Editorial
GUEST EDITORIAL
the journey of patient portals in New
Zealand general practice: early learnings
and key challenges
Sue Wells
Since first proposed by the National Health
information technology (it) Plan in 2010,
New Zealand has embarked on a patient portal
journey. The Plan was a roadmap towards an
integrated healthcare system enabled by health
it and included a goal that all New Zealanders
would have electronic (e) access to a core set of
personal health data.1 This core set is mainly
held by general practices that are highly
computerised, receive e-laboratory and hospital
discharge data and use e-referral and web-based
decision support functions. in the ensuing years,
several software companies developed patient
portals as an additional function within existing
patient management systems.2 These applications
integrated with health provider electronic health
records, allowing patients a secure internet
entry point to view their health information,
facilitate patient-provider messaging and
provide other functions such as requests for
repeat prescriptions and booking appointments.
Through portals, patients could also potentially
access information on their current diagnoses,
medications, test results, immunization history,
alerts and allergies and past events such as
hospital discharge summaries, specialist letters
and consultation notes.
Portals have been adopted in many countries
including the United States (US), United
Kingdom (UK), The Netherlands and
Scandinavian countries although impetus for
implementation has varied. in the US portal
implementation has been largely driven by
a competitive health market and health it
incentives via ‘meaningful Use’ of health it
policies.3 The NHS england had a different
approach with a 2016 mandate that their GPs
register for portal use 10% of the patients by
march 2017 and 20% by march 2018.4 as of July
2017, 78% of english practices had 10% or more
patients enabled for online access (r Sullivan,
personal communication, Patient Online UK
2017).
So where are we up to?
New Zealand did not incentivise or mandate
the implementation of patient portals. instead
in 2014, $3 million was set aside for Primary
Health Organisations (PHOs) to develop portal
implementation plans for their member practices
and seven early adopters (six of whom were GPs)
were appointed by the minister of Health as ehealth ambassadors to support uptake in general
practice.5 in the three years since, portal uptake
has been remarkably rapid; 47% of New Zealand
general practices have now implemented a portal
with 407,049 patients registered (representing
~10% of the New Zealand population over 18
years).5 Portal adoption as a contributory measure to some of the regional health alliances’ system level measures will support further uptake.6
However, all new technologies and interventions
can increase population health disparities due
to differential uptake. monitoring the registration and use of portals by age, gender, ethnicity,
deprivation and geography will be important. at
present these data are not routinely collected and
available at practice, PHO or regional level.
What are the lessons so far?
Portals represent a new partnership between
patients and providers and this change is developing and maturing. in an era of Facebook,
trademe, internet banking and booking travel
on-line, there have been few reports of difficulties for patients using the portals. While patient
experience so far is limited, a qualitative study
focusing on rural New Zealanders in this issue7
concluded that while patients were variably
engaged with different portal functionalities,
CSIRO Publishing
Journal Compilation © Royal New Zealand College of General Practitioners 2017
This is an open access article licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License
J Prim HealtH Care
2017;9(4):237–239.
doi:10.1071/HCv9n4_eD2
Published online 20 December 2017
CorrespondenCe to:
sue Wells
Section of Epidemiology
and Biostatistics, School of
Population Health, University
of Auckland, P.O. Box 92019
Auckland Mail Centre,
Auckland, New Zealand
s.wells@auckland.ac.nz
237
Editorial
GUEST EDITORIAL
they readily accepted the technology and were
enthusiastic adopters. Benefits described were
improving access and understanding of laboratory results, knowing the availability of appointments with their preferred doctor, the ability to
obtain an appointment in the middle of the night
when sick and being able to get a repeat prescription rather than have to make an appointment.7
Providers have overcome many challenges of portal implementation including the development of
new policies and governance, satisfying privacy
and security concerns and working through the
need to develop parallel work processes within
practices for online versus traditional practice
interactions such as booking appointments,
prescription refills, and the ability for patients to
view their laboratory results and securely message the practice. applying the 80:20 rule, portal
implementation is at least 80% a socio-cultural,
role and work flow adjustment and 20% a technical intervention.8
New Zealand reports of consumer and practice
issues with portal functions have been rare; ~2
patient in 1000 patients get alarmed by results
that are essentially ‘normal’ or expected but outside of laboratory ranges (personal communication r medlicott, 2017); 1 patient in over 125,000
may inappropriately book multiple daily or
weekly appointments (personal communication
C Driven, 2017). acknowledging the considerable
upfront costs of change (eg person-time needed
to register patients), for the most part the benefits
have outweighed concerns in terms of patient satisfaction and convenience, safer results handling
and time saving (e-health ambassadors have
reported that for every 30 portal appointments
booked, this saves an hour of front desk time).
