Like many patients, my husband and I have been encouraged to use the electronic patient portal to communicate with our healthcare providers. We assumed that when we addressed a message to a physician, the message — or at least the clinical concern it contained —would reach that physician or another appropriate member of the clinical team.
I recently learned that assumption may not always be justified.
A Dartmouth Health clinic nurse told me that three portal messages I had addressed to my neurologist had been intercepted and handled by a non-clinical supervisor. Clinical questions were answered by that employee and it appears the messages never reached the physician for whom they were intended.
I had not been told this was happening.
More troubling, the communication restriction is not limited to one physician, one clinic or hospital, or one patient. My husband, a stroke patient, and I can no longer use the portal to communicate with any of our care-team providers across any of the Dartmouth Health affiliates. Providers who had previously appeared as members of our care teams are no longer available to us for messaging.
That experience raises an issue much larger than our family’s difficulties: What does it actually mean to “message your doctor”? Electronic portals have become an important part of healthcare. Patients use them to report symptoms, ask medication questions, describe changes in function, clarify instructions and seek guidance about whether a new problem requires attention. Certainly, physicians cannot personally read and answer every message. Large healthcare systems need nurses, clinical staff and administrative personnel to sort enormous volumes of electronic communication. Appropriate triage is both reasonable and necessary.
But triage and obstruction are not the same thing. If a healthcare organization centrally restricts a patient’s communication across an entire health system, the patient should know. And so should the clinicians who provide medical care for that patient. That distinction matters in our case. This is not simply an inability to message one physician. Our usual electronic pathway to our established care-team providers across Dartmouth Health affiliates has been removed. Yet we were not notified beforehand, given an explanation of the scope of the restriction, or provided an equivalent clinical communication pathway.
That raises practical patient-safety questions.
Do physicians at affiliated practices know when their patients have lost the ability to message them? When clinic staff tells a patient, “send your doctor a portal message,” can they see that the patient cannot do so? If telephone calls become the only remaining route for a clinical question, do staff answering those calls know that there is no electronic alternative?
And who decides whether a clinical concern intercepted outside the clinical team needs to reach a licensed clinician?
These questions become particularly important when a patient has a serious illness, disability or complicated medical history. A portal message may contain a new symptom, a medication problem, a change in cognition or mobility, or information whose significance may be apparent only to someone familiar with the patient’s medical history.
There is another danger. When patients believe they have communicated with their healthcare team, they may stop looking for another way to obtain help.
That false reassurance may be more concerning than receiving no answer at all.
This is not an argument that patients are entitled to unlimited access to physicians. They aren’t. Nor is it an argument against reasonable screening and triage of portal messages.
It is an argument for transparency.
If my message is going to a centralized pool rather than directly to my physician, tell me. If a nurse will review it first, tell me. If my ability to communicate with every member of my care team across an affiliated health system has been restricted, tell me — and tell the clinicians whose patients can no longer reach them.
Most importantly, provide another reliable way for medically significant information to reach a qualified clinician.
Electronic portals have fundamentally changed communication between patients and healthcare systems. With that convenience comes an obligation to make the rules transparent.
Patients should never discover after the fact that the message they believed they sent to their doctor never reached the doctor. Nor should they discover by trial and error that a communication restriction extends throughout their healthcare system.
A patient portal should be a pathway to healthcare — not an invisible barrier to it.
Susan Boyer, of Perkinsville, is the clinical alliance director of Nurses International, a nonprofit organization.