Helping Patients Be Better Patients: A Qualitative Study of Perceptions About Inpatient Portal Use

Clinician and staff experiences with frustrated patients during an electronic health record transition: a qualitative case study

BACKGROUND

Electronic health record (EHR) transitions are known to be highly disruptive, can drastically impact clinician and staff experiences, and may influence patients' experiences using the electronic patient portal. Clinicians and staff can gain insights into patient experiences and be influenced by what they see and hear from patients. Through the lens of an emergency preparedness framework, we examined clinician and staff reactions to and perceptions of their patients' experiences with the portal during an EHR transition at the Department of Veterans Affairs (VA).

METHODS

This qualitative case study was situated within a larger multi-methods evaluation of the EHR transition. We conducted a total of 122 interviews with 30 clinicians and staff across disciplines at the initial VA EHR transition site before, immediately after, and up to 12 months after go-live (September 2020-November 2021). Interview transcripts were coded using a priori and emergent codes. The coded text segments relevant to patient experience and clinician interactions with patients were extracted and analyzed to identify themes. For each theme, recommendations were defined based on each stage of an emergency preparedness framework (mitigate, prepare, respond, recover).

RESULTS

In post-go-live interviews participants expressed concerns about the reliability of communicating with their patients via secure messaging within the new EHR portal. Participants felt ill-equipped to field patients' questions and frustrations navigating the new portal. Participants learned that patients experienced difficulties learning to use and accessing the portal; when unsuccessful, some had difficulties obtaining medication refills via the portal and used the call center as an alternative. However, long telephone wait times provoked patients to walk into the clinic for care, often frustrated and without an appointment. Patients needing increased in-person attention heightened participants' daily workload and their concern for patients' well-being. Recommendations for each theme fit within a stage of the emergency preparedness framework.

CONCLUSIONS

Application of an emergency preparedness framework to EHR transitions could help address the concerns raised by the participants, (1) mitigating disruptions by identifying at-risk patients before the transition, (2) preparing end-users by disseminating patient-centered informational resources, (3) responding by building capacity for disrupted services, and (4) recovering by monitoring integrity of the new portal function.

Differences by Race in Outcomes of an In-Person Training Intervention on Use of an Inpatient Portal: A Secondary Analysis of a Randomized Clinical Trial

Importance

Differences in patient use of health information technologies by race can adversely impact equitable access to health care services. While this digital divide is well documented, there is limited evidence of how health care systems have used interventions to narrow the gap.

Objective

To compare differences in the effectiveness of patient training and portal functionality interventions implemented to increase portal use among racial groups.

Design, Setting, and Participants

This secondary analysis used data from a randomized clinical trial conducted from December 15, 2016, to August 31, 2019. Data were from a single health care system and included 6 noncancer hospitals. Participants were patients who were at least 18 years of age, identified English as their preferred language, were not involuntarily confined or detained, and agreed to be provided a tablet to access the inpatient portal during their stay. Data were analyzed from September 1, 2022, to October 31, 2023.

Interventions

A 2 × 2 factorial design was used to compare the inpatient portal training intervention (touch, in-person [high] vs built-in video tutorial [low]) and the portal functionality intervention (technology, full functionality [full] vs a limited subset of functions [lite]).

Main Outcomes and Measures

Primary outcomes were inpatient portal use, measured by frequency and comprehensiveness of use, and use of specific portal functions. A logistic regression model was used to test the association of the estimators with the comprehensiveness use measure. Outcomes are reported as incidence rate ratios (IRRs) for the frequency outcomes or odds ratios (ORs) for the comprehensiveness outcomes with corresponding 95% CIs.

Results

Of 2892 participants, 550 (19.0%) were Black individuals, 2221 (76.8%) were White individuals, and 121 (4.2%) were categorized as other race (including African, American Indian or Alaska Native, Asian or Asian American, multiple races or ethnicities, and unknown race or ethnicity). Black participants had a significantly lower frequency (IRR, 0.80 [95% CI, 0.72-0.89]) of inpatient portal use compared with White participants. Interaction effects were not observed between technology, touch, and race. Among participants who received the full technology intervention, Black participants had lower odds of being comprehensive users (OR, 0.76 [95% CI, 0.62-0.91), but interaction effects were not observed between touch and race.

Conclusions and Relevance

In this study, providing in-person training or robust portal functionality did not narrow the divide between Black participants and White participants with respect to their inpatient portal use. Health systems looking to narrow the digital divide may need to consider intentional interventions that address underlying issues contributing to this inequity.

