes East Cheshire NHS Trust and Liverpool University Hospitals NHS Foundation Trust.
In total, 24 NHS trusts meeting the minimum functionality level for patient portals as of March 2023.
Now let’s take a look at a patient portal in action, focusing on empowering patients through a clinical and administrative engagement portal using Patients Know Best (PKB).
Hull University Teaching Hospitals is a great example of a trust using both administrative and clinical engagement to deliver positive outcomes. Since implementing PKB the trust has delivered an impressive reduction in DNAs, made digital letters savings, implemented digital pre-assessments leading to fewer visits to clinics and triages and used digital communication to reduce phone calls and provide ongoing remote clinical support:
Did Not Attend (DNA) reductions
39 percent reduction in missed appointments, or ‘did not attends’, in registered vs unregistered patients. This correlates with PKB’s wider user base with an average 35 percent reduction in DNAs across 16 trusts.
Digital letter savings
Over 50,000+ letters are now being read digitally per quarter, saving the trust print & postage costs as well as supporting carbon reductions.
Improved surgical pre-assessment flow
HUTH recently implemented a digital pre-assessment pathway using patient questionnaires to determine what level and type of interaction a patient needed ahead of surgery. Answers are extracted and inputted to a local custom built dashboard used by the admin and nursing team to triage patients.
The first few months the workflow was piloted across three pathways resulted in:
- 96 hours of face to face appointments being avoided
- 94 additional hours of face to face switched to phone calls
- 127 face to face appointments were a reduced length
This pre-assessment pathway has now been implemented in multiple cohorts and adoption is growing quickly.
If a patient has access to data and tools to support more informed action they can become active partners in their healthcare management. By using a portal which incorporates tools like care plans, clinical questionnaires, messaging and symptom tracking and test results, trusts can shift from admin efficiencies to safely implement clinical transformational changes like supported decision making, PIFU and Waiting Well.
Again clinical teams within HUTH are seeing tangible results using these tools:
Reducing telephone messages by 47 percent
Patients in the Kidney Dietetics team can access relevant information in personalised care plans and curated libraries then message their clinical teams, minimising admin time for care teams while providing an enhanced service for patients.
The Rheumatology Healthcare Prescription Team has saved approximately 46 hours admin time per year (1.5 weeks) using PKB to remind patients to book their blood tests. Other teams are utilising a similar workflow so that if blood tests are stable PKB is used to notify patients to collect and continue taking their medication avoiding discussions their clinical teams.
Genetic Haemochromatosis patients are given a care plan supporting patients to determine whether self-referral for venesection or specialist review is necessary.
Post surgical dressing teams are securely collecting questionnaires and photographs to identify what support a patient needs and if an infection has occurred, remove unnecessary face to face appointments.
Many sites using PKB are now trialling waiting list validation programmes, both to provider resources to patients whilst on waiting lists and also to validate who may be removed. Initial data shows this has supported trusts in waitlist reduction resulting in more accurate data round wait times.
As this data grows, and with practical examples from trusts like HUTH, the benefits of clinically engaging patients via portal become ever clearer.
So what does research into patient portals tell us?
Studies: Impact of portals on health outcomes, system efficiency and patient attitudes
In a study, published in JMIR Publications, the authors aimed to summarise evidence on the impact of patient portals on health outcomes and healthcare efficiency, along with examining user characteristics, attitudes and satisfaction.
In order to develop their summary, the researchers searched PubMed and Web of Science databases for eligible studies reporting on the impact of patient portal adoption. Of the 47 studies included for analysis, they found that 11 studies addressed health outcomes reporting positive results such as better monitoring of health, improved interactions between clinicians and patients, and improved quality of care. In particular, researchers found a “significant association” between patients’ preventative health behaviours and portal use; diabetes and blood pressure control portal users, for example, were found to be more likely to control their HbA levels successfully when compared to non-users. Researchers also highlighted improved clinical condition over time when using the portal to assist with the management of asthma in children, and patients using the portal for mental health care saw a positive clinical impact in many areas. However, “no marked short-term impact was described, and differences in patient-reported physical and mental health changes were minor”.
