Patient and physician perspectives on training to improve communication through secure messaging: Clarifying the rules of engagement

Phenotyping Adherence Through Technology-Enabled Reports and Navigation (the PATTERN Study): Qualitative Study for Intervention Adaptation Using the Exploration, Preparation, Implementation, and Sustainment Framework

BACKGROUND

Older adults with multiple chronic conditions (MCC) and polypharmacy often face challenges with medication adherence. Nonadherence can lead to suboptimal treatment outcomes, adverse drug events, and poor quality of life.

OBJECTIVE

To facilitate medication adherence among older adults with MCC and polypharmacy in primary care, we are adapting a technology-enabled intervention previously implemented in a specialty clinic. The objective of this study was to obtain multilevel feedback to inform the adaptation of the proposed intervention (Phenotyping Adherence Through Technology-Enabled Reports and Navigation [PATTERN]).

METHODS

We conducted a formative qualitative study among patients, clinicians, and clinic administrators affiliated with a large academic health center in Chicago, Illinois. Patient eligibility included being aged 65 years or older, living with MCC, and contending with polypharmacy. Eligibility criteria for clinicians and administrators included being employed by any primary care clinic affiliated with the participating health center. Individual semistructured interviews were conducted remotely by a trained member of the study team using interview guides informed by the Exploration, Preparation, Implementation, and Sustainment Framework. Thematic analysis of interview audio recordings drew from the Rapid Identification of Themes from Audio Recordings procedures.

RESULTS

In total, we conducted 25 interviews, including 12 with clinicians and administrators, and 13 with patients. Thematic analysis revealed participants largely found the idea of technology-based medication adherence monitoring to be acceptable and appropriate for the target population in primary care, although several concerns were raised; we discuss these in detail.

CONCLUSIONS

Our medication adherence monitoring intervention, adapted from specialty care, will be implemented in primary care. Formative interviews, informed by the Exploration, Preparation, Implementation, and Sustainment Framework and conducted among patients, clinicians, and administrators, have identified intervention adaptation needs. Results from this study could inform other interventions using the patient portal with older adults.

Differences in Patient Secure Message Volume Among Otolaryngologists: A Retrospective Cohort Study

OBJECTIVE

To identify differences in inbox and secure message burden among otolaryngologists based on demographics and subspecialty over 4 years.

METHODS

Inbox data were queried from January 2019 until December 2022. Otolaryngologists were categorized into cohorts by area of practice and gender. All inbox tasks, secure messages, and clinical encounters were collected and compared by gender, practice type, and years in practice. Means were compared using t-tests and chi-squared tests.

RESULTS

Of the 128 physicians, 45.7% were comprehensive otolaryngologists and 61.3% were male. The most common subspecialties were facial plastics (15.6%), oncology (8.6%), and otology (7.8%). Otolaryngologists had an average of 143.5 inbox tasks per month, with 97.2 (67.7%) of them being secure messages, resulting in an average of 1.14 inbox tasks and 0.80 secure messages per clinical encounter. The ratio of secure messages per clinical encounter was consistent across all specialties except oncology (1.10, P = .003). Otology (0.86, P = .032) and facial plastics (0.95, P = .028) had significantly lower ratios of inbox tasks to clinical encounters when compared to their colleagues, while oncology had a higher ratio (1.70, P < .001). No significant differences in inbox burden were observed between genders, years in practice, or languages spoken. Secure messages steadily increased over the study period.

CONCLUSION

Inbox burden for otolaryngologists primarily stems from patient secure messages and varies across subspecialties. Considerations should be made to the inbox burden of head and neck oncologists. The implementation of support systems for inbox management could improve the imbalance between clinical and non-clinical responsibilities in otolaryngology.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort Study.

New insights about community benefit evaluation: Using the Community Health Implementation Evaluation Framework to assess what hospitals are measuring

BACKGROUND

Nonprofit hospitals are required to conduct community health needs assessments (CHNA) every 3 years and develop corresponding implementation plans. Implemented strategies must address the identified community needs and be evaluated for impact.

