Take 2 aspirin and e-mail me in the morning

At Penn Medicine, patients with questions e-mail instead of phoning their healthcare providers. Doctors e-mail back. Ne’er the twain need pick up a mobile phone.


Currently 240,000 people actively use MyPennMedicine (MPM), submitting questions, reading test results and requesting appointments online. Between December 2009 and April 2015, electronic messages to and from patients soared from zero to almost two million a month. That’s a lot of avoided phone calls and office paper.


Patients and most providers like both the 24/7-ness of the electronic system and its directness, the opposite of whispering down the lane. Any literate, clear-thinking patient can submit any clinical message without fear of distortion and expect an educated, medically sound response within a few days.


MyPennMedicine (MPM) is the University of Pennsylvania Health System’s electronic patient portal, the cloud-based connection that allows doctors and their staffs to communicate with patients and their families – but not in person nor by phone. It’s the healthcare equivalent of ordering a pizza, a pillow or a Peugeot. A patient can schedule a Pap smear, request a prescription renewal or find the dates of appointments from a desktop, smartphone or wearable computer. 


Susan Day, MD, is professor of clinical medicine, primary-care provider, director of population health for the division of general and internal medicine and associate chief medical information officer for the medical center’s patient portal and population health. 


She says patients, especially younger ones, like the ability to stay up-to-date on health maintenance, refills and easy referrals without unnecessary trips to the doctor’s office. They even like receiving test results, which sometimes arrive in an inbox without adequate explanation. That, too, is changing, with new access to the Healthwise online library, which explains and interprets lab tests.


“We have just turned on the ability for patients to send in data on their weight, blood pressure, step count and blood sugar by linking mobile devices, such as Apple Watch, scales, blood pressure cuffs and glucometers, through the patient portal.” Day says this technology “Should help us manage chronic conditions like diabetes and high blood pressure.”


Penn’s electronic medical records (EMR), called PennChart, went live at Penn 1998. The software comes from EPIC, a private company in Wisconsin, that serves large medical groups, hospitals and integrated healthcare organizations. In 2006 or 2008??? the system first allowed patient interaction.


Scott Schlegel, associate vice president, EMR Transformation at Penn, co-chairs the MyPennMedicine efforts with Susan Day, MD. Currently MPM handles only ambulatory data within Penn’s EMR system. Schlegel says the service receives more than 500,000 messages each quarter. More than three-fourths of UPHS employees have accounts, plus 21,000 13- to 17-year-olds. Over half the users are 50 or older, and, amazingly, 14 people over 100 – or their caretakers –have tried the Penn portal. Usage is accelerating rapidly. 


MPM flourishes at all four Penn hospitals: HUP, Pennsylvania, Presbyterian, Chester County and “It transforms how we practice and how we do research. It has huge potential,” says Day.


“Your Mailbox Was Full”

MyPennMedicine is a boon for practitioners. Neil Malhotra, MD, assistant professor of neurosurgery at Penn and director of the Neurosurgery Quality Improvement Initiative, is an enthusiastic user. “When I remove a tumor from a patient’s brain, of course I want to be sure that the procedure goes smoothly,” he says. “But I also want to be sure that the patient understands what’s going on and is able to participate in their ongoing care. That’s one of the ways I use MyPennMedicine.”


Malhotra calls MPM “remarkable for patient empowerment. There’s no time for clinicians to spend time during a complex physical exam explaining every detail to a patient. But if my patients look at reports and lab tests online before they come in, we can have more constructive conversations. During a repeat visit, I can explain why their numbers matter.


“With this system,” he says, “rather than leaving my office and forgetting what I said, they can now ask whether their potassium level could possibly relate to their cramps. They may not understand cell biology, but they are more empowered than without the online information. If you’re a little bit scared, you’re a little more likely to remember what we say on that topic.”


Managing prescription refills no longer needs to occur face to face. “So MPM frees valuable time for us to focus together on their care,” he says.


Michael Ashburn, MD, MPH, professor of Anesthesiology and Critical Care and director of Pain Medicine and the Penn Pain Medicine Center, also values MPM. “It allows me to look at a patient request and respond without having to track the patient by phone,” he says. “If it’s a simple request like a refill, I can send it to the pharmacy electronically, notify the patient and close the loop in one interaction. It interferes less with my routine clinical practice.”


When Ashburn phones patients, he says, “At least 30 percent of the time the patient doesn’t answer or there’s a bad connection or they have forgotten why they called. Then they want an appointment, and I have to refer them to someone else to schedule.” MPM responds more effectively and efficiently to half the inquiries, he says. “That gives us more bandwidth to handle the calls that need to be made.” 


If a patient doesn’t present adequate information when querying online, Ashburn can request more. “If the message requires the participation of other team members, or prior authorization, or myriad other scenarios, sometimes I can respond and route the message to others.” For a refill when Ashburn is unavailable, a staff member can authorize a partial supply and recommend a repeat visit to discuss the medication and/or dosage with the doctor. 


“And I have a paper trail, he says, “which is still important, not only for legal reasons, but also to resolve prior questions. Like a patient complains that no one called them back, and you look at the file and say, ‘I called you back on April 1, but your mailbox was full.’”