15 studies evaluated the impact of digital patient portals upon the utilisation of health services. Researchers noted that the use of the digital portal had an effect on the number of clinical visits, especially for asthmatic patients, but there were “no statistically significant changes in the number of primary care visits reported in association with the use of secure messaging.” A decreasing trend for emergency room visits was observed, along with a reduction in hospitalisations for asthma and mental health conditions.
On clinician attitudes, researchers pointed out that the portal seemed to “enable a new way of managing stable patients, facilitating clinical and cost-effective use of specialist nurses (improved two-way communication, and more optimal use of outpatient appointments and consultant time).” It also “facilitated a single rationalised pathway for stable patients, enabling access to information and proactive support.”
In addition, there was a reduction in missed appointments for patients using the portal along with an improvement in appointment adherence after portal adoption. However, researchers found no significant association in no-show appointments or cancellations between those using a portal and those not.
Finally, 30 studies examined patient attitudes and defined key barriers, which included privacy and data security along with lack of time to engage with the portals. In terms of demographics, the study found variety in usage among age groups, with higher use in older patients (50+); younger people were also major users in disease/speciality-specific cohorts. In a number of patients, white patients were observed as more likely to use the portals. The authors highlight that most articles found a positive association between females and portal use. Patients with depression were positively associated with portal use; patients with schizophrenia or schizoaffective disorders were less likely to engage. The authors found in three studies that people living in rural areas were less likely to engage, whilst higher education levels were “often related to broader use of portals”.
On patient attitudes, the researchers said: “Some of the main issues were related to perceived or preconceived security concerns, limited knowledge, satisfaction with current care, paying for the service, disinterest in managing one’s own disease, personal/time constraints and not thinking about accessing the portal, doubts about the reliability of the patient portal to facilitate a timely and productive message exchange with providers, and prior negative experiences with secure messaging.”
Read the study in full here. ©Elettra Carini, Leonardo Villani, Angelo Maria Pezzullo, Andrea Gentili, Andrea Barbara, Walter Ricciardi, Stefania Boccia. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 08.09.2021.
Exploring implementation strategies to improve engagement with a multi-institutional patient portal
This study, published in the National Library of Medicine, sought to explore how the implementation approach of a multi-institutional patient portal impacted the adoption and use of the technology, along with identifying lessons learned to guide future implementations.
The researchers analysed data collected during an evaluation of the MyChart patient portal deployed in Ontario, Canada, along with performing interviews with stakeholders, patients, providers and a caregiver to understand how the implementation approach influenced user experience.
Here, responses perceived that their experience of the portal would have been improved by enhancing the data comprehensiveness of the technology, and emphasised that provider engagement, change management support and senior leadership endorsement were key to fostering uptake. Many participants said that “regional alignment and policy support should have been sought to streamline implementation efforts across participating sites”, with lack of enrolment attributed to the absence of a broad rollout and marketing strategy across organisations.
The researchers concluded that multi-institutional portals can suffer from minimal adoption if proper management and planning is not in place, and said that “it is important to look beyond the category of the technology (ie, patient portal) and consider its functionality (eg, data aggregation, appointment scheduling, messaging) to ensure that it aligns with the underlying strategic priorities of the deployment.” In addition, they pointed out that it is “critical to establish a clear vision and ensure buy-ins from organisational leadership and health care providers to support a cultural shift that will enable a meaningful and widespread engagement.”
The full study can be found here. Fujioka JK, Bickford J, Gritke J, Stamenova V, Jamieson T, Bhatia RS, Desveaux L. Implementation Strategies to Improve Engagement With a Multi-Institutional Patient Portal: Multimethod Study. J Med Internet Res. 2021 Oct 28;23(10):e28924. doi: 10.2196/28924. PMID: 34709195; PMCID: PMC8587179.