PURPOSE

Using the Community Health Implementation Evaluation Framework (CHIEF), we assessed whether and how nonprofit hospitals are evaluating the impact of their CHNA-informed community benefit initiatives.

METHODOLOGY

We conducted a content analysis of 83 hospital CHNAs that reported evaluation outcomes drawn from a previously identified 20% random sample ( n = 613) of nonprofit hospitals in the United States. Through qualitative review guided by the CHIEF, we identified and categorized the most common evaluation outcomes reported.

RESULTS

A total of 485 strategies were identified from the 83 hospitals' CHNAs. Evaluated strategies most frequently targeted behavioral health ( n = 124, 26%), access ( n = 83, 17%), and obesity/nutrition/inactivity ( n = 68, 14%). The most common type of evaluation outcomes reported by CHIEF category included system utilization ( n = 342, 71%), system implementation ( n = 170, 35%), project management ( n = 164, 34%), and social outcomes ( n = 163, 34%).

PRACTICE IMPLICATIONS

CHNA evaluation strategies focus on utilization (the number of individuals served), with few focusing on social or health outcomes. This represents a missed opportunity to (a) assess the social and health impacts across individual strategies and (b) provide insight that can be used to inform the allocation of limited resources to maximize the impact of community benefit strategies.

Telehealth Care Through Internet Hospitals in China: Qualitative Interview Study of Physicians' Views on Access, Expectations, and Communication

BACKGROUND

Internet hospitals in China are an emerging medical service model similar to other telehealth models used worldwide. Internet hospitals are currently in a stage of rapid development, giving rise to a series of new opportunities and challenges for patient care. Little research has examined the views of chronic disease physicians regarding internet hospitals in China.

OBJECTIVE

We aimed to explore the experience and views of chronic disease physicians at 3 tertiary hospitals in Changsha, China, regarding opportunities and challenges in internet hospital care.

METHODS

We conducted semistructured qualitative interviews with physicians (n=26) who had experience working in internet hospitals affiliated with chronic disease departments in 3 tertiary hospitals in Changsha, Hunan province, south central China. Interviews were transcribed verbatim and analyzed by content analysis using NVivo software (version 11; Lumivero).

RESULTS

Physicians emphasized that internet hospitals expand opportunities to conduct follow-up care and health education for patients with chronic illnesses. However, physicians described disparities in access for particular groups of patients, such as patients who are older, patients with lower education levels, patients with limited internet or technology access, and rural patients. Physicians also perceived a gap between patients' expectations and the reality of limitations regarding both physicians' availability and the scope of services offered by internet hospitals, which raised challenges for doctor-patient boundaries and trust. Physicians noted challenges in doctor-patient communication related to comprehension and informed consent in internet hospital care.

CONCLUSIONS

This study explored the experience and views of physicians in 3 tertiary hospitals in Changsha, China, regarding access to care, patients' expectations versus the reality of services, and doctor-patient communication in internet hospital care. Findings from this study highlight the need for physician training in telehealth communication skills, legislation regulating informed consent in telehealth care, public education clarifying the scope of internet hospital services, and design of internet hospitals that is informed by the needs of patient groups with barriers to access, such as older adults.

Development of a conceptual model of the capacity for patients to engage in their health care: a group concept mapping study

BACKGROUND

Patient engagement is seen as a necessary component in achieving the triple aim of improved population health, improved experience of care, and lower per capita health care costs. While there has been a substantial increase in the number of tools and patient-centered initiatives designed to help patients participate in health decisions, there remains a limited understanding of engagement from the perspective of patients and a lack of measures designed to capture the multi-faceted nature of the concept.

METHODS

Development of a concept map of patient engagement followed a five-step modified Group Concept Mapping (GCM) methodology of preparation, generation, structuring, analysis and interpretation. We engaged a Project Advisory Committee at each step, along with three rounds of survey collection from clinicians and patients for element generation (272 clinicians, 61 patients), statement sorting (30 clinicians, 15 patients), and ranking and rating of statements (159 clinicians, 67 patients). The survey of three separate samples, as opposed to focus groups of 'experts,' was an intentional decision to gain a broad perspective about the concept of patient engagement. We conducted the structure and analysis steps within the groupwisdom concept mapping software.