Trial Registration

ClinicalTrials.gov Identifier: NCT02943109.

Patient perceptions of in-hospital laboratory blood testing: A patient-oriented and patient co-designed qualitative study

BACKGROUND

Indiscriminate use of laboratory blood testing in hospitals contributes to patient discomfort and healthcare waste. Patient engagement in low-value healthcare can help reduce overuse. Understanding patient experience is necessary to identify opportunities to improve patient engagement with in-hospital laboratory testing.

OBJECTIVES

To understand patient experience with the process of in-hospital laboratory blood testing.

METHODS

We used a qualitative study design via semistructured interviews conducted online or over the phone. Participants were adult patients or family members/caregivers (≥18 years of age) with a recent (within 12 months of interview) experience of hospitalization in Alberta or British Columbia, Canada. We identified participants through convenience sampling and conducted interviews between May 2021 and June 2022. We analysed transcripts using thematic content analysis. Recruitment was continued until code saturation was reached.

RESULTS

We interviewed 16 participants (13 patients, 1 family member and 2 caregivers). We identified four themes from patients' experiences of in-hospital laboratory blood testing: (i) patients need information from healthcare teams about expected blood testing processes, (ii) blood draw processes should consider patient comfort and preferences, (iii) patients want information from their healthcare teams about the rationale and frequency of blood testing and (iv) patients need information on how their testing results affect their medical care.

CONCLUSION

Current laboratory testing processes in hospitals do not facilitate shared decision-making and patient engagement. Patient engagement with laboratory testing in hospitals requires an empathetic healthcare team that provides clear communication regarding testing procedures, rationale and results, while considering patient preferences and offering opportunities for involvement.

PATIENT OR PUBLIC CONTRIBUTION

We interviewed 16 patients and/or family members/caregivers regarding their in-hospital laboratory blood testing experiences. Our findings show correlations between patient needs and patient recommendations to make testing processes more patient-centred. To bring a lived-experience lens to this study, we formed a Patient Advisory Council with 9-11 patient research partners. Our patient research partners informed the research design, co-developed participant recruitment strategies, co-conducted data collection and informed the data analysis. Some of our patient research partners are co-authors of this manuscript.

A systematic review of the effectiveness of patient education through patient portals

Objective

The objective of this study was to systematically review all literature studying the effect of patient education on patient engagement through patient portals.

Introduction

Patient portals provide patients access to health records, lab results, medication refills, educational materials, secure messaging, appointment scheduling, and telehealth visits, allowing patients to take a more active role in their health care decisions and management. A debate remains around whether these additional aids actually improve patient engagement and increase their ability to manage their own health conditions. This systematic review looks specifically at the effect of educational materials included in patient portals.

Materials and Methods

In accordance with PRISMA guidelines, the literature search was mapped across 5 databases (PubMed, CINAHL, Scopus, PsychINFO, Embase), and implemented on June 2, 2020.

Results

Fifty-two studies were included in the review. Forty-six (88.5%) reported rates of patient utilization of educational resources in the patient portal. Thirty (57.9%) shared patients' perceptions of the usefulness of the education materials. Twenty-one (40.4%) reported changes in health outcomes following educational interventions through the patient portal. This review found that efforts are indeed being made to raise awareness of educational resources in patient portals, that patients are increasingly utilizing these resources, that patients are finding them useful, and that they are improving health outcomes.

Conclusion

It seems that patient portals are becoming a powerful tool for patient education and engagement, and show promise as a means of achieving the quadruple aim of healthcare. Moving forward, research should establish more uniform methods of measurement in order to strengthen the literature surrounding the effectiveness of patient education through patient portals.

Effect of In-Person vs Video Training and Access to All Functions vs a Limited Subset of Functions on Portal Use Among Inpatients: A Randomized Clinical Trial

Importance

Inpatient portals provide patients with clinical data and information about their care and have the potential to influence patient engagement and experience. Although significant resources have been devoted to implementing these portals, evaluation of their effects has been limited.

Objective

To assess the effects of patient training and portal functionality on use of an inpatient portal and on patient satisfaction and involvement with care.

Design, Setting, and Participants

This randomized clinical trial was conducted from December 15, 2016, to August 31, 2019, at 6 noncancer hospitals that were part of a single health care system. Patients who were at least 18 years of age, identified English as their preferred language, were not involuntarily confined or detained, and agreed to be provided a tablet to access the inpatient portal during their stay were eligible for participation. Data were analyzed from May 1, 2019, to March 15, 2021.