Participant experiences of a shared patient portal
In a study entitled ‘Participants’ views and experiences from setting up a shared patient portal for primary and specialist health services – a qualitative study’, published in BCM Health Services Research, researchers sought to investigate participant views on content and experience from the configuration process involved in setting up a portal for primary and specialist health services.
Results from participant interviews indicated that they saw it as a good thing to have numerous participants present in discussions on configuration. They considered a patient portal to be “of great value” for patient care, with a particular reason highlighted in the way that it would “lead to improvements in patient follow-up and increased patient empowerment.”
Participants also noted that their involvement in the configuration process increased the complexity of the work, with some sharing concerns that the patient portal could lead to an increase in healthcare provider workloads, a rise in health-related anxieties and worries, and a potential rise in digital exclusion.
Read the study here. Nøst, T.H., Faxvaag, A. & Steinsbekk, A. Participants’ views and experiences from setting up a shared patient portal for primary and specialist health services- a qualitative study. BMC Health Serv Res 21, 171 (2021). https://doi.org/10.1186/s12913-021-06188-8
Who isn’t using portals and why?
In an article entitled ‘Connecting the dots: health information technology expansion and health disparities’, the authors state: “Health technologies like portals have great potential to improve healthcare quality and efficiency by enhancing communication between patients/caregivers and healthcare providers… portals can lower barriers to engaging in health-related tasks by increasing convenience and access to medical record information and tools online. This improved communication and care coordination is particularly important for patients with chronic illness because they need increased assistance managing complex self-management tasks, and chronic illness disproportionately affects more vulnerable patient subgroups. Thus, many have argued that patient use of health technology such as portals could reduce health disparities related to race/ethnicity and limited health literacy.”
However: “We believe lack of usability is a formidable barrier to achieving widespread use of portals and other patient-facing health technology, particularly for diverse groups. Although usability data for portals remain relatively sparse, the few formal studies that have been conducted demonstrate that portals are difficult to use, with multiple challenges involved in apparently straightforward tasks, such as requesting access to the site, and in more complex tasks, such as comprehension of the medical information presented.” Similarly, they add, portals can “amplify the existing challenges of patient—provider communication during and between visits.”
In a recent study of a racially/ethnically diverse group of 51 older adults, the authors note that when participants were shown a video showcasing the features of a portal website, 86 percent said that they would use it, but only 12 percent were able to correctly complete a set of simple tasks during a simulation. None were able to complete complex tasks.
The medical community must advocate for improvements in usability to ensure that portals are relevant to diverse groups, the authors continue. They encourage the application of principles from product design and health communication science when designing or implementing technologies. They note that user-centred product design can improve the quality of interactions with technology and user perceptions of it, as it has been designed with their needs, values and abilities in mind.
They add that online platforms “have the potential to address disparities in language and health literacy, largely because they can leverage audio and video to enhance engagement, can more seamlessly provide non-English language access, and can provide interactivity and feedback to optimise comprehension.”
Finally, the authors state that they “see an opportunity for the marketplace to capitalise on these challenges with long-term patient engagement to differentiate products based on how well they are able to improve understanding and decision-making among patients and providers.” With this in mind, they state that healthcare providers should look to purchase EHR with patient-facing products “that meet the basic needs of their patient population; language and literacy should not be considered “add-on” or “extra” features”. In addition, EHR or portal programmers should “familiarise themselves with the issues of health literacy and healthcare disparities, perhaps by establishing and consulting with patient advisory groups that include bilingual patients and individuals across the socioeconomic status spectrum.”
Read the article in full here. Lyles C, Schillinger D, Sarkar U. Connecting the Dots: Health Information Technology Expansion and Health Disparities. PLoS Med. 2015 Jul 14;12(7):e1001852. doi: 10.1371/journal.pmed.1001852. PMID: 26172977; PMCID: PMC4501812.
