Putting Patient Portals into Practice

Patient portals hold out the promise of making health care more efficient, effective and satisfying for patients and clinicians. But successfully deploying these modern tools is not easy. It requires careful planning, experimentation and wisdom. Dr. Lori Posk is a practicing internist at The Cleveland Clinic where she also serves as the medical director for both her practice and Cleveland Clinic’s patient portal. This unique combination of roles has given her deep insights into how patient portals can be used to increase practice efficiency, improve health outcomes and create a more satisfying experience for all. Dr. Posk also introduces us to the concept of medical group visits and mountain unicycles. The episode concludes with some sage advice on achieving one of the most elusive goals for health care professionals: life-work balance.

Dr. Dave Levin: Welcome to 4 x 4 Health, sponsored by Sansoro Health. Sansoro Health, integration at the speed of innovation. Check them out at www.sansorohealth.com. I’m your host Dr. Dave Levin. Today I’m talking with Lori Posk from the Cleveland Clinic where she plays multiple roles. Dr. Posk is the Medical Director for the Twinsburg Family Health and Surgery Center with over 100 physicians and 400 employees where she also practices Internal Medicine. She’s also an Informatics Leader and Medical Director for the Clinics, Patient Portal based on Epics MyChart. This combination of clinical, administrative and IT responsibilities puts Lori in an unique position to lead work on issues like patient engagement, practice efficiency and improving chronic disease management. Dr. Posk has led key patient facing IT initiatives including Open Notes, the sharing of doctor’s notes with patients, electronic messaging, patient access and test result release. Anyone who has worked on these important and challenging topics know they require careful attention to people, process and technology as well as courage, wisdom and diplomacy. Having worked closely with Lori when I was at Cleveland Clinic, I can personally attest, she has all three. I suspect our listeners will agree after hearing our discussion today. Welcome to 4 x4 Health, Lori.

Dr. Lori Posk: Thank you David, thanks for inviting me.

Dave: Great! We’re gonna jump right in today. We’re gonna do a series of four questions and I’d like you to take about four minutes to answer each one. So, if you are ready to go, we can get started.

Lori: I am.

Dave: Alright! The first question, tell us about yourself and your organization.

Lori: So, as you noticed, I’m an internal medicine physician and I practice primary care. About thirty percent of my time is spent on seeing patients in the office. I work for the Cleveland Clinic which is a large multi-specialty non-profit organization and we not only have locations in Cleveland but now Florida where expanding, Nevada, we will be opening in London, we have a place in Abu Dhabi and Toronto. So, we’re a pretty vast expansive system with opportunities to serve patients in many different areas. I also like you said, a Medical Director for large Family Health Center that gives me an opportunity to really see workflow and how patients walk through their office experience on a day-to-day basis and then probably what I’m most passionate about is my role as Medical Director for our Patient portal which gives me an opportunity to really improve quality and safety of healthcare.

Dave: How are you diving up your time between these three areas, you said you are about thirty percent clinical, is that right?

Lori: Yeah and it’s never exactly thirty percent.

Dave: Right.

Lori: Having the additional administrative time gives me opportunity to add patients and be creative with that time too. I will do video visits, e-visits and other things in between seeing patients in the office but I still see patients in the office. Not only the traditional one-to-one patient visit in the office but I do share medical appointments with my patients too and then all my portal work and other administrative work is divided throughout the day as needs arise and as meetings continue to roll.

Dave: We may have to have you come back just to do a deep dive on group visits and shared visits. It’s a…

Lori: I’d love to do that.

Dave: It’s a topic of interest of mine. How much of your time are you spending on administrative work?

Lori: Well, administrative work, depending on how you define that is at least the other seventy percent. Some of it is around operations just on how our Family Health Center works and then the vast majority is around MyChart and how we are impacting workflow, patient experience and many other things that go along with the Patient portal.

Dave: It’s interesting to me that you and answering that question, you lumped in if you will the IT work, the portal work. I suppose that’s a reflection of how integrated that is with your view of what you are trying to accomplish and frankly your personal experience of, if you will have it to eat the dog food that you’re making, is that right?

Lori: Yeah, but in a very positive way. I mean, I really got interest in the portal because I was looking for a tool to really improve safety, quality, communication, patient experience. So, every single thing that we do every day is impacted by the portal and you, it was initially a clinical tool but now it’s being really used much more as an operational tool to schedule appointments, to show potentially cost estimates on things eventually and many other things that serve other roles besides just showing test results in Open Notes. So, it does impact you know, every really minute of the day that I’m working whether it’s seeing patients or doing things for their Family Health Center or then the MyChart work itself.

