Older Adults' Experience Using Patient Portals in Communities: Challenges and Opportunities

Supportive Digital Health Service During Cancer Chemotherapy: Single-Arm Before-and-After Feasibility Study

BACKGROUND

Digital supportive cancer care is recommended to improve patient outcomes. A portal was designed and embedded within the electronic medical record and public health portal of Iceland, consisting of symptom and needs monitoring, educational material, and messaging.

OBJECTIVE

This study aims to assess (1) portal feasibility (adoption, engagement, usability, and acceptability), (2) potential predictors of usability and acceptability, and (3) the potential impact of the portal on patient-reported outcomes.

METHODS

This was a single-arm, before-and-after feasibility study at a university hospital among patients with cancer who were undergoing chemotherapy. Participation included filling out the Edmonton Symptom Assessment System-Revised (ESASr) weekly and the Distress Thermometer and Problem List (DT&PL) 3 times; reading educational material and messaging; and completing study questionnaires. Clinical and portal engagement data were collected from medical records. Data from patients were collected electronically at baseline and 7 to 10 days after the third chemotherapy round. Usability was assessed using the System Usability Scale (score 0-100), and acceptability was assessed using a 35-item survey (score 1-5). Patient-reported outcome measures included ESASr and DT&PL; a single-item scale for quality of life, family support, and quality of care; and multi-item scales for health literacy (Brief Health Literacy Screener), health engagement (Patient Health Engagement Scale), self-care self-efficacy (Self-Care Self-Efficacy scale), symptom interference (MD Anderson Symptom Inventory), knowledge expectations (Hospital Patients' Knowledge Expectations), and received knowledge (Hospital Patients' Received Knowledge). Health care professionals were interviewed regarding portal feasibility.

RESULTS

The portal adoption rate was 72% (103/143), and the portal use rate was 76.7% (79/103) over a mean 8.6 (SD 2.7) weeks. The study completion rate was 67% (69/103). The combined completion rate of the ESASr and DT&PL was 78.4% (685/874). Patients received a mean 41 (SD 13) information leaflets; 33% (26/79) initiated messaging, 73% (58/79) received messages, and 85% (67/79) received follow-up phone calls. The mean System Usability Scale score was 72.3 (SD 14.7), indicating good usability. Usability was predicted by age (β=-.45), ESASr engagement (β=.5), symptom interference (β=.4), and received knowledge (β=.41). The mean acceptability score, 3.97 (SD 0.5), was above average and predicted by age (β=-.31), ESASr engagement (β=.37), symptom interference (β=.60), self-care self-efficacy (β=.37), and received knowledge (β=.41). ESASr scores improved for total symptom distress (P=.003; Cohen d=0.36), physical symptoms (P=.01; Cohen d=0.31), and emotional symptoms (P=.01; Cohen d=0.31). Daily symptom interference increased (P=.03; Cohen d=0.28), quality of life improved (P=.03; Cohen d=0.27) and health engagement (P=.006; Cohen d=0.35) improved, while knowledge expectations decreased (P≤.001; Cohen d=2.57). Health care professionals were positive toward the portal but called for clearer role delineation and follow-up.

CONCLUSIONS

This study supports the feasibility of a support portal and the results indicate the possibility of improving patient outcomes, but further developments are warranted.

Empowering patients to address diabetes care gaps: formative usability testing of a novel patient portal intervention

Objective

The aim of this study was to design and assess the formative usability of a novel patient portal intervention designed to empower patients with diabetes to initiate orders for diabetes-related monitoring and preventive services.

Materials and Methods

We used a user-centered Design Sprint methodology to create our intervention prototype and assess its usability with 3 rounds of iterative testing. Participants (5/round) were presented with the prototype and asked to perform common, standardized tasks using think-aloud procedures. A facilitator rated task performance using a scale: (1) completed with ease, (2) completed with difficulty, and (3) failed. Participants completed the System Usability Scale (SUS) scored 0-worst to 100-best. All testing occurred remotely via Zoom.

