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Healthcare IT advances are pulling together to manage an expanding universe.

Web portals that allow patients and physicians to communicate online have a firm foot in the door. "There's certainly evidence that organizations are investing more in portals," says David Ahern, national program director for Boston-based Health e-Technologies Initiative, the foundation arm of the Robert Wood Johnson Foundation, Princeton, N.J. "All the major players in healthcare have had an interest in portal development."

As doctors realize their effectiveness, portals will open up in smaller organizations, too, says Giovanni Colella, M.D., president and CEO of RelayHealth, Emeryville, Calif. "I expect about half of the physicians in the United States will communicate online with their patients within the next five years," he says.

Bob Letzeisen, president of portal manufacturer PatienTree, Tampa, Fla., predicts that portals will be universal within that timeframe, because patients will demand bedside access. "We expect [Internet access] at McDonald's, we expect it at the airport, and we expect it at the Hampton Inn, and I only pay them $79 a night," he says. Many healthcare consumers do appreciate the convenience of access to multiple services in one place. A recent article in the Journal of the American Medical Informatics Association revealed that the majority of 4,282 patients who used Danville, Pa.-based Geisinger Health System's patient portal expressed positive attitudes about the experience.

This finding is underscored by statistics from Manhattan Research, New York. Mark Bard, president, says that about 16 million consumers reported using a hospital Web site last year, up 6 million from just two years ago. Another 30 million used health plans' portals. "If you're one of the leading hospitals, it's a big enough segment that you can't ignore it," Bard says. "In a competitive market, a 2 percent, 3 percent market share can be the difference between losing money and making money one year."

Adoption rates are difficult to quantify because there is no standardized definition of a portal. "You've got these degrees, ranging from regular email to secure email to Webbased communication," says Lyle Berkowitz, M.D., an internist and medical director of clinical information services, Northwestern Memorial Physicians Group, Chicago. But the consensus is that healthcare, true to its reputation, is investing only slowly in portals, despite growing interest.

"There's no other service sector in the United States in which you can't communicate online," Colella says. Bard agrees, noting, "The only one that is resisting it is healthcare." However, Bard believes that 2005 will be a critical juncture for the technology. In a recent survey from Capgemini, New York, 88 percent of executives at 84 healthcare organizations said they have either begun to invest in an EHR or plan to do so within the next six months, a good indication that portals aren't far behind. "As more physicians start using electronic medical records, they're going to want to communicate electronically with their patients as well," Berkowitz says.

A range of options
Portals range widely in functionality. Home-grown portals typically consist of a Web site that allows one-way communication between patients and healthcare staff. On the portal at Berkowitz's facility, for example, patients can use a form to securely email requests for prescription refills and appointments and to ask nonurgent questions about billing, referrals and clinical issues. For nonclinical issues, the appropriate staff person contacts the patient during the timeframe requested. For clinical issues, the text is sent to the physician by "cutting and pasting" it into the group's EMR messaging system. Physicians then deal with the message as they would a phone message. Berkowitz says the system is a good first step, but he wants to fully integrate it with the EMR and set up a system for two-way communication.

Although the group hasn't done a return-on-investment analysis, it knows the system saves time and reduces frustration by eliminating phone tag. "The time-shifting makes things more efficient," Berkowitz says. "There's no question that it can decrease the wait time for patients and the pressure on our call agents."

Independent commercial portals such as those offered by RelayHealth and Kryptiq, Beaverton, Ore., offer two-way communication over a secure Web connection through multiple templates. Such systems may or may not integrate with an EMR. Colella says health plans see significant savings from physician-patient communications. "When patients and physicians communicate online, they are saving approximately $3 per member per month, which is an astonishing savings," he says. "For reference, the net income of health plans is usually around $3 per member per month."

EMR-based portals such as those offered by Cerner, Kansas City, Mo., and Epic Systems, Madison, Wis., integrate with hospital information systems. Letzeisen, whose PatienTree bedside portal also links to CPOE and EMR systems in real time, says that staff access to even nonclinical information, such as billing and inventory, saves money. "If you send $10 of inventory to the seventh floor, are you going to capture all $10 of inventory?" he asks. "Unless you capture all 10, there are areas for improvement."

John Halamka, M.D., CIO of Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, reports savings from his system's intranet, extranet, and EMR-linked customized patient portal, PatientSite. "In this era where everyone has to cut cost, this is a way that everyone can contribute, rather than [hiring] an army of HTML programmers," he says. PatientSite has recorded 2.5 million transactions since it went live in 1999. Investing in applications that allow PatientSite to link to all area insurance and doctors' offices for billing purposes has reduced filing costs from $5 per transaction to 10 cents, Halamka says. And its link to all pharmacies in New England has cut down on phone calls to patients regarding lab results and prescriptions. Email communications between patients and healthcare providers go into the patient's medical record, where they will remain for 30 years.

Overcoming the obstacles
Reasons for lack of portal adoption are familiar. "It requires a change in habits, and doctors are not comfortable with it," Colella says. "And doctors don't get paid for this, so [investment] requires a longer time than in other industries." But Berkowitz believes that the growing number of organizations adopting EMRs will also adopt portals to make care delivery that much more efficient. When patients can complete their history from home and doctors don't have to leave patients multiple phone messages, the full benefit of portals will come to light. "It's a big pain to track someone down to give them their lab results," Berkowitz says.

Another roadblock has been doctors' concern that patients with "cyberchondria" will clog their email inboxes with long missives about their condition, a fear that Halamka says is unfounded. "Patients and doctors treat each other with the greatest respect over email," he says. About 35,000 patients use the Beth Deaconess portal each month, but on average, a patient sends only 1.2 emails per month, 90 percent of which are handled by a nurse practitioner or other staff member. In addition, certain inquiries are very common, and doctors can store answers to frequently asked questions. "So the average busy doctor is only seeing five to 10 emails from patients a day, which replaces phone calls. And doctors tell me they actually get out of the office sooner, because the beauty of emails are that they are asynchronous," Halamka says.

Patient privacy is an often-cited concern about portals, but Halamka says the Health Insurance Portability and Accountability Act (HIPAA) does not prohibit securely sharing information about a patient's treatment. "HIPAA is meant to keep me from sharing your medical information with the Boston Globe, not from sharing your medical information with a doctor responsible for delivering quality care," he says.
The proof is in the portal
Finding a way to save money may be the primary driver behind portals, but improved patient care is expected to come along on the ride. Some good research has been done in this area, Ahern says, but nothing very scientific. "There certainly have been studies looking at the cost benefits of certain functions; for example, in the area of secure messaging." However, there has been no study "looking at a range of functions, although some are emerging," Ahern says. To fill this void, Health e-Technologies Initiative has undertaken a tightly controlled study of whether patient and physician use of portals improves management of weight, diabetes and other chronic diseases. Last October, it awarded $2.45 million in two-year grants to six healthcare organizations to study the effectiveness of their portals. It provided a basic definition of portals and required that each organization's portal have a certain number of transactions in certain functional areas.

The potential benefit from this study is substantial, Ahern says. "If the results are favorable for their projects, the healthcare groups and hospitals have the capacity to generalize these findings fairly quickly to a much larger population." There would be little reason to keep a technology waiting at the door once it's found to save money and promote patient care.

(extraído da publicação Healthcare Informatics, focada no estudo de TICs para Healthcare) Fevereiro 2005