Death by Patient Portal (2025)

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July 1, 2023

Human Factor

Esra Bilir, MD, MSc | Die Klinik in Preetz, Germany

Amazing and so moving. I read this through without stopping. We are humans and AI and other technologies are there to help us, not make our lives/professions miserable, and not to create distance within the physician-patient relationship.

CONFLICT OF INTEREST: None Reported

July 1, 2023

Oh, To Be Humanized!

MaLinda LaVonn Zimmerman-Cooney, MPH(c), BA, BIS | University of Arizona

Thank you Dr. Stillman for sharing your experience while pulling back the esoteric cloak of a medical provider. Your piece wonderfully adds to the building literature from professionals sharing their human experiences. Reading these stories gives me the same feeling I got as a kid when I would see my teacher out in public doing "real people things," like grocery shopping. These stories need to be shared as these vulnerabilities are moments that provide opportunities to grow individually and communally. Looking forward to more shares by you. Cheers!

CONFLICT OF INTEREST: None Reported

July 1, 2023

Very Well Done

Victor Ostrower, MD | Retired GI and Liver

Your scenario, conflicts, assessments, and outcomes were very well described. Your commitment to highly competent and compassionate practice is admirable and a model for others. Please force yourself to take time off for yourself and your family.

CONFLICT OF INTEREST: None Reported

July 1, 2023

Excellent Description of the Practice of Medicine in the Age of EHRs

Paul Fortgang, MD | Yale University Department of Surgery, Otolaryngology

I think your strategy was fantastic, as most patients don’t conceive of what we go through to keep up with constant bombardment of emails and other incoming. For the better, or worse?, patients are highly educated these days, have access to unlimited medical information, and are not afraid to question or inquire about their treatment.

One other item that we now have to deal with, which in some ways is more frustrating, is the CURES act and the immediate availability of patient results as soon as they are posted. As we all know, they often will get their

CONFLICT OF INTEREST: None Reported

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July 2, 2023

Love This!

Pamela Rudolph, BSN awaiting MSN | MSN FNP student

This is a fantastic idea for someone about to jump to the next step of becoming a provider. I hope that you have a great nurse practitioner working with you who can take some of your load off. Don't get burned out, get that Mini Z score above 40!

CONFLICT OF INTEREST: None Reported

July 2, 2023

Thank you Doctors & Medicos

Barbara Keating | Patient

As a patient, I appreciate the availability of the patient portal but I am very careful using it. I was appalled to find my doctor would respond on a Sunday eve. So now I am very careful about what I ask and when I ask it. The latest message I sent was just an FYI and said “no response needed” regarding missing an internet-linked daily test I take; I just wanted them to know. Most doctors I know work way beyond what they are compensated for (are you listening Medicare & insurance companies?). We need them to stay healthy and sane and to help the rest of us while still loving what they do.

CONFLICT OF INTEREST: None Reported

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July 1, 2023

Not Just Physicans Find Fault With Patient Portals

Sid Hymes, D.Sc., M.S., M.B.A. | Patient

Many patient portals are poorly designed, seemingly without the input of the actual users, which is to say doctors, staff members, or patients. They're often hard to navigate, with links (not infrequently circular) to minimally or completely useless webpages or websites. Similarly, the now obvious over-reliance on technology, even prior to the now wide-scale interest in, and accelerated adoption of, AI, has created confusion for patients and additional work for physicians and their support staff.

And no doubt many patients expecting a near-instantaneous, if not instantaneous, response to a portal-posted question are not just disappointed but feel ignored. Maybe

CONFLICT OF INTEREST: None Reported

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July 2, 2023

Thanks

Ann Mahan, WHNP, APRN | Office

Thanks, I needed that!

CONFLICT OF INTEREST: None Reported

July 2, 2023

I Love It!

Maria Pugliese, MD, BS | Retired from private practice in Philadelphia and Malvern, PA

It is such a wonderful letter. You must be such a wonderful person. As a sole proprietor, I never had to deal with a patient portal except as a patient in MyChart Jefferson Health. But I had an answering machine. In the early days I had it forward messages to my home off hours and then I stopped it without repercussions and gave people my home number for emergencies. Psychiatry is different from primary care internal medicine. But people would leave rarely 22 messages on the answering machine. I dealt with it by talking to patients personally on an individual basis. I admire your courage, and your patients have responded to it superbly. A Piece of My Mind is my favorite part of JAMA. Because of your letter, I will make sure I don't overuse my own doctors on the patient portal.