Results

We identified 3 main categories of usability issues: distrust about the automated system, content concerns, and layout difficulties. Changes included improving clarity about the ordering process and simplifying language; however, design constraints inherent to the electronic health record system limited our ability to respond to all usability issues (eg, could not modify fixed elements in layout). Percent of tasks completed with ease across each round were 67%, 60%, and 80%, respectively. Average SUS scores were 87, 74, and 93, respectively. Across rounds, participants found the intervention valuable and appreciated the concept of patient-initiated ordering.

Conclusions

Through iterative user-centered design and testing, we improved the usability of the patient portal intervention. A tool that empowers patients to initiate orders for disease-specific services as part of their existing patient portal account has potential to enhance the completion of recommended health services and improve clinical outcomes.

Patient-Centered Digital Health Records and Their Effects on Health Outcomes: Systematic Review

BACKGROUND

eHealth tools such as patient portals and personal health records, also known as patient-centered digital health records, can engage and empower individuals with chronic health conditions. Patients who are highly engaged in their care have improved disease knowledge, self-management skills, and clinical outcomes.

OBJECTIVE

We aimed to systematically review the effects of patient-centered digital health records on clinical and patient-reported outcomes, health care utilization, and satisfaction among patients with chronic conditions and to assess the feasibility and acceptability of their use.

METHODS

We searched MEDLINE, Cochrane, CINAHL, Embase, and PsycINFO databases between January 2000 and December 2021. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Eligible studies were those evaluating digital health records intended for nonhospitalized adult or pediatric patients with a chronic condition. Patients with a high disease burden were a subgroup of interest. Primary outcomes included clinical and patient-reported health outcomes and health care utilization. Secondary outcomes included satisfaction, feasibility, and acceptability. Joanna Briggs Institute critical appraisal tools were used for quality assessment. Two reviewers screened titles, abstracts, and full texts. Associations between health record use and outcomes were categorized as beneficial, neutral or clinically nonrelevant, or undesired.

RESULTS

Of the 7716 unique publications examined, 81 (1%) met the eligibility criteria, with a total of 1,639,556 participants across all studies. The most commonly studied diseases included diabetes mellitus (37/81, 46%), cardiopulmonary conditions (21/81, 26%), and hematology-oncology conditions (14/81, 17%). One-third (24/81, 30%) of the studies were randomized controlled trials. Of the 81 studies that met the eligibility criteria, 16 (20%) were of high methodological quality. Reported outcomes varied across studies. The benefits of patient-centered digital health records were most frequently reported in the category health care utilization on the "use of recommended care services" (10/13, 77%), on the patient-reported outcomes "disease knowledge" (7/10, 70%), "patient engagement" (13/28, 56%), "treatment adherence" (10/18, 56%), and "self-management and self-efficacy" (10/19, 53%), and on the clinical outcome "laboratory parameters," including HbA1c and low-density lipoprotein (LDL; 16/33, 48%). Beneficial effects on "health-related quality of life" were seen in only 27% (4/15) of studies. Patient satisfaction (28/30, 93%), feasibility (15/19, 97%), and acceptability (23/26, 88%) were positively evaluated. More beneficial effects were reported for digital health records that predominantly focus on active features. Beneficial effects were less frequently observed among patients with a high disease burden and among high-quality studies. No unfavorable effects were observed.

CONCLUSIONS

The use of patient-centered digital health records in nonhospitalized individuals with chronic health conditions is potentially associated with considerable beneficial effects on health care utilization, treatment adherence, and self-management or self-efficacy. However, for firm conclusions, more studies of high methodological quality are required.

TRIAL REGISTRATION

PROSPERO (International Prospective Register of Systematic Reviews) CRD42020213285; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=213285.

FHIRedApp: a LEAP in health information technology for promoting patient access to their medical information

Objective

Our aim is to develop a patient engagement technology that makes it easy for patients to access their own medical information and share it with others.

Materials and Methods

This paper describes our design through an adapted Community Engagement Studio methodology to identify the needs and preferences of a diverse group of Latinx, African–American, and Asian–American individuals in the community. We use Human-Centered Design to interpret these needs and preferences to build a digital app platform, using national data standards, clinical data aggregators, and privacy-preserving solutions while maintaining the security and confidentiality of patients.