Interventions

A 2 × 2 factorial intervention design was used to compare 2 levels of a training intervention (touch intervention, consisting of in-person training vs built-in video tutorial) and 2 levels of portal function availability (tech intervention) within an inpatient portal (all functions operational vs a limited subset of functions).

Main Outcomes and Measures

The primary outcomes were inpatient portal use, measured by frequency and comprehensiveness of use, and patients' satisfaction and involvement with their care.

Results

Of 2892 participants, 1641 were women (56.7%) with a median age of 47.0 (95% CI, 46.0-48.0) years. Most patients were White (2221 [76.8%]). The median Charlson Comorbidity Index was 1 (95% CI, 1-1) and the median length of stay was 6 (95% CI, 6-7) days. Notably, the in-person training intervention was found to significantly increase inpatient portal use (incidence rate ratio, 1.34 [95% CI, 1.25-1.44]) compared with the video tutorial. Patients who received in-person training had significantly higher odds of being comprehensive portal users than those who received the video tutorial (odds ratio, 20.75 [95% CI, 16.49-26.10]). Among patients who received the full-tech intervention, those who also received the in-person intervention used the portal more frequently (incidence rate ratio, 1.36 [95% CI, 1.25-1.48]) and more comprehensively (odds ratio, 22.52; [95% CI, 17.13-29.62]) than those who received the video tutorial. Patients who received in-person training had higher odds (OR, 2.01 [95% CI, 1.16-3.50]) of reporting being satisfied in the 6-month postdischarge survey. Similarly, patients who received the full-tech intervention had higher odds (OR, 2.06 [95%CI, 1.42-2.99]) of reporting being satisfied in the 6-month postdischarge survey.

Conclusions and Relevance

Providing in-person training or robust portal functionality increased inpatient engagement with the portal during the hospital stay. The effects of the training intervention suggest that providing personalized training to support use of this health information technology can be a powerful approach to increase patient engagement via portals.

Trial Registration

ClinicalTrials.gov Identifier: NCT02943109.

Evidence and implication of interventions across various socioecological levels to address pre-exposure prophylaxis uptake and adherence among men who have sex with men in the United States: a systematic review

BACKGROUND

Pre-exposure prophylaxis (PrEP) represents a proven biomedical strategy to prevent HIV transmissions among men who have sex with men (MSM) in the United States (US). Despite the design and implementation of various PrEP-focus interventions in the US, aggregated evidence for enhancing PrEP uptake and adherence is lacking. The objective of this systematic review is to synthesize and evaluate interventions aimed to improve PrEP uptake and adherence among MSM in the US, and identify gaps with opportunities to inform the design and implementation of future PrEP interventions for these priority populations.

METHODS

We followed the PRISMA guidelines and conducted a systematic review of articles (published by November 28, 2021) with a focus on PrEP-related interventions by searching multiple databases (PubMed, MEDLINE, Web of Science and PsycINFO). Details of PrEP interventions were characterized based on their socioecological level(s), implementation modalities, and stage(s) of PrEP cascade continuum.

RESULTS

Among the 1363 articles retrieved from multiple databases, 42 interventions identified from 47 publications met the inclusion criteria for this review. Most individual-level interventions were delivered via text messages and/or apps and incorporated personalized elements to tailor the intervention content on participants' demographic characteristics or HIV risk behaviors. Interpersonal-level interventions often employed peer mentors or social network strategies to enhance PrEP adoption among MSM of minority race. However, few interventions were implemented at the community-, healthcare/institution- or multiple levels.

CONCLUSIONS

Interventions that incorporate multiple socioecological levels hold promise to facilitate PrEP adoption and adherence among MSM in the US given their acceptability, feasibility, efficacy and effectiveness. Future PrEP interventions that simultaneously address PrEP-related barriers/facilitators across multiple socioecological levels should be enhanced with a focus to tackle contextual and structural barriers (e.g., social determinants of health, stigma or medical mistrust) at the community- and healthcare/institution-level to effectively promote PrEP use for MSM of color.

Improving Provisioning of an Inpatient Portal: Perspectives from Nursing Staff

BACKGROUND

 Inpatient portals are recognized to provide benefits for both patients and providers, yet the process of provisioning tablets to patients by staff has been difficult for many hospitals.