CONFLICT OF INTEREST: None Reported

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July 2, 2023

Nice Parable, Unfortunate Title

Colin Doherty, MD | Trinity College Dublin

This story resonates with many physicians who are merging with their digital selves (and not in a good way). The problem of 24/7 digital communication through a portal could have been solved by adopting a co-design approach to the portal's capabilities, and building in a covenant on contact from the beginning instead of near the end approaching the breaking point before sending out the white flag! As it turns out patients are very willing participants in covenants like this, which we learned locally when we designed our epilepsy portal with them from scratch. It is unfortunate that the title is "Death By Portal, when the message of the parable is uplifting, having to do with the human connection and respect that both patients and physicians crave. Dare I suggest this piece should have been titled "Redemption by Portal'?!

CONFLICT OF INTEREST: None Reported

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July 2, 2023

A Serious Problem

David Rose | Patient

When I use a patient portal (in my case, "MyChart"), I noticed that when I send a message to my doctor, that message remains in the patient portal, and can later be seen by my doctor and/or other logged-in providers. I also noticed that my health records, as seen in the patient portal, were woefully inadequate and thus harmfully misleading. I asked my doctor if I could post my medical background information to the patient portal, where it would become part of my permanent medical records, by sending the medical background information as a message to her via the patient portal. I said I was going to send a number of messages to her and that she should ignore them, since I was just making my electronic health records accurate and did not require any medical advice or attention. She said I could do so.

After I sent multiple messages, some quite lengthy, the system reacted severely. I am no longer allowed to communicate with my doctor, except for very brief messages to her staff about refilling prescriptions, etc. A "Behavioral Warning" about me was posted on the patient portal and a registered letter sent informing me that the clinic and my doctor believe in giving "equal attention to all patients" and that since I had sent more messages than other patients I had violated that rule and was doing something very wrong.

CONFLICT OF INTEREST: None Reported

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July 5, 2023

Boundaries

John Spine, DO | Tri-County Medical Center, PC

This article is an eloquent description of appropriately establishing boundaries, specifically in regard to patient use of their portal access to their physician. I believe the take-home point and one of the best ways to minimize burnout is to establish boundaries with patients across the board. We need to value ourselves and our time in the same manner as do attorneys, accountants, and other professionals. In my practice, anything that takes more than a moment's thought requires an appointment whether it is in office or via telehealth. I have spent as long as 45 minutes on the phone attempting peer to peer authorizations for studies such as MRIs. However, it has been many years since I have done a peer to peer review without the patient present. And, if it takes 45 minutes at least two things are accomplished: First, it generates huge empathy on the part of the patient for what we need to do, and, secondly, it generates a billable visit at the 99215 level. If I call or email my accountant or attorney, I receive a bill for their time. My time is at least as valuable; so is yours.

CONFLICT OF INTEREST: None Reported

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July 6, 2023

Patient Email

David Smith, MD FAAFP | Consultant, Former President AAFP

Dr Tillman’s email well describes the ugly underbelly of corporate medicine. Medical employers now have the EHR and patient portals to vastly overwork physicians until they drop, or die. Corporate “report cards” reflect nothing about panel sizes or work volumes now - only how fast you make the widgets. Now that more than half of American doctors are employed by Mega Health, they need a forum for discussion on work load and professional standards that can help defend patient care as well as physicians' personal health. Thank you, Dr Tillman for speaking out.

CONFLICT OF INTEREST: None Reported

July 6, 2023

Bill for your time!

Thomas Grugle, M.D. | Private Practice

The activities on the patient portal described in the article are telemedicine! There are CPT codes for all telemedicine activities, including patient portal interactions. CPT codes 99421 - 99423 are specifically for billing patient portal interactions. You could be billing 50 99421's per day at $50 apiece. That might change your perspective, and your patients' behavior!

CONFLICT OF INTEREST: None Reported

July 7, 2023

Not Death, but Mismanagement by Patient Portal

Geraldine Powell, MB BcH BAO | Retired Physician

Between the EHR and the patient portal I have seen numerous errors creep into my record.

As both a physician and patient I have come to loathe finding the same incorrect details show up in more and more of my records, like amoebae constantly dividing across healthcare systems.