Results

We designed and developed FHIRedApp, an app platform, that allows patients to access their data and to share that access as HL7^® FHIR^® application programming interfaces with third-party app developers. We accomplished 2 major tasks: first, to demonstrate the use of interoperability and authentication standards, such as HL7^® FHIR and OAuth2, to help develop patient engagement technologies, and second, to co-develop and co-design FHIRedApp with active involvement of African–American, Latinx, and Asian–American community members. Usability results show high satisfaction rates for FHIRedApp.

Conclusion

The development of FHIRedApp demonstrates how technology innovations using national interoperability standards can be informed through a methodology of community engagement and human-centered design that involves local racial and ethnic groups.

Our aim is to develop a patient engagement technology (PET) that makes it easy for patients to access their own medical information and share it with others. We adapted a methodology to identify the needs and preferences of a diverse group of Latinx, African–American, and Asian–American patients. We used Human-Centered Design to interpret these needs and preferences to build a digital app platform, using national data standards, clinical data aggregators, and privacy-preserving solutions while maintaining the security and confidentiality of patients. We designed and developed FHIRedApp, a platform that allows other applications to work on it. Patients showed high satisfaction with the use of FHIRedApp. The development of FHIRedApp demonstrates how technology innovations using national standards for exchanging data can be informed through a methodology of community engagement and human-centered design.

Using a Patient Portal to Increase Enrollment in a Newborn Screening Research Study: Observational Study

BACKGROUND

Many research studies fail to enroll enough research participants. Patient-facing electronic health record applications, known as patient portals, may be used to send research invitations to eligible patients.

OBJECTIVE

The first aim was to determine if receipt of a patient portal research recruitment invitation was associated with enrollment in a large ongoing study of newborns (Early Check). The second aim was to determine if there were differences in opening the patient portal research recruitment invitation and study enrollment by race and ethnicity, age, or rural/urban home address.

METHODS

We used a computable phenotype and queried the health care system's clinical data warehouse to identify women whose newborns would likely be eligible. Research recruitment invitations were sent through the women's patient portals. We conducted logistic regressions to test whether women enrolled their newborns after receipt of a patient portal invitation and whether there were differences by race and ethnicity, age, and rural/urban home address.

RESULTS

Research recruitment invitations were sent to 4510 women not yet enrolled through their patient portals between November 22, 2019, through March 5, 2020. Among women who received a patient portal invitation, 3.6% (161/4510) enrolled their newborns within 27 days. The odds of enrolling among women who opened the invitation was nearly 9 times the odds of enrolling among women who did not open their invitation (SE 3.24, OR 8.86, 95% CI 4.33-18.13; P<.001). On average, it took 3.92 days for women to enroll their newborn in the study, with 64% (97/161) enrolling their newborn within 1 day of opening the invitation. There were disparities by race and urbanicity in enrollment in the study after receipt of a patient portal research invitation but not by age. Black women were less likely to enroll their newborns than White women (SE 0.09, OR 0.29, 95% CI 0.16-0.55; P<.001), and women in urban zip codes were more likely to enroll their newborns than women in rural zip codes (SE 0.97, OR 3.03, 95% CI 1.62-5.67; P=.001). Black women (SE 0.05, OR 0.67, 95% CI 0.57-0.78; P<.001) and Hispanic women (SE 0.07, OR 0.73, 95% CI 0.60-0.89; P=.002) were less likely to open the research invitation compared to White women.

CONCLUSIONS

Patient portals are an effective way to recruit participants for research studies, but there are substantial racial and ethnic disparities and disparities by urban/rural status in the use of patient portals, the opening of a patient portal invitation, and enrollment in the study.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03655223; https://clinicaltrials.gov/ct2/show/NCT03655223.