What are the next key challenges?
The next key challenges in the portal journey are
opening up consultation notes to patients and
tackling the complexity around access for youth.
While a patient has a fundamental right to see all
their medical records, the prospect of opening
up the electronic patient record, especially the
consultation or visit notes, is a major patientprovider relationship change that has many GPs
238
alarmed and apprehensive. if the functionality
is turned on, the portal facilitates electronic
patient notes to be shared anytime, anywhere
with registered patients outside of the practice
and without face-to-face conversations with their
doctor or nurse. Doctors have been concerned
that access to visit notes may cause patients to
be unduly alarmed, confused or anxious.9,10 The
notes serve (among other functions) to remind
doctors of their patient’s unique characteristics,
and medical history, outline possible differential diagnoses (including worse case scenarios)
and possible strategies for action.11 There are
concerns about the security of patient on-line
records especially for sensitive health issues.12
The visit notes have traditionally been written for
an internal practice audience and would require
doctors and nurses to write their notes differently
(and potentially take more time) if the audience
widened to patients.11 Doctors’ notes tend to be
highly idiosyncratic and may contain cryptic
abbreviations and incomprehensible jargon. The
fear is that this may lead to patient complaints or
require increased time as patients raise concerns
or seek clarification or potential liability issues.11
The good news is that Open Notes project in US
(a highly litigious health market) has found that
these fears have largely not eventuated.13 This project and other studies have cited major benefits
of open notes for patient-provider relationships,
trust, improved patient-provider communication, greater engagement of patients in their own
care, improved adherence to medications, selfmanagement of chronic conditions, improved
recording of drug interactions and allergies and
follow-up of referrals and test results.9,12–18 indeed,
if patients are the most under-utilised resource
in the health system, portals are a catalyst to a
new shared working model. as e-patient David
deBronkart said at the 2017 Health informatics
New Zealand conference, ‘Let patients help. If one
party has access to data and the other hasn’t there
can be no teamwork.’ rather than passive recipients of care, access to their own health information allows patients to be engaged, empowered
and equipped to deal with their health problems.
in New Zealand, an estimated 20% of practices
with portals have opened up their patient notes
often prospectively from a set time forward to
J OUrNal OF PrimarY HealtH Care
Editorial
GUEST EDITORIAL
allow for a change in the documentation mindset. There have been no reports of issues with
open notes access so far but this requires further
evaluation.
The second challenge is youth access. Up to this
point, portal registration has largely occurred for
adults over 18 years. assuming it is in the child’s
best interests, providing proxy access for parents
or caregivers to access their children’s health
information on their behalf (and to look after
elderly members of the family) is a logical next
step. However, at some point this arrangement
may not be appropriate. For example, when a
five year old grows to be 15 and needs to confidentially discuss sexual health issues with their
doctor. Therefore on-line record access will need
to shift from parental access or shared parentchild access to independent portal access by a
competent young person who may be less than 16
years old. While health information privacy and
informed consent are not new, patient portals are
a new medium for information disclosure and
need to be considered within the same legal and
ethical framework. in this issue of the Journal of
Primary Health Care, Wong and morgan-lynch
provide us with an approach to address portal access to health information for young people and
point us to a resource to assist general practices.19
The New Zealand patient portal journey in general practice is in its early stages and holds much
promise for new models of care. However we
require more studies evaluating uptake, indicating how to use this technology more effectively
and identifying applications that are especially
beneficial to support health literacy, teamwork
and long-term condition self-management.