“Remember to Schedule Your Flu Shot”

Beyond direct doctor-patient messages, MyPennMedicine reminds enrolled patients about appointments and inoculations. Not long ago, women had to remember to schedule their own mammograms. Now e-mails alert them. Sometimes watchful patient find errors in their own records. 


In 1998 Penn began using EPIC for ambulatory care, adding MPM, the patient portal, 10 years later. Two years ago, Penn Medicine Senior Leadership approved converting all clinical care and billing activity at all Penn Medicine locations to EPIC. Phase One, completed early in 2015, involved bringing emergency care, transplantation and radiology on board, says Schlegel. Phase Two, due for completion by March 2017, involves inpatient clinical documentation, pharmacy, hospital billing and homecare settings onto the single medical record should be complete by October 2016 and the rest by March 2017. 


Ashburn acknowledges that MPM cannot serve every patient in every situation. Some people need to refill potent opioids, which is impossible. “Sometimes patients try to use MPM to address urgent issues, but the system is not prepared for that.” And although the portal posts clear warnings that it is not intended for emergency care, some patients still may expect rapid answers. “We respond throughout the day, but no one is dedicated to responding all day long, so the patient may not receive an immediate answer.”


For all its benefits, says Day, the patient portal raises issues about health and age disparities, computer access and literacy. It will never be possible to switch all patients or all discussions to the web. “Initially this feels like extra work. We need to teach physicians and staff that answering e-mails is just as important and needs to be just as quick as a phone call – and that may mean that there’s different work, not more work.” 


Some providers and staff fear that electronic communications might destroy the barriers that shield them from being overwhelmed by patient needs. And points of resistance for physicians remain, such as:

• Informing patients about complicated test results, such as chest x-rays that suggest       cardiomegaly.

• Coordinating one patient’s care across multiple practices.

• Staffing the MPM queries. Determining which staff person handles which questions. 


Day says that each hospital-based medical practice strives to be a “patient-centered home,” a new buzzword. As such, it coordinates and delivers care, and it shares health information, including technologically. Patients might come in three or four times a year, she says, but between visits, lots of treatment and prevention efforts occur. MyPennMedicine enables the interactions.


National research praises online patient portals. A 2012 Kaiser Permanente study showed that patients with access to their online records used their healthcare system more than people who opted out of a portal. Ted Palen, MD, the study’s lead author, said that portal participants might have been more concerned about their health than those who didn’t enroll, a situation that would account for some difference in usage.


A 2015 literature review in the Journal of Medical Internet Research concluded that patient portals show significant improvements in patient self-management of chronic disease and improve the quality of care provided by providers. 


The electronic system can also function as a way to conduct patient surveys. Ashburn’s office sends patients an after-visit summary (AVS) with instructions for answering questions. “We are reasonably aggressive in collecting patient-outcome data, particularly how intense their pain is. These answers are very important to us.” 


Schlegel expects that patient-reported outcomes will change as more people participate ion MPM. Questionnaires plus USB-enabled devices, such as glucometers, blood pressure cuffs and scales can directly download information into a portal that care teams can use,” without a need for office visits, or, indeed, any direct contact.


Day and Schlegel are looking at ways to inform interested patients about participating in research studies that might be relevant to them.


The Health Kit app on iPhones can link directly to Penn’s site, and additional software is developing. “The software and the interface can be intimidating” because it’s new, says Susan Day. “There’s a learning curve for everyone.” An intrepid mountain climber, Day is always looking for challenges.


No, MyPennMedicine is not perfect. Patients have legitimate beefs.

A man receives a diagnosis of a basal-cell carcinoma on his face, and his dermatologist recommends a Mohs specialist. The patient has more questions than simply the openings on the doctor’s schedule. He wants to know how soon afterward he can swim, whether he needs to alter his vacation plans and how large and disfiguring the scar will be. No website designed to schedule appointments can answer those questions.


Because of an undiagnosed months-long cough, a woman’s primary orders a pulmonary-function test and a chest x-ray. Days after the exams, an e-mail in her inbox says: “You have a new message in MyPennMedicine.” She clicks, signs in and heads for test results. She passed the pulmonary test. The radiologist has posted: “No acute process in the lungs. Borderline cardiomegaly.” CARDIOMEGALY? Panic sets in.


An advisory committee, comprised of patients and advocates, evaluates these types of issues and makes recommendations for improving the processes.


Schlegel looks forward. “It took a long time for electronic communications to come to healthcare,” he says. Some medical centers put physicians’ notes on their electronic charts, “But doctors’ notes have traditionally remained behind the curtain. We’re not pushing for that right now.” He sees the future of MPM as adding bill paying, enhancing functionality and considering video visits. 


“It’s a rapidly evolving and exciting world,” says Susan Day. “It engages the whole medical team – doctors, nurses, nurse practitioners, social workers, front desk and, most importantly, patients – in designing better ways to access and deliver care. It’s not perfect, but it has a lot of potential. This is my soapbox.”


“Take two aspirin, sit in front of your computer screen and say ‘Aaah.’”


This article appeared in Penn Medicine.