Benefits, Problems, and Potential Improvements in a Nationwide Patient Portal: Cross-sectional Survey of Pharmacy Customers' Experiences

BACKGROUND

Patient engagement is a worldwide trend in health care. Patient portals have the potential to increase patients' knowledge about their health and care and therefore enhance patient engagement. Portal users' experiences are needed to determine if these portals work appropriately and if there are barriers to achieving the aims that were set before their implementation.

OBJECTIVE

The aim of this study is to analyze pharmacy customers' experiences of the Finnish nationwide patient portal My Kanta in terms of benefits, problems, and potential improvements.

METHODS

A questionnaire survey was conducted among pharmacy customers in the spring of 2019. The questionnaires (N=2866) were distributed from 18 community pharmacies across mainland Finland to customers aged ≥18 years who were purchasing prescription medicines for themselves or their children aged <18 years. Using open-ended questions, customers were asked about their experiences of the benefits and problems of My Kanta and what improvements could be made. Their responses were encoded and categorized using inductive content analysis, stored in SPSS Statistics for Windows, and analyzed using frequencies.

RESULTS

Of the 2866 questionnaires, a total of 994 (34.68%) questionnaires were included in the analysis. Most respondents were My Kanta users (820/994, 82.5%); of these 820 users, 667 (81.3%) reported at least one benefit, 311 (37.9%) reported at least one problem, and 327 (39.9%) reported at least one potential improvement when using My Kanta. The most commonly mentioned benefits were opportunities to view health data (290/667, 43.5%) and prescriptions (247/667, 37%) and to renew prescriptions (220/667, 33%). The most extensively reported problems with My Kanta were that the portal lacks health data (71/311, 22.8%), navigating the service and searching for information is difficult (68/311, 21.9%), and the delay before health data are incorporated into the service (41/311, 13.2%). The most frequently suggested potential improvements were that My Kanta needs more comprehensive health data (89/327, 27.2%); the service should be easier to navigate and information easier to access (71/327, 21.7%); the service should have more functions (51/327, 15.6%); and health data should be entered into the portal more promptly (47/327, 14.4%).

CONCLUSIONS

Pharmacy customers reported more benefits than problems or potential improvements regarding the use of My Kanta. The service is useful for viewing health data and prescriptions and for renewing prescriptions. However, portal users would like to see more data and functions available in the portal and data searches to be made easier. These improvements could make the data and functions provided by the portal easier to view and use and hence promote patient engagement.

The My Diabetes Care Patient Portal Intervention: Usability and Pre-Post Assessment

BACKGROUND

My Diabetes Care (MDC) is a novel, multifaceted patient portal intervention designed to help patients better understand their diabetes health data and support self-management. MDC uses infographics to visualize and summarize patients' diabetes health data, incorporates motivational strategies, and provides literacy level-appropriate educational resources.

OBJECTIVES

We aimed to assess the usability, acceptability, perceptions, and potential impact of MDC.

METHODS

We recruited 69 participants from four clinics affiliated with Vanderbilt University Medical Center. Participants were given 1 month of access to MDC and completed pre- and post-questionnaires including validated measures of usability and patient activation, and questions about user experience.

RESULTS

Sixty participants completed the study. Participants' mean age was 58, 55% were females, 68% were Caucasians, and 48% had limited health literacy (HL). Most participants (80%) visited MDC three or more times and 50% spent a total of ≥15 minutes on MDC. Participants' median System Usability Scale (SUS) score was 78.8 [Q1, Q3: 72.5, 87.5] and significantly greater than the threshold value of 68 indicative of "above average" usability (p < 0.001). The median SUS score of patients with limited HL was similar to those with adequate HL (77.5 [72.5, 85.0] vs. 82.5 [72.5, 92.5]; p = 0.41). Participants most commonly reported the literacy level-appropriate educational links and health data infographics as features that helped them better understand their diabetes health data (65%). All participants (100%) intended to continue to use MDC. Median Patient Activation Measure® scores increased postintervention (64.3 [55.6, 72.5] vs. 67.8 [60.6, 75.0]; p = 0.01).

CONCLUSION

Participants, including those with limited HL, rated the usability of MDC above average, anticipated continued use, and identified key features that improved their understanding of diabetes health data. Patient activation improved over the study period. Our findings suggest MDC may be a beneficial addition to existing patient portals.

