The doctor is out

"The doctor is no longer taking calls from patients after hours," the recording stated. "If this is an urgent issue, please seek care at your nearest urgent clinic, emergency department, or call 911 if this is an emergency."

The leg had looked a little bit redder and it definitely was warmer than usual -- two of the cardinal signs of infection, thought my physician colleague of his daughter's knee. She had suffered a scrape at the playground a few weeks prior and it had appeared to be healing well. However, while getting showered and packed for an early morning bus trip to summer camp, she had noted that it was starting to hurt more than usual.

My friend had hoped a quick call to the pediatrician's office would result in a quick appointment prior to the trip or an antibiotic that she could take while away to make sure it didn't get worse. However, she didn't have a fever or any systemic signs of toxicity to suggest that she needed to tax the healthcare system with an emergency department visit. With no other options and not wanting to miss out on the $2,000+ already sunk into the summer adventure, the two went to the ED, where she was diagnosed with early cellulitis and given a prescription for a short course of oral antibiotics.

"What a waste of time and money," he later lamented.

With the declining reimbursement profiles for primary care physicians and especially pediatricians, this may unfortunately become more of the trend, rather than the exception. An online physician job opportunity search reveals numerous practices enticing physicians with the absence of call. One listing for a family practice position in Colorado boasts, "Monday to Friday outpatient clinic…no call, and no inpatients." And a neurologist, in a discussion on the utility of after-hours call on the online physician forum Sermo, commends physician practices who rebuke traditional call responsibilities, "As it stands now with declining reimbursement, physicians need to get paid for everything we do. No more free care!"

While this scenario may be gaining favor among exhausted and burnt-out physicians and physician-practices, it does stand strikingly in contrast to the increasing connectedness and mobility of not only healthcare, but our world. Mobile technology and apps have opened a world of instant connections and transactions, from international e-health visits to Thai food delivery.

We can record intermittent symptoms with high-definition video and bring photos showing the healing of incisions and wounds over time. We can even connect with millions of patients online with similar symptoms and conditions on online forums at sites like PatientsLikeMe. And while numerous hospitals and physician practices have well-developed patient portals intended to increase communication, improve care and save dollars, we have yet to find the magic bullet.

The Mayo Clinic, an industry leader in self-developed enterprise technology, recently announced at the HIMSS13 conference and exhibition that after sinking millions of dollars and signing up an initial 240,000 patients for their portal, they have yet to meaningfully engage with 5 percent of them, as required by Stage 2 of meaningful use. Numerous reasons have been proposed for the poor adoption by both patients and physicians, from poor end-user/patient experience, lack of physician education and training, absence of a reimbursement structure, liability and a paucity of time. However, all of these pale in comparison to most portals' lack of mobility, portability and spontaneity.

Thinking that a feature-rich portal that allows patients to access static physician information, their laboratory results and some aspects of their medical history will be an effective patient engagement strategy suggests an inherent misunderstanding of how patients interact with their health and healthcare. Patients don't interact with their health or their physicians linearly or continuously. Whereas symptoms are sporadic, intermittent, fluid and cumulative, most patient portals are static and tucked away behind rarely used and often forgotten username/password combinations.

"Engagement" requires sitting at the computer and actively addressing the problem. However, chances are that when the symptoms first became severe enough for the patient to seek care, they were not sitting at their computer with their portal access handy. Much more likely is that they were out to dinner with their spouse and experienced that "horrible throat pain again" after a spicy pasta dish or at the local softball game when that "bad" shoulder finally demanded some attention. These moments are examples of what I term personal "healthcare thresholds," and are the instances when patients are ready to engage with their physicians. If they are unable, one of two things will happen: They will seek care at an emergency facility, or they'll re-file the problem into the "chronic" category and readdress only when it reaches a new healthcare threshold, likely at a more severe and difficult-to-treat level.

With that said, how then does a portal effectively engage patients? Three main components are required. It needs to be accessible, responsive and reliable when the patient is reaching his threshold. Functionally speaking, it needs to be mobile, platform-independent and functionally accessible -- no obscure passwords, registration requirements or new app download or updates. And ultimately, for it to be an effective communication, exchange needs to occur. Simply, a patient has to have the faith that there is a provider on the other side of the communication who is trusted, reliable and timely.

In parts two and three of this post, I will expand on the specifics of patient engagement and how physician adoption and use is as critical to an effective portal design as patient satisfaction.

Zachary Landman, MD, is the chief medical officer for Doctorbase, a developer of scalable mobile health solutions, patient portals and patient engagement software. He earned his medical degree from UCSF School of Medicine. As a resident surgeon at Harvard Orthopaedics, he covered Massachusetts General Hospital, Brigham and Women's Hospital and Beth Israel Deaconess Medical Center.