Throughout my years working in health care, I have been able to experience a plethora of changes, some of which I really do feel are progress. For example, the ability to add a comment to my patient’s labs or test results is a way to keep patients in the loop and informed quickly. As a patient myself, I like being able to look at my results, and luckily I’m able to understand what they mean (and if not I have the resources to figure it out). That said, I have found that over the last couple of years, my experiences with the patient portal are increasingly negative, and in some cases, create more stress for patients while also taking time away from other patients.
At my first job as an NP, we used paper charts, and most results were delivered in a clinic visit — unless something critical was found, and then results were delivered by phone to the patient. When I transitioned out of private practice into a larger teaching institution, the patient portal was starting to flourish. In my early practice, I had a lot more time and when a very long message came through, I had the time to formulate a thoughtful response. We are measured on our response time to messages so I tried to make it a priority in my day to address them as they came in, and I was able to keep up for a while. But as my patient panel grew, it was hard to get to all the portal messages when results needed to be reviewed and delivered to patients who don’t use the portal, patients needed to be seen, and notes needed to be closed in a timely manner. I’m still figuring out how to prioritize this.
While I struggle with the prioritization, what I have found more difficult is navigating the social media aspect of patient charts. I have found that some people are comfortable sending messages virtually that would be almost unthinkable in person. I have been threatened, called names, and insulted. The two times it happened, it was patients I had seen recently in clinic and they did not seem to have any objections to the plan of care we came up with. Yet somehow, behind the safety of a screen, they let it all rip. As much as I wish I could let these instances roll off my back, I find it very difficult to stay present after these types of incidents. The time spent diffusing a situation (or absorbing someone’s anger) cuts into my ability to stay in the moment for my patients and coworkers. I may be able to carry on with the rest of my day but the dismayed feeling that I am left with lingers — and often follows me home. Why is it acceptable to turn a part of the medical record into something similar to a nasty comment section on social media? I’m not sure that patients know that the messages they send become part of the record and can be seen by anyone who accesses the record. I do wish that patients would use the messaging with a little more care.
Another element of the portal that could use more care and thought is the delivery of lab results. I know this contradicts what I said earlier about having easy access to my test results. It is not that I have a problem with patients knowing their results. I think that reliable and easy access to your health information should come part and parcel with any plan of care. Yet as a clinician, I have an advantage when it comes to looking at my information. If I am not sure what it means, I can discuss with a colleague or research in UptoDate pretty easily before my clinician gets back to me. Because of this, I am OK with seeing my results without an explanation from my clinician. My knowledge and access to resources is a privilege that the Cures Act does not account for, but this is not to say that only people in medicine deserve unadulterated access. It is to say that an abnormal finding on a test is not always something that requires treatment. Yet when results hit the inbox after business hours, patients are left to find information on their own, which is not always from a scholarly source. This can be distressing for patients.
Typically, most of the tests we order in the clinic are resulted during normal business hours, unless they are a send out to pathology. Getting positive results on your lung biopsy on a Saturday night because the test was released by the send out lab (in another time zone) is a nightmare for patients and clinicians. Results like this should ideally be accompanied by a clinician response, whether by message or telephone — cancer deserves discussion and planning. But do we work 24/7? This expectation sets us up for disaster. Most of the time we are waiting on pathology because we are suspicious and have discussed this with the patient, but it still does not soften the blow of finding out via email.
Of course, there are flaws in how the information is released to us, as well. I can think of one incident in particular where I ordered the test, but the result was sent to the fellow who performed the bronchoscopy and their attending staff through an inbox that was rarely checked. I found out from the patient sending me a message asking what the plan was to address the abnormal cells on the bronchoalveolar wash. This was from a mycobacterial infection and thankfully not cancer, but I felt horrible. I checked path results rather obsessively for several months after.
It may seem small, these “trivial” issues with a patient portal, but it ends up becoming a big deal. We give a lot of ourselves every day, sometimes more than we should. To have to navigate the big feelings that are expressed in small type is more than I want some days. I try to maintain a sense of neutral opinion, realizing that sometimes the “Message Your Provider” tab is tantamount to screaming into the void, letting go of whatever is most troublesome that day. But sometimes I don’t feel very accommodating, and I’ve got my own screams that I need to put somewhere. Despite exercise, knitting, and gardening, I am running out of coping mechanisms, and the weight of some of the vitriol ends up settling with me. It is hard to keep seeing patients, asking genuine questions, and providing thoughtful answers when I feel dejected. I try not to carry these ambient feelings with me but that energy has to go somewhere. Although I guess being accosted through the internet may seem less intense than in person, I disagree. I think this makes "instaculture" in health care even more of a drawback.
If it seems like I’m saying a lot of bad things about patient portals, it is because I am. Yet I have had great experiences with them, and know that we have been able to save patients time and money by monitoring blood pressure logs and daily weights through portal messages, as well as clarifying questions without the need to come into the office.
So complaints aside, I wouldn’t want the portal to go anywhere. I use it and believe that it does help improve health care. That said, I don’t want to be made to feel like a bad clinician just because I did not answer a patient message within the hour of receipt. Getting results and replies right away may be satisfying, but things are not instantly solved, and when tackling disease processes like cancer, a thoughtful, multidisciplinary approach should occur. Health is not an instant process. And despite the pressure to make health care as simple as ordering groceries, this is not always the best way. The way that I have tried to handle this in my practice is by telling patients that they will often see their results before I do, but that I will be in touch to discuss what these results mean as soon as I can. Sometimes it works out, but other times I’m getting panicked messages about things that are actually baseline for the patient. This is just par for the course I guess, but I wish there was some way to help patients see that waiting for results may save a large amount of anxiety and end up saving time in the end.
What pros do you see from the patient portal? What about the cons? Compare and contrast in the comments.
Blythe is a cardiology NP in the greater New Orleans area. Her special interests include improving social determinants of health in underserved communities and prevention of lateral violence in health care. She is a devoted mother, enjoying sewing and gardening in her spare time. She is a 2021–2022 Doximity Op-Med Fellow.
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