Testing a Model of Patient Portal Use in Adult Patients

PURPOSE

The aim of this study was to test a modified version of the Technology Acceptance Model, which describes users' technology adoption, to examine the relations between patient portal use and potential influencing factors in adult patients who have used patient portals. The modified model posits that patient portal use can be explained by attitude and self-efficacy for using patient portals, perceived usefulness and ease of use, data privacy and security concerns, eHealth literacy, education level, and age.

DESIGN

A cross-sectional anonymous online survey was conducted for adult patients who had used their patient portals in the past 12 months.

METHODS

Participants were recruited from 20 settings selected in a large integrated health care system. Data from 743 patients were subject to structural equation modeling for model testing.

FINDINGS

Sixty-eight percent were White and female, with a mean age of 53.1 years (SD = 15.34). Forty-seven percent used patient portals about monthly or more frequently. Scores for perceived usefulness and ease of use of patient portals were relatively high (as measured using the modified Perceived Health Web Site Usability Questionnaire; each item mean, 6.0-6.2; range, 1-7). The final model adequately fit the data (comparative fit index = .983, standardized root mean square residual = .064, root mean square error of approximation = .059). Patient portal self-efficacy and data privacy and security concerns had a direct impact on patient portal use. Perceived usefulness and ease of use, eHealth literacy, education level, and age indirectly influenced patient portal use.

CONCLUSIONS

This study contributes to expanding a theoretical understanding of adult patients' patient portal use in a real health care environment. Future studies need to include more diverse populations in various settings.

CLINICAL RELEVANCE

Knowledge gained from this study can be used by technology experts to make patient portals more user friendly and by administrators to implement patient portals more effectively.

Issues Related to the use of a Mobile Application of the Protocol for Preventing and Managing Urinary Catheter Blockage Among Long-term Indwelling Urinary Catheter Users for Visiting Nurses: An Interview Study of Visiting Nurses in Japan

Background:

We developed a mobile application of the protocol for preventing and managing catheter blockage among long-term indwelling catheter users for visiting nurses. We conducted meetings at four visiting nurse stations in Japan from May to June 2017 to explain the application to visiting nurses.

Objective:

The purpose of the present study was to clarify issues related to the full-scale use of this protocol application, using data from focus group interviews with visiting nurses.

Methods:

We conducted focus group interviews with the meeting participants. The focus group interviews were conducted at four different venues. Three focus groups had eight participants, and the fourth had two participants, for a total of 26 study participants. Specifically, the group interviews covered (1) the application’s structure and content; (2) operability; (3) portability; (4) possibilities for use, effects, and expectations; and (5) concerns about use.

Results:

The results of the group interviews were classified into five categories: possibilities for the use of the mobile application, possibilities for further use of the application by nurses, suggestions for the use of the application by caregivers and nursing care workers, the burden associated with the use of the mobile application, and opinions and desires for improvements in the mobile application.

Conclusion:

The results suggested that visiting nurses would use the mobile application. However, for full-scale use, it would be necessary to add the ability to use accumulated data, increase the number of learning screens, and take safety management measures for the transmission of medical information.

Older adults' use of patient portals: Experiences, challenges, and suggestions shared through discussion board forums

Patient portals (PPs) are robust health IT programs that engage and empower patients in their care. Although PPs can benefit older adults who manage chronic conditions, their use of PPs have been largely overlooked and little training has been provided to them. Previously, our research team developed an older-adult-friendly Theory-based PP eLearning Program (T-PeP) and tested its impact on older adults with chronic conditions. As part of T-PeP, participants used discussion forums. The aim of this study was to explore older adults' experiences with using PPs, perceived impact of PP on their health, and suggestions for improvement through analysis of discussion posts. A total of 205 posts were subjected to content analysis. Findings from 10 major themes explained older adults' experiences with PPs and offered suggestions for vendors and healthcare organizations. As U.S. population is aging, older adults must be considered during the development and implementation of health IT programs.