Patient portals open the door to a new challenge for pediatricians: Unbounded messaging from parents

It used to be when a child had a fever for a few hours, a parent would likely wait a while, keeping a close watch on the kid or seek advice from friends or relatives.

That was before the dawn of the patient portal, which has created a whole new challenge for physicians, especially pediatricians. Now there is portal messaging, which allows parents and clinicians to exchange email-type messages via a practice’s electronic records portal.

Like much of technology, messaging has created "unprecedented opportunities and dilemmas in pediatrics,” according to a Viewpoint piece published in JAMA Pediatrics Monday. 

With no boundaries, it’s opened the door on all kinds of messages from parents, according to Tracy A. Lieu, M.D., of the division of research at Kaiser Permanente Northern California and The Permanente Medical Group in Oakland, and Gary L. Freed, M.D. of the division of general pediatrics at the University of Michigan Health Systems in Ann Arbor.

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“Portal messaging is currently completely unbounded, with no limit to the number or nature of messages that parents can initiate,” the two doctors wrote.

In one large group practice, the average pediatrician currently answers approximately 10 patient portal messages a day, a number that is expected to grow, they said.

Parents like the patient portal and messaging because of the convenience and increased access it affords. For their part, many pediatricians and family practitioners consider messaging useful in building relationships with families. But—and there is a big but—messaging has lowered the bar for parents to contact physicians with their concerns, the co-authors said.

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Parents no longer have to come in for an office visit or call and speak with a nurse to seek a doctor’s advice. There’s nothing to get in the way of a parent’s concern and the perception and expectation the physician should be available.

“In addition, today’s parents have grown up in an environment of personalization, intimacy and immediacy stemming from social media and may expect greater responsiveness from pediatricians than past generations,” they wrote.

It can create a slew of problems for doctors. For instance, there’s the time to respond to messages that can drag into off-hours work—already a problem for doctors trying to keep up with electronic health records and battling burnout.

There’s erosion of the boundary between work and personal life as they try to tend a stream of patient communication that is always open and continually growing, they said. And it may increase a doctor’s work that goes unpaid under current payment systems.

There’s also the nuances of language in electronic messaging and the possibility of misunderstandings about the tone, urgency or even clinical content.

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“Because portal messaging is so new, today’s parents and physicians lack cohesive cultural, institutional and professional norms for how to interact through this communication mode,” the doctors wrote.

For example, what’s a reasonable time for a physician to reply to a message? What’s the liability if a patient sends a clinically urgent message during the night or on the weekend? And will pediatricians soon be dealing with messages from their adolescent patients, as well as their parents?

It may be time for proactive steps, the authors suggest. Medical groups and practices can develop standards and establish expectations for what is a reasonable time to respond to portal messages. They can create guidelines for parents about what concerns are appropriate for a portal message rather than a telephone, video or office visit.

Medical groups may want to address issues such as who covers when a doctor is on vacation and whether other clinicians can be trained to respond to portal messages.

“Learning how to use portal messaging for its best possible effects while avoiding its potential harms and retaining the human connections traditionally built through face-to-face encounters represents the next evolution for primary care physicians and families,” the doctors concluded.