CORR Insights®: Psychosocial Factors Are Associated with Electronic Portal Registration

Where Are We Now?

I am writing this commentary from an office-turned-bunker that no other person has entered since January, because of the changes to practice since the outbreak of coronavirus disease 2019 (COVID-19) in Portland, OR, USA. For weeks, our clinics have been nearly entirely virtual, and as of this writing (late April, 2020), I expect to work virtually for many more weeks yet. Even when we come out of this pandemic, how we work may never be the same.

While there is plenty of time to evaluate how this pandemic will influence musculoskeletal care, one point is clear: The electronic health record (EHR) portal is a central hub for patient care. Its prominence certainly will not diminish after lockdowns are lifted.

Patient communication through a portal promotes health information security, medical record documentation, and perhaps a more-efficient method of triaging patient concerns. Electronic health records and portals may improve patient satisfaction, safety, and outcomes [9]. They also permit billing within fee-for-service systems, through E-visits. These portals are also a means of collecting patient-reported outcome (PRO) measures, which is relevant both for orthopaedic practice and research,

Portal-based patient communications, test results, messages from other providers, and administrative tasks also contribute to the high and growing percentage of time that doctors spend away from direct (or virtual) face-to-face care [2]. Health information technology related stress has been reportedly high among orthopaedic surgeons in particular [7] and may contribute to burnout [4]. My Epic portal (Epic Systems, Verona, WI, USA) is yet another way (in addition to three email inboxes, pager, text messages, other messaging apps, collaboration site notifications, social media, and actual phone calls) that people can reach out and request attention.

Portals are full of capability, but how do they actually perform? Asking who accesses these portals, as was done by Fatehi and colleagues [5], is critical on several fronts. It is striking that disadvantaged people, who already face barriers to care, are also under-represented in portal registrations. Are these portals to be a means of easy cheap communication, or a furtherance of socioeconomic disparities in healthcare delivery? For those utilizing portals to collect PROs, patient satisfaction metrics, or business analytics, having particular groups not participating in the portal would be a critical source of selection bias.

Where Do We Need to Go?

The quality equation—value divided by cost—should apply to EHR portals at least as much as surgical interventions. But more is not always better. The costs here are often time, and as someone who has received a constructively critical attachment detailing my excessive time spent on an EHR “outside of clinic hours”, I know that data on time spent reviewing records and sending messages can be broken down rather discretely [11]. So, is my Epic in-basket worth it? I would feel better about the effort if I knew that time spent managing patients within the portal actually leads to improved patient outcomes, improved patient experience, or even improved physician wellness. Rather than assume that portal-based triage is faster or easier, I think that trials are feasible; for example, one could test whether MyChart messages as a primary means of communication after outpatient surgery take less staff time while keeping emergency department visits and readmissions equivalent, compared to a phone-based triage system. If high portal enrollment and utilization improves orthopaedic patient outcomes, practice management, or physician wellness, then I think these should be reported.

It was discouraging to read that Epic MyChart utilization was not associated with decreased emergency department visits or readmissions following hip and knee arthroplasty in one retrospective study, and that patients at higher risk were less likely to be MyChart users [10]. Substantial research is underway, including through Patient-Centered Outcomes Research Institute-funded telehealth projects [8]; unfortunately, one such study on patient portals similarly found disparities in utilization and internet access as a barrier [9]. How do we stay in contact while apart, and ensure that disadvantaged people are included while avoiding care systems being inundated beyond their capabilities? These seem like especially relevant questions at the moment, in light of COVID-19.

How Do We Get There?

We can all contribute to decreasing the disparities noted by Fatehi and colleagues to improve portal participation [5]. If orthopaedic surgeons see value in the portal, then we will want our patients enrolled.

For my department, it was the roll-out of EHR portal-based PRO that drove a push for enrollment. However, if the reason for not signing up is related to language, literacy, or internet access then simply increasing portal registration percentage will not be enough. Facilitating actual meaningful participation requires access to resources that are not universal. Schools struggling to pivot online during the pandemic, as commitments to equal instruction face the digital divide, is another exposed edge of economic inequities generating educational inequities. Electronic health record portals as the central hub of care can likewise exacerbate health inequities from un-universal access to the (not yet public utility) internet.

But there are some more immediately tangible ways forward. For Journal editors and reviewers, portal-derived outcomes should be reported with response rates and how responders compare with nonresponders [3]. Such information will help readers to understand whether study results reflect their own patient population. For researchers, there are many unanswered questions about the appropriate role of the EHR portal—for both patient care and physician wellness. And perhaps our Societies will tackle a clinical practice guideline and appropriate use criteria for telehealth, with the process of creating them shining light on where more evidence is needed [1].