Dave: Well, knowing all the different things that you’re involved in, this next question might be a bit of a challenge for you but what’s the most important or interesting thing that you’re working on right now?

Lori: So, one of the areas I’m really passionate about delivering patient care because I see patients that are tend to be a little bit older, 65 and older as an internal medicine but memory loss cognitive impairment is an area that we are all gonna be impacted about whether we have it personally or whether or not we have family members or friends that will be impacted. So, I’m actually working on a project to implement a cognitive assessment tool on an iPad. This will consist of three different tests that will be delivered to a patient prior to their Medicare Wellness appointment on an annual basis and it consists of measures of episodic memory, processing speed, executive functions, things that are often done by a technician when you have Neuropsych testing, if you are doing a further workup for dementia by a Geriatrician or a Neurologist. However we have incorporated this into an iPad to be a screening tool to, in order to effectively screen patients that may have very early Mild Cognitive Impairment or very early Alzheimer’s disease and so I’ve been working with Dr. Rao at the clinic and his team to implement this and roll it out in our practice and it’s not only about the tool, it’s really about the workflow around that and how we can do that and not just rub patient care but contribute positively to it. So, we’re gonna be actually implementing it very soon.

Dave: Oh interesting. So, let’s get a little deeper on this because you know, this is one of those ideas that sounds great in theory and seems at least on the surface like it would be pretty simple, hey, we’ll just hand iPads to patients when they come in and they’ll do this stuff and it will be great but I suspect that it’s a lot more complicated than that, that there’s a lot of devils in the details and so as you said, you’re just getting started but walk us through some of those considerations that might not be so obvious at first glance.

Lori: Yes so, really the work that has been done right now, it’s not really about the tool itself, it’s really about the workflow around it. This impacts how patients are being scheduled, the fact that they have to come twenty minutes early, the fact that we need to get the information that we are getting on the iPad into the electronic medical record to act upon right at the point of care and so we are looking at all those different steps and then implementing that before we actually give the patients the tool and just throw out an electronic tool to try. Our goal is really to innovate to decrease burnout, not to increase it. So, I’ve had the benefit of actually having this tool being used in our MS Department at the Cleveland Clinic already. So, they’ve gone before me and been able to kind of iron out some of the things in the workflow and we’re now gonna be implementing in a primary care to do more mass screening, starting with the pilot in my office.

Dave: I had a colleague that used to say, I wanna be first in line to go second and there’s a lot of wisdom in that. I think you said a lot of really important things there. I just wanna try to tease the out a little bit. So, it’s really less about the software, I mean not that, that’s not important but there are all these really practical workflow considerations for the office staff, for the patient and as you noted that you know, the informations gotta be delivered in  way hat it’s useful to the clinician and doesn’t just become one more burden but I actually can enhance the care. That’s a really tall order. Even the simple basic things of, is the wireless network adequate. Do we have enough iPads, what do we do to keep them charged, whet if one of them breaks, what if we have a patient that shows up but they don’t know how to use it, what if they speak a language that’s not supported? I mean, there’s just a hundred little things in there, it’s again really valuable important work and you’re pointing us towards the kind of transformation that it can lead to but it’s often a lot harder than it looks.

Lori: It sure is. We’ve had the benefit of doing patient inner data on tablets for while at the clinic, whether be a PHQ or a GAD-7 or things like that. So, really working on that workflow and learning from some of the mistakes that we made earlier is very important.

Dave: Yeah. What do you think is your most important lesson learned so far out of this type of activity?

Lori: I think it would be people process technology, always keep that in mind. The technology is really the easy part of all this. It’s the people in the process that you really want to make sure you pay attention and nail down.

Dave: Well, I tell you what, regular listeners to this podcast have heard this theme consistently. I refer to it as the Iron Triangle. I’ve never seen a significant be successful without attention to all three, so good on you. If you just joined us, you’re listening to 4 x 4 Health, I’m your host Dr. Dave Levin. We are talking today with Lori Posk from the Cleveland Clinic where she is a practicing Internist and Medical Director for the Twinsburg Family Health and Surgery Center and for the Clinic’s Patient portal. For question three before you answer, I want to remind you Lori, this is a family show, it’s PG-13.

Lori: Thank you.