RESULTS

The final concept map comprised 47 elements organized into 5 clusters: Relationship with Provider, Patient Attitudes and Behaviors, Access, Internal Resources and External Resources. There was considerable agreement in the way elements in each cluster were rated by patients and clinicians. An analysis of the importance of the constitutive elements of patient engagement relative to their addressability highlighted actionable items in the domain of Relationship with Provider, aimed at building trust and enabling patients to ask questions. At the same time, the analysis also identified elements traditionally considered barriers to engagement, like personal access to the internet and the patient's level of digital literacy, as difficult to address by the healthcare system, but also relatively less important for patients.

CONCLUSIONS

Through our GCM approach, incorporating perspectives of both patients and clinicians, we identified items that can be used to assess patient engagement efforts by healthcare systems. As a result, our study offers specific insight into areas that can be targeted for intervention by healthcare systems to improve patient engagement.

Automated Strategy Feedback Can Improve the Readability of Physicians' Electronic Communications to Simulated Patients

Modern communication between health care professionals and patients increasingly relies upon secure messages (SMs) exchanged through an electronic patient portal. Despite the convenience of secure messaging, challenges include gaps between physician and patient expertise along with the asynchronous nature of such communication. Importantly, less readable SMs from physicians (e.g., too complicated) may result in patient confusion, non-adherence, and ultimately poorer health outcomes. The current simulation trial synthesizes work on patient-physician electronic communication, message readability assessments, and feedback to explore the potential for automated strategy feedback to improve the readability of physicians' SMs to patients. Within a simulated secure messaging portal featuring multiple simulated patient scenarios, computational algorithms assessed the complexity of SMs written by 67 participating physicians to patients. The messaging portal provided strategy feedback for how physician responses might be improved (e.g., adding details and information to reduce complexity). Analyses of changes in SM complexity revealed that automated strategy feedback indeed helped physicians compose and refine more readable messages. Although the effects for any individual SM were slight, the cumulative effects within and across patient scenarios showed trends of decreasing complexity. Physicians appeared to learn how to craft more readable SMs via interactions with the feedback system. Implications for secure messaging systems and physician training are discussed, along with considerations for further investigation of broader physician populations and effects on patient experience.

Electronic Medical Record-Based Electronic Messaging Among Patients with Breast Cancer: A Systematic Review

BACKGROUND

Electronic medical record (EMR) systems and electronic messages are an increasingly common conduit between physicians and patients. Clear benefits of this type of communication have been established, especially among cancer patients. Studies suggest that patient portals and electronic messaging platforms can help with care coordination between oncology providers and facilitate asynchronous patient-provider communication. Despite the many benefits, there is little research regarding EMR and secure messaging use, particularly among patients with breast cancer.

OBJECTIVES

The objective of this systematic review was to examine the evidence supporting the use of EMR-based messaging systems in patients with breast cancer.

METHODS

A systematic literature search of Ovid MEDLINE, PubMed, Scopus, Web of Science CINAHL, and Cochrane Library was conducted. Studies were required to be published between 2005 and 2022 and report data on demographic information and electronic messaging between patients and providers. Studies were excluded if they reported insufficient data, did not include breast cancer patients, or were not published in English.

RESULTS

This study identified 10 articles that met inclusion criteria. The resulting studies investigated topics such as: patterns of messaging and medication adherence, cancer screening, messaging as a predictor of behavior or outcomes, and symptom management. The literature indicates that electronic messaging with providers was associated with clinical benefits for breast cancer patients and improved screening behaviors.

CONCLUSION

This review uncovered multiple areas to focus future research on, including ideal volume of electronic messages sent and their relation to prescription adherence, studies focusing solely on the breast cancer population, racial disparities in electronic messaging, and provider perceptions of electronic messaging. It is vital that more work be done to understand barriers and gaps in EMR usage to ensure that all individuals can access this increasingly essential medical service while minimizing physician workload and burnout.

