A Review of Portals versus Health Information Exchange Solutions
Portals are used by a number of hospitals as a way for physicians to view patient information stored within the hospital information systems. With the adoption of electronic medical records (EMRs), more and more physicians are asking that results be delivered directly into their EMR system. Portals and HIE both occur in the context of health information technology adoption, a key feature of the Obama-Biden plan to reduce healthcare costs. This article reviews the history of portals, the differences between push and pull technologies and the results of various community studies on health information exchange versus query models.
The term “portal”, which became well known after the Internet boom, is widely understood to be a web page of consolidated links and web applications that facilitate the navigation to favorite places, as well as organizes and allows for access of pertinent information on the screen. The Internet boom also spawned the advertising model where “eyeballs are king”, and industry behemoths like Netscape, Yahoo and Microsoft built user-configurable portals so that users could track their own stocks, setup news feeds or weather reports, and a host of other tailored features.
Portals also existed in healthcare. Hospitals built portals for affiliated or employed physicians as a single place where they could remotely access various hospital-based applications. Initially these were on private networks, which eventually gave way to secure Internet technologies. The notion was the same, though: drive the physician eyeballs to a hospital marketing page that also allowed them to seek and find the data they needed on a patient. Most placed hospital news and other links of interest to their pages, and branded the pages so the physicians could not mistake the institution they were getting this information from.
Many times, hospital systems are not completely integrated and each application requires a login and password. As physicians complained about multiple logins, or having to search for the same patient in multiple applications - technologies and solutions were built to address those problems. Single sign-on (SSO) tools were developed to enable one login event to be used by multiple applications, and context management tools were built to enable patient context to be maintained as the user switched application. But other fundamental issues were not able to be addressed, and with only limited exceptions, hospital portals have not met the utilization expectations of the hospital administrators.
Put simply, physicians don’t want to have to go looking for data on their patients. They want to be notified when new information is available and, preferably, be sent relevant clinical data automatically in a useful and manageable format. The rise of EMR adoption in ambulatory practices is further driving demand for clinical data delivery, and is causing hospitals to rethink the marketing worth and utility of their portals.
Deciphering Portal, Query and HIE Technologies
There is a fundamental difference between push and pull technologies. Portals are a pull (or query) technology, requiring physicians to search for the data they need. Push technology, on the other hand, automatically delivers clinical data to the user in the format they wish: paper, fax, electronically to a viewer, or electronically to their EMR. Good push technologies also allows for individual tailoring of various types of results and data delivery. Being able to manage the information sent to them is also critical. A good HIE solution should provide a push technology, delivering the vast majority of hospital and other results, while also providing a query solution for the few use cases where there doesn’t yet exist a patient-physician relationship that would enable push delivery.
Study Reveals Truth
A study performed in 2007 by Quality Health Network (QHN) in Western Colorado, showed that when both push and query technologies are made available to physicians for patient data from hospitals, the physicians viewed pushed clinical results significantly more often than queried results. In this study, results were automatically delivered to physicians of record and also stored so as to be available in a patient-centric query. Dick Thompson, Executive Director of QHN reported, in a presentation at the 2008 Wiring Michigan for HIE conference, that 99.3% of all electronically viewed results were those that were pushed to the physicians, while only 0.7% were viewed via a query. Physicians are 100 times less likely to search for a result then to look at it when it is delivered to them in an EMR or other clinical tool. The study revealed that query is a last resort, used when the push doesn’t occur, such as the situations where a physician is seeing a patient for the first time and wasn’t provided the needed relevant clinical results.
Not only do physicians desire and utilize push technology, but the benefits of automating data delivery from hospital to physician practice saves hospitals money. One of the critical functions hospitals perform is the timely distribution of patient data to their affiliated physicians. With an increasing number of physicians requesting delivery into their chosen EMRs, and others requiring paper or fax records, communication can be chaotic and require multiple staff hours to manage the flow of data. Courier and fax costs can become overwhelming and clinical information does not always reach the intended recipient, or get there soon enough, resulting in requests for additional copies. Portals and viewers do not solve these problems, as physicians require information to be delivered and seamlessly integrated with their existing workflow. Physicians and staff simply do not have time to look in one or more places to determine if there are any new patient results available.
At the same Michigan HIE conference, Keith Hepp from HealthBridge, an HIE operating in the greater Cincinnati area, reported that hospitals in their network were each saving over $300,000 annually over their previous distribution methods. HealthBridge is providing automation in distribution of results to over 4,500 physicians in the area, from all over twenty five hospitals. HealthBridge refers to their push technology as ‘Clinical Messaging’.
Interestingly enough, another exchange in nearby Indianapolis, known as the Indiana Health Information Exchange (aka IHIE – pronounced “eye high”), also uses Clinical Messaging to describe their push technology between participating physicians, hospitals and other institutions. IHIE presented at the Michigan conference and reported on their goal to spread Clinical Messaging to all of Indiana.
With Clinical Messaging, hospitals have less need to support complex SSO portals, which are getting more difficult to maintain as ambulatory care EMR adoption climbs. Besides being isolated from the physicians’ IT systems, the principal limitation with portals is that physicians are not notified when new data becomes available. These silos of information are merely storehouses for physicians to access. This is analogous to the US Postal Service not delivering your mail, instead requiring you to visit the post office to pick it up, with no certainty that any mail is there or when the next parcel will arrive. Although recent legislation has allowed hospitals to support the provisioning of EMRs to physicians, the fact is, many independent practices have selected their own EMRs, thus, creating environments of heterogeneous EMRs. Hospitals are finding it is easier to deliver data into those various EMRs then to tie them all into a portal through SSO.
Other physicians, not yet using EMRs, may not wish to start but still demand that clinical information is available to them immediately upon release. Hospital systems have realized that providing clinical connectivity to physician practices will increase quality of care, retain physician loyalty, and provide competitive advantages. However, while hospitals may be able to influence the choices made by closely affiliated physicians, they will never be able to control the entire ambulatory care IT landscape with which they interact. Therefore, pushing standard format data to those practices makes the most sense.
It seems the time for portals has waned. The marketing value of them is dubious, as the physicians have found that always seeking information is time consuming and, therefore, have stayed away in droves. Meanwhile, the complexity of maintaining them has increased with the adoption of ambulatory EMRs. Hospitals are finding that delivering information to their affiliated physicians in the way they want garners more loyalty and marketing value than a portal site. Because of this, the industry should expect to see significant increases in the adoption of Clinical Messaging technology by hospitals and hospital systems in order to solve their physician connectivity needs while reducing costs.
While portals may have been popular with the arrival of the Internet, it no longer solves the business problems for the hospitals nor the data needs for the physician. Real health information exchange has been proven to save costs, foster physician relationships and improve patient care – providing data when and where it is needed most by the physician.