Dave: But we’d like to hear what’s your pet peeve or favorite rant these days?

Lori: Well, I’ll pick one and it’s actually similar to some of the things we actually just talked about, really around workflow and how we are delivering care to patients but one of my biggest concerns right now is how we are delivering primary care. We continue to hear that there is a shortage of primary care physicians and how are we gonna address this. Isn’t more medical students said, we wanna get into primary care type residency or hiring more NPs or PAs and I’m not convinced that, that actually is the answer because when you look at it, the care model is still the same. See the patients in the exam room, make adjustments and then see them back again another three to six months. Using a team approach I think is definitely much more valuable and it is being talked about but what I see the biggest advantage is really trying to deliver primary care different with shared medical appointments, with other opportunities for device integration, eventually having algorithms and AI behind  a lot of this. So, that the vast majority of patients actually, did I see today one right after the other for 15-20 minute appointments, they really could be taken off my schedule and being cared for differently and then create the opportunity to have open access on my schedule or do the shared medical appointments to other things to deliver care differently. I really think that we don’t necessarily have a crisis on a primary care shortage of providers. I think the crisis really is in the model of care that we’re delivering and so my biggest rant is really to examine this and think about not necessarily hiring a lot more people to do the same thing but to do it differently.

Dave: Well, I think that’s a great rant and it resonates really, really deeply with me. I mean, it’s pretty clear, the approaches and processes that got us here aren’t gonna get us to the future. Could you take a minute and just talk a little bit about shared visits? I suspect that many of our listeners are not familiar, only vaguely familiar with that idea.

Lori: Yes so, this has actually brought a lot of joy to practice for me. So, short visits are the opportunity to see a group of patients and it maybe anywhere from six to ten for certain medical problems. You can do this actually for physicals, I do mine for the diabetes, hypertension and lipids and the patients meet together as a group after they sign a waiver for confidentiality and then we review their medical problems individually within the group though and then we will go over their lab and we talk about medication changes, lifestyle changes which is often the bulk of my shared medical appointment and we make those adjustments and then we send the patients on their way. The whole visit is about an hour and a half  and again, most of it is around patient education, insured experiences amongst the patients. Often with me telling patients what to do with their diet and exercise, it’s not as effective as the group itself sharing their experiences and what’s been accessible but we have several of these shared medical appointments at the Cleveland Clinic for many different disease processes and the thing about it is patients really enjoy it and the providers do too. So, it shakes up our day a little bit in a very positive way.

Dave: I had the opportunity to get exposed to this a few years ago when I was at Eastern Virginia Medical School and part of what’s so fascinating to me about this topic is so much of what the assumptions might be about while patients won’t like that and you know, turn out to be exactly the opposite and you’ve alluded to a lot of that. I remember observing one of these, it was a diabetic group visit. There was a, you know, it’s a mix of ages and races and everything else and there was a younger guy there who was kind of early on in his diabetes management and he was sitting next to an older gentleman who had had a lower limp amputation and you could just see the impact of this older gentleman speaking to this younger man saying, this is why you really need to take good care and control your diabetes. You know clearly, much more impact than me as the physician delivering that message.

Lori: Exactly.

Dave: So, it’s a, it’s, as if you’re kind of activating a whole new kind of influence here through these visits. It’s not just about efficiency, it may actually be more effective in some settings. Am I over the top there or is that…?

Lori: No, not at all. Completely agree. I mean, patients are a wealth of education and experiences that they can share with other patients. So, that’s what the real value is of this group.

Dave: Yeah, and it does seem to have very broad applicability as well that you can use it for many, many different kinds of visits. I suspect some of our listeners might have been taken aback when you said, well, you can do group visits for physicals. Well, it turns out again most of that is about education and general assessment and things. So, it actually can work pretty well.

Lori: Exactly. Yeah but just…, yet, nobody undresses them in front of the patients. So…

Dave: Yeah, it did exactly. Ha, ha [Laughing], exactly. Well, so for our last question today, we’d like to hear your most sage advice.

Lori: You know, I think my most sage advice is really don’t allow yourself to play the role of a victim. I think often we feel we are the victim of the EMR or victims of our insurance companies or administrative burdens and I would encourage people to really think about this and don’t get into that negative cycle. Take time for yourself to really reflect on where we wanna make an impact, where you feel the negative energy is coming from and how you can make a change and if you do that, I think providers and even other administrative people around you will actually find a lot more joy in delivering the care that we do today. So, I encourage everybody, jump out of that victim role and really be active and make a change in some small way.