5. Ministry of Health. Patient portals. 2017. Available from:
http://www.health.govt.nz/our-work/ehealth/otherehealth-initiatives/patient-portals.
6. Ministry of Health. System Level Measures Framework.
2017. Available from: https://nsfl.health.govt.nz/dhb-planning-package/system-level-measures-framework
7. Carryer J, Kooienga S. Patients’ experience and understanding of E-portals in rural general practice: an ethnographic exploration. J Prim Health Care. 2017;9(4):262–
268.
8. Wells S, Rozenblum R, Park A, et al. Organizational strategies for promoting patient and provider uptake of personal
health records. J Am Med Inform Assoc. 2015;22(1):213–
22.
9. Ross SE, Lin C-T. The effects of promoting patient access
to medical records: a review. J Am Med Inform Assoc.
2003;10(2):129–38. doi:10.1197/jamia.M1147
10. Bloch S, Riddell CE, Sleep TJ. Can patients safely read
their psychiatric records? Implications of freedom of information legislation. Med J Aust. 1994;161(11–12):665–6.
11. Delbanco T, Walker J, Darer JD, et al. Open notes:
doctors and patients signing on. Ann Intern Med.
2010;153(2):121–5. doi:10.7326/0003-4819-153-2201007200-00008
12. Ferreira A, Correia A, Silva A, et al. Why facilitate patient
access to medical records. Stud Health Technol Inform.
2007;127:77–90.
13. Delbanco T, Walker J, Bell SK, et al. Inviting patients to
read their doctors’ notes: A quasi-experimental study
and a look ahead. Ann Intern Med. 2012;157(7):461–70.
doi:10.7326/0003-4819-157-7-201210020-00002
14. Ball MJ, Smith C, Bakalar RS. Personal health records: empowering consumers. J Healthc Inf Manag.
2007;21(1):76–86.
15. Bichel A, Erfle S, Wiebe V, et al. Improving patient access
to medical services: preventing the patient from being
lost in translation. Healthc Q. 2009;13:61–8. doi:10.12927/
hcq.2009.21100
16. Honeyman A, Cox B, Fisher B. Potential impacts of patient access to their electronic care records. Inform Prim
Care. 2005;13(1):55–60.
17. Masys D, Baker D, Butros A, et al. Giving patients access
to their medical records via the internet: the PCASSO
experience. J Am Med Inform Assoc. 2002;9(2):181–91.
doi:10.1197/jamia.M1005
18. Pyper C, Amery J, Watson M, et al. Patients’ experiences
when accessing their on-line electronic patient records in
primary care. Br J Gen Pract. 2004;54(498):38–43.
19. Wong D, Morgan-Lynch S. Patient portals and young people: addressing the privacy dilemma of providing access
to health information. J Prim Health Care. 2017;9(4):240–
243.
References
1. National Health IT Board. National Health IT Plan: enabling
an integrated healthcare model. Wellington, New Zealand:
National Health IT Board. Available from: http://www.
ithealthboard.health.nz; 2010.
2. Patients First and National Institute of Healthcare Innovation. PMS Review 2 – Sector Briefing on Portals. Wellington: Patients First/NIHI; 2014.
3. Blumenthal D, Tavenner M. The “meaningful use”
regulation for electronic health records. N Engl J Med.
2010;363(6):501–4. doi:10.1056/NEJMp1006114
4. NHS England. Patient online: What GP practices need to
do. 2017. Available from: https://www.england.nhs.uk/
patient-online/about-the-prog/gp-practices/.
J OUrNal OF PrimarY HealtH Care
239