Treatment Adherence in CKD and Support From Health care Providers: A Qualitative Study

Rationale & Objective

Adherence to recommended medical treatment is critical in chronic kidney disease (CKD) to prevent complications and progression to kidney failure. Overall adherence to treatment is low in CKD, and as few as 40% of patients with kidney failure receive any documented CKD-related care. The purpose of this study was to explore the experiences of patients with CKD and their adherence to CKD treatment plans, and the role their health care providers played in supporting their adherence.

Study Design

One-on-one interviews were conducted in 2019-2020 using a semi-structured interview guide. Participants described experiences with adherence to treatment plans and what they did when experiencing difficulty.

Setting & Participants

Participants were recruited from the Chronic Renal Insufficiency Cohort (CRIC) study. All CRIC participants were older than 21 years with CKD stages 2-4; this sample consisted of participants from the University of Pennsylvania CRIC site.

Analytical Approach

Interviews were recorded, transcribed, and coded using conventional content analysis. Data were organized into themes using NVivo 12.

Results

The sample (n = 32) had a mean age of 67 years, 53% were women, 59% were non-White, with a mean estimated glomerular filtration rate of 56.6 mL/min/1.73 m2. From analysis of factors relevant to treatment planning and adherence, following 4 major themes emerged: patient factors (multiple chronic conditions, motivation, outlook), provider factors (attentiveness, availability/accessibility, communication), treatment planning factors (lack of plan, proactive research, provider-focused treatment goals, and shared decision making), and treatment plan responses (disagreeing with treatment, perceived capability deficit, lack of information, and positive feedback).

Limitations

The sample was drawn from the CRIC study, which may not be representative of the general population with CKD.

Conclusions

These themes align with Behavioral Learning Theory, which includes concepts of internal antecedents (patient factors), external antecedents (provider factors), behavior (treatment planning factors), and consequences (treatment plan responses). In particular, the treatment plan responses point to innovative potential intervention approaches to support treatment adherence in CKD.

Health Care Professionals' Experiences of Patient-Professional Communication Over Patient Portals: Systematic Review of Qualitative Studies

BACKGROUND

The popularity of web-based patient-professional communication over patient portals is constantly increasing. Good patient-professional communication is a prerequisite for high-quality care and patient centeredness. Understanding health care professionals' experiences of web-based patient-professional communication is important as they play a key role in engaging patients to use portals. More information is needed on how patient-professional communication could be supported by patient portals in health care.

OBJECTIVE

This systematic review of qualitative studies aims to identify how health care professionals experience web-based patient-professional communication over the patient portals.

METHODS

Abstract and full-text reviews were conducted by 2 reviewers independently. A total of 4 databases were used for the study: CINAHL (EBSCO), ProQuest (ABI/INFORM), Scopus, and PubMed. The inclusion criteria for the reviewed studies were as follows: the examination of health care professionals' experiences, reciprocal communication between patients and health care professionals, peer-reviewed scientific articles, and studies published between 2010 and 2019. The Joanna Briggs Institute's quality assessment criteria were used in the review process. A total of 13 included studies were analyzed using a thematic synthesis, which was conducted by 3 reviewers.

RESULTS

A total of 6 analytical themes concerning health care professionals' experiences of web-based patient-professional communication were identified. The themes were related to health care professionals' work, change in communication over patient portals, patients' use of patient portals, the suitability of patient portals for communication, the convenience of patient portals for communication, and change in roles.

CONCLUSIONS

Health care professionals' experiences contain both positive and negative insights into web-based patient-professional communication over patient portals. Most commonly, the positive experiences seem to be related to the patients and patient outcomes, such as having better patient engagement. Health care professionals also have negative experiences, for example, web-based patient-professional communication sometimes has deficiencies and has a negative impact on their workload. These negative experiences may be explained by the poor functionality of the patient portals and insufficient training and resources. To reduce health care professionals' negative experiences of web-based patient-professional communication, their experiences should be taken into account by policy makers, health care organizations, and information technology enterprises when developing patient portals. In addition, more training regarding web-based patient-professional communication and patient portals should be provided to health care professionals.