Dave: Boy, what terrific and sage advice. I mean, we can play the victim or we can empower ourselves. Personally, I’d rather be empowered and seeing problems as opportunities. Now, it’s hard to sustain some days, right. Everybody…, we all have our down moments but it certainly is a much better way to live and I think more productive and I agree with you. I think particularly as physicians, we’ve seeded a lot of our ability to influence things for the good because we were frankly spending too much time having a pity party. I see changes there and I think your advice is really consistent with that. I’d like to probe one other issue with you today if I could and that is the question of balance and part of what I find so interesting and have always admired about you is the apparent balance that you’ve been able to maintain and there’s kind of two dimensions to this for me. The first is, as we’ve talked about today, you’re wearing essentially three different hats in your professional life. You’re a practicing clinician, you’re an administrator for a busy and diverse practice and you’re leading important informatics initiatives but you’ve also got a balanced professional and personal life and like you I’ve been married a long time, I have children. I wanna be really clear, I don’t…, this is not a question to you because of your gender, it’s a question that all of us really should be facing and I’m just wondering if you’d share you know, some of your thoughts about how you maintain balance between your roles at work and also how you maintain balance between your professional and personal life?

Lori: Yeah, thank you for asking that question. So, I have been married many years and I do have three children, still have a 12 year old at home and so it is always a challenge to make sure that you’re doing the right thing for each part of your life but I actually don’t believe in a work/life balance. I think that it actually is very difficult to achieve and you are never gonna be there. What I believe in is really work/life integration and so for example, on Saturday mornings I walk with my patients. I get my exercise in and I get to see some patients, not only mine but other patients that come from the Family Health Center. We talk about simple health problems and we walk. Sometimes I’ll bring my kids if they will not sleep in and will come with me. So, I integrate what I do with my life every day, the personal family, as much as you can. There has to be some separation but as much as you can. For school, I don’t volunteer to bake cookies, I volunteer to do science talks instead or simple physical exam skills that I might show the kids and things like that. So, really work on integrating. I think if you’re always trying to strive a perfect balance, you’re never gonna be there and you’re gonna be disappointed because so many times personal life needs to take more of a role and then other times your work needs to take more of your time and so really trying to not always go home everyday thinking that you did fifty percent here and fifty percent there. It’s not necessarily the right approach that I take at least.

Dave: What a beautiful and interesting way to think about it and to marry those things together. I’m sorry, I think I interrupted you there.

Lori: Oh no, no. I was just gonna say two and then in my work, I mean most of the stuff, all really combines together, the workflow, the Patient portal, the patient experience. I feel very lucky that I am able to have these three different roles that actually all come together to try and create a good patient experience.

Dave: And what about ‘me’ time, how does that fit into all of this?

Lori: Ha! Well, you may remember I’m a runner. So, I like to get out and go for a long run when I can to clear my mind and then I am an unicyclist too, so that is time on my unicycle that I do long distance or even a little mountain bike unicycling, that there’s nobody else that’s with me, they can’t see. So, I get an opportunity to really think, reflect and exercise at the same time. So, I highly recommend integrating exercise in whatever form into your day, every day gets you an opportunity to clear your mind.

Dave: Well again, another example of integration. I would also make sure I heard you correctly, you’re doing an unicycle on a mountain, is that correct?

Lori: Yeah so, the mountain sometimes are not as big as you would imagine but there is a thing as mountain bike unicycling and the greatest thing is you fall, you get backup, you try again and we should be doing that in our life every single day.

Dave: Well, maybe we can get you to send us a picture that we can include on the website for this episode.

Lori: I’d love to.

Dave: This has been terrific and really appreciate your time today.

Lori: Thank you so much or inviting me and thank you for the great podcast.

Dave: We’ve been talking with Lori Posk from the Cleveland Clinic where she is a practicing Internist and serves as Medical Director for the Twinsburg Family Health and Surgery Center and as the Medical Director for the Clinic’s Patient portal. Lori again, thanks for joining us today.

Lori: Thank you, Dave.

Dave: You’ve been listening to 4 x 4 Health, sponsored by Sansoro Health. Sansoro Health, integration at the speed of innovation. Check them out at www.sansorohealth.com. I hope you’ll join us next time for another 4 x 4 discussion with healthcare innovators. Until then, I’m your host Dr. Dave Levin, thanks for listening.