It is absolutely no use trying to get the errors corrected, and I have tried.

The advantage of these digital marvels is totally outweighed by the dissemination of false information far and wide.

Companies only interested in money making are absolutely ruining the integrity of medical

CONFLICT OF INTEREST: None Reported

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July 9, 2023

No Need For Immediate Response

Philip Ayoung-Chee, MBBS(UWI) FRCS (Glasg) | Retired Urologist, Trinidad and Tobago

In today's setting, many believe that there needs to be an immediate response. My only immediate response is to a telephone call, not messages.

For an immediate response from the public, call the emergency service.

For an immediate consult from another doctor, let them make the telephone call.

Messages through email, Facebook, Instagram, and similarly are not emergencies and can be dealt with at leisure.

For the record, I read messages at night when I am relaxed and have leisure time.

And this is how I've existed for the last twenty years.

Technology did

CONFLICT OF INTEREST: None Reported

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July 9, 2023

Balancing Efficiency and Engagement

You Chen, PhD | Vanderbilt University Medical Center

As digital communications become a norm in healthcare, patient portals have emerged as crucial links between providers and patients. While reducing portal message volume, as suggested in your strategy, can lighten a physician's immediate workload, I propose that refining message quality and controlling their count would be more effective, ensuring the portal's continued utility.

Implementing a nominal fee for each sent message, lower than a traditional office or telehealth visit, could incentivize patients to send fewer, more comprehensive messages. This could help preserve the portal for key communications without impeding timely exchanges.

Simultaneously, introducing a message prioritizing system

CONFLICT OF INTEREST: None Reported

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July 9, 2023

I Found the Portal Better than Phone Calls

Gordon Banks, PhD MD | Retired

Requests for medication refills shouldn't go to the physician, but to the pharmacy, or the medical administrator or other support should take care of it. Only those questions that only you can answer should go to you.

I preferred the portal to phone calls. I hate trying to play phone tag. With the portal, you can be concise and you do it when it is convenient and it always will reach the patient when it is convenient for them. There is also a record so there is no chance of misunderstandings later on

CONFLICT OF INTEREST: None Reported

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July 9, 2023

Moving, Engaging, and Fostering Awareness of the Function of Portals

Raquel Hernandez, PhD(c), MPH | CDC Foundation

A moving and engaging article. I could not stop reading once I started! The scenarios, dilemmas, decisions, and outcomes were well described. I admire your dedication to providing the best possible care while maintaining the human touch. Patient portals and even SMS have improved non-emergency communications among providers and patients. However, at one end of the spectrum is that someone (such as the practitioner in this article) is following up on the portal communications. Thank you for sharing your experience and fostering awareness to improve both the patient and provider portal experience.

CONFLICT OF INTEREST: None Reported

July 18, 2023

Revolving Doors

Lindsey Morrison Grant, Social Work | Unaffiliated

The mental health lesson we were supposed to have gleaned from COVID-19 lockdowns and innovations like telehealth was how integral human connection/interaction is to wellness. Nevertheless, AI and virtual solutions continue to displace human interactions for the sake of expedience and convenience. The author's point is well-taken that it is not a patient or clinician problem, but rather a human problem, and a universal one.

CONFLICT OF INTEREST: None Reported

July 22, 2023

Death by Patient Portal

Stuart McCalley, MD | Retired

Early in my practice years a senior colleague advised me “You have to train your patients.” That’s easier to do than it sounds. But over the years I saw some doctors who never said no to patients, or who never set boundaries, and thus became overwhelmed by their need to accommodate patient whims. They were popular and with big practices, but were they were unable to stop working, unable to get adequate amounts of sleep, or incapable of taking enough personal or family time off, so eventually they collapsed under the burden of catering to their dependent patient panels. One of the greatest rewards of being a physician is the feeling of being needed. But that can bowl you over if you don’t set limits for yourself and your patients.

CONFLICT OF INTEREST: None Reported

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July 22, 2023

Feedback from a Private Practice Doctor

Farshid Rahbar | Los Angeles Integrative Gastroenterology and Nutrition, Inc.

Kudos to Dr. Stillman for this well-written, erudite article that comes in time. Physician burnout is an illness and, based on supportive literature, is a US epidemic of its own. As part of the physician's inbox, the patient portal can clearly be identified as a potential causative factor.