OBJECTIVE

 Our study aimed to identify and describe practices important for provisioning an inpatient portal from the perspectives of nursing staff and provide insight to enable hospitals to address challenges related to provisioning workflow for the inpatient portal accessible on a tablet.

METHODS

 Qualitative interviews were conducted with 210 nursing staff members across 26 inpatient units in six hospitals within The Ohio State University Wexner Medical Center (OSUWMC) following the introduction of tablets providing access to an inpatient portal, MyChart Bedside (MCB). Interviews asked questions focused on nursing staffs' experiences relative to MCB tablet provisioning. Verbatim interview transcripts were coded using thematic analysis to identify factors associated with tablet provisioning. Unit provisioning performance was established using data stored in the OSUWMC electronic health record about provisioning status. Provisioning rates were divided into tertiles to create three levels of provisioning performance: (1) higher; (2) average; and (3) lower.

RESULTS

 Three themes emerged as critical strategies contributing to MCB tablet provisioning success on higher-performing units: (1) establishing a feasible process for MCB provisioning; (2) having persistent unit-level MCB tablet champions; and (3) having unit managers actively promote MCB tablets. These strategies were described differently by staff from the higher-performing units when compared with characterizations of the provisioning process by staff from lower-performing units.

CONCLUSION

 As inpatient portals are recognized as a powerful tool that can increase patients' access to information and enhance their care experience, implementing the strategies we identified may help hospitals' efforts to improve provisioning and increase their patients' engagement in their health care.

Examining Patients' Capacity to Use Patient Portals: Insights for Telehealth

BACKGROUND

The increase in telehealth in response to the coronavirus disease 2019 pandemic highlights the need to understand patients' capacity to utilize this care modality. Patient portals are a tool whose use requires similar resources and skills as those required for telehealth. Patients' capacity to use patient portals may therefore provide insight regarding patients' readiness and capacity to use telehealth.

OBJECTIVE

The aim of this study was to examine factors related to patients' capacity to use a patient portal and test the impact of these factors on patients' portal use.

RESEARCH DESIGN AND SUBJECTS

Using data from a large-scale pragmatic randomized controlled trial of patient portal use, 1081 hospitalized patients responded to survey items that were then mapped onto the 4 dimensions of the Engagement Capacity Framework: self-efficacy, resources, willingness, and capabilities.

MEASURES

The outcome variable was frequency of outpatient portal use. We evaluated associations between Engagement Capacity Framework dimensions and patient portal use, using regression analyses.

RESULTS

Patients with fewer resources, fewer capabilities, lower willingness, and lower overall capacity to use patient portals used the portal less; in contrast, those with lower perceived self-efficacy used the portal more.

CONCLUSIONS

Our findings highlight differences in patients' capacity to use patient portals, which provide an initial understanding of factors that may influence the use of telehealth and offer important guidance in efforts to support patients' telehealth use. Offering patients training tailored to the use of telehealth tools may be particularly beneficial.

Understanding cancer patients' use and perceptions of inpatient portal: A case study at a tertiary hospital in Saudi Arabia

BACKGROUND

Inpatient portals have been introduced into tertiary hospitals to meet patients' information and communication needs, to increase their awareness of health care, and to facilitate their transition after discharge. However, there is inadequate knowledge about hospitalised oncology patients' use and perceptions of these technologies.

OBJECTIVE

To explore cancer patients' use and perceptions of an inpatient portal in a tertiary hospital and to identify the main benefits and barriers for patients in using the portal.

METHOD

A qualitative case study was conducted in a tertiary hospital in Riyadh, Saudi Arabia. Only cancer patients were invited to participate. Twenty-two semi-structured interviews were conducted in the patient's room in a cancer care centre in January 2020. Interviews were audio-recorded, fully transcribed, and analysed using a thematic analysis method.

RESULTS

Most patients used the portal for the first time. The most used features were entertainment, watching fall prevention videos and viewing medication lists. Although the majority of patients were positive towards the portal, and considered it to be useful and easy to use, only a small number of them used the key clinical feature of the system such as pain assessment, health education, and discharge preparation. The patients would like to see further improvement in usability of the portal, appropriate user training, adding further information, and incorporating more services and features in the portal.

CONCLUSION

The introduction of the inpatient portal is successful in improving cancer patients' hospitalisation experience. It helped cancer patients to acquire knowledge about their own health, to actively engage in their care processes, and to request and acquire electronic services, in addition to providing entertainment. Future research on which factors inspire patients' use of the portal and how the influence is achieved is needed for the successful integration of the portal into the patients' hospital care process.