On the other hand, the patient portal, as a model of service, is crucial for proper ongoing care and patient satisfaction. Two to 3 questions, within 2-3 days post-visit, is a reasonable expectation to offer clarification for visit-related matters. Ongoing support through the patient portal 24 hrs a day without

CONFLICT OF INTEREST: None Reported

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July 22, 2023

Are Patient Portals Working for Anyone?

Bob Klein | CEO of Digital Scientists, a technology strategy and innovation firm

The current functionality within the patient portals doesn't seem to be working well for either patients or providers.

While the provider can end up overwhelmed with messaging from patients, keep in mind that patients, especially older adults, are struggling to manage their own care across many portals, not just one.
My father-in-law has 5 portals alone, not counting Medicare.gov.

Providers need more tools to prioritize and streamline asynchronous communication with patients. This assumes that the health system is also providing great notes (opennotes.org) or even recordings (openrecordings.org) to help patients engage with their own health encounter and

CONFLICT OF INTEREST: Digital Scientists is a custom software development firm focused on patient and provider ecosystems.

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July 27, 2023

What About the Future?

Maurice Hodos, BS, DC, CEBS | Retired Chiropractic Physician

After reading your article and the comments, I wondered about the impact of artificial intelligence (AI) in the world of EHRs and the patient portal. A forward-looking position could surely envision AI to ease the burden of patient portal responses. As more data are collected, interrelated, and organized, there will be more potential for forward "progress" in these areas. As always, time will tell. Stay tuned.

CONFLICT OF INTEREST: None Reported

July 28, 2023

The Issue is Two Sided

William Gallerizzo, MBe | Catholic Pastoral Bioethicist

I was captured by your article. Truly there are two factors The first is that you are frustrated by the lack of human contact, and human contact for healing is why you went into medicine. The other side is the patient, using myself as an example. I've come to hate portals when I really want to see a doctor or any other human being to help me solve my health, home maintenance, or other question or problem. Both of these are impacting you to a level of discomfort. But, there are two parts to the "recovery" process and your frame of mind is critical.

First, look at the advantage the portal has given. There may not be the human contact, but it can almost serve as a kind of triage to help determine if the patient truly needs to come in for an in-person appointment. In that regard, you can encourage the patient to take a more proactive role in his or her health.

The second is you. Make time, even if it's only 10 minutes a day, to do something apart from the doctoring. I know a neurologist who keeps an electric guitar and a small headphone amp in his office just for that. I know a surgeon who took up knitting. He put his skills at stitching up patients to making something physically tactile that was non-critical. I know another who took photos of the birds outside his office window. A neurosurgeon I know very well watches one short Disney cartoon every day. Another started writing poetry in a separate journal. I play a cheap harmonica that fits in my pocket. Then take a deep breath and return to the daily foray.

We can't change the emphasis on tech. COVID just changed the fact that tech could give advantage over distance that always worked against us. It still cannot replace the human factor. But we can do something positive to affect our frame of mind. We can make the effort to be more human. And that helps us and how we eventually work with our patients.

CONFLICT OF INTEREST: None Reported

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July 30, 2023

Guidelines on Patient Portal Usage

May Hong, MD | Hospital

I love the idea of doing the peer-to-peer with the patient present. Thanks! If this were a presentation I would fill out the evaluation form with this nugget on "how I am going to change my practice."

CONFLICT OF INTEREST: None Reported

July 30, 2023

Setting Boundaries

Ikenna Nweke, MD, MBA | Southwestern Health Resources

Thanks for this well-written article. Over-utilization of the patient portal is certainly one perceived downside of providing access to care. I particularly liked the idea of sending a portal blast message to all patients seeking their assistance in setting boundaries. Patients are focused on their individual issues when sending messages and aren’t often aware/concerned about other hundreds of messages we receive daily with medical questions and refill requests.

Even when we set a limit on the number of characters allowed, portal users sometimes find creative ways around that; in one instance, attaching a word document to the message as

CONFLICT OF INTEREST: None Reported

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July 31, 2023

Different Format, Similar Dilemma

Rebecca Byrd, RN, BSN | Consulting Firm

I empathize with the feeling of being overwhelmed by patients’ questions. I managed a primary care practice for 11 years and changed direction just as the EHR was coming to the office environment. I would arrive two hours before the day started to listen to and notate voicemails that we had received overnight. I listened to more instead of taking lunch and would stay two hours late to listen to those that were left between lunch and 5:00P. I triaged the messages, made call-backs for clarification when needed, then ran the messages by the physicians. Many of the questions I could handle without disturbing the doctors. I then called the patients back with an answer, called prescriptions in or faxed them to the pharmacy, and documented everything in the paper chart. I have to say, it was stressful. Perhaps your nursing staff needs better education regarding what should be escalated to the provider? Messages are nothing new. At least with the portal you don’t have a child screaming in or your ear or being sworn at and hung up on.

CONFLICT OF INTEREST: None Reported

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July 31, 2023

Well Described and Great Idea!

William Laffond | Sentara Medical Group

So glad you found a way to decrease the burden of communications. In our group, the messages are pre-screened by clinical staff which has been somewhat helpful. If it’s clear the patient needs a refill they tee up the refill. If it’s a complicated question, they offer to contact the patient to schedule an appointment.
When the question or questions are particularly taxing, I have found it helpful to just get them scheduled, either for telehealth or in the office. If the complexity and /or risk match the degree of an office visit, you deserve to get paid for it and have a real-time dialogue about it. That would also serve the patient best. I must say that as a patient, using the portal to contact my providers has been most helpful.

CONFLICT OF INTEREST: None Reported

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July 31, 2023

Disagree

Gary Green, Clinical Professor | St. John's Physician Partners

As someone who used paper charts for the first 34 years of my career and switched to electronic records just 3 years ago, I was initially terrified about the change. While I initially railed against the EHR, I have to admit I've become a convert and appreciate the added efficiency and access to full medical records. I read the article with great interest, but have to disagree with the conclusions and the comments in several areas. First, the author has created (with help from the system) his own problems by not setting boundaries. There are many barriers to patients communicating with their physicians and the portal has created an easy way around this. You can't blame patients for wanting access, and people will always take the quickest route. The problem is that failure to initially set workable boundaries leads to the inevitable outcome. There are many "dot" phrases that could be used to communicate with patients that would make the boundaries quite clear, such as "please schedule an appointment if you would like to discuss your tests in more detail," or "This is a significant issue and requires a full evaluation. Please schedule an appointment at your convenience." COVID has ushered in a new era of telehealth that can be used to address many issues, such as explaining abnormal lab results. A second issue is that physicians, motivated by helping patients, are not being reimbursed by the health care system for these emails and other communications. Each time we review a lab test, we are providing a medical interpretation for that patient and making a medical decision. Having patients bring in their medications to each visit and ensuring that they have enough refills until the next visit is an easy way to avoid excessive refill requests. It is also good medicine in that it allows you to fully review the patient record and ensure that the medication and dose is still appropriate. Lastly, while I am sympathetic to physician burnout and stress, I disagree with communicating that to the patients as a way of justifying the changes to one's practice. While patients certainly do "care" about their physicians, their main concern is getting their health care needs met. If a physician has a mental or physical health issue, then the patients expect they will take care of it and it is not really their responsibility. They expect that someone else will meet their health care needs in the interim. There are many ways around these issues, but much of it is of our own creation in not setting adequate boundaries for patients so that we function more efficiently.

CONFLICT OF INTEREST: None Reported

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December 19, 2023

Billing for Portal Usage Unhealthy

Mike Mychajlonka, Ph.D. | Patient

The University of Michigan health care system has now placed a notice on its patient portal stating that a question asked of a physician may end up being billed to the patient's insurance and be therefore subject to co-pays and other billing legerdemain. I take this to mean that some nameless clerk is reading this communication with an eye to extracting money from it. Here I am having thought that patient/physician communications were supposed to be confidential! Does this faceless clerk have a quota to fill? How can a bill be issued for an action the patient has never authorized as a billable item? Does such a bill constitute insurance fraud? Is a notice on a website supposed to somehow automatically answer these questions? If a physician is overwhelmed with portal communications and is looking to be thrown a life preserver, why throw them a lead weight instead by compromising confidentiality and getting the physician involved in billing issues?

CONFLICT OF INTEREST: None Reported

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December 31, 2023

Great article

Ziva Patt-Rappaport, DO | St Luke’s Kansas City

Exactly my sentiment. I refrain from giving medical advice on the portal. I have my staff call patients and schedule appointments to discuss.

CONFLICT OF INTEREST: None Reported

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