Patient perceptions and interactions with their web portal-based laboratory results

Patient and Health Care Provider Perspectives on Patient Access to Test Results via Web Portals: Scoping Review

BACKGROUND

A frequently used feature of electronic patient portals is the viewing of test results. Research on patient portals is abundant and offers evidence to help portal implementers make policy and practice decisions. In contrast, no comparable comprehensive summary of research addresses the direct release of and patient access to test results.

OBJECTIVE

This scoping review aims to analyze and synthesize published research focused on patient and health care provider perspectives on the direct release of laboratory, imaging, and radiology results to patients via web portals.

METHODS

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Searches were conducted in CINAHL, MEDLINE, and other databases. Citations were screened in Covidence using the inclusion and exclusion criteria. Primary studies that focused on patient and health care provider perspectives on patient access to laboratory and imaging results via web portals were included. An updated search was conducted up to August 2023. Our review included 27 articles-20 examining patient views, 3 examining provider views, and 4 examining both patient and provider views. Data extraction and inductive data analysis were informed by sensitizing concepts from sociomaterial perspectives, and 15 themes were generated.

RESULTS

Patient perspectives (24 papers) were synthesized using nine themes: (1) patterns of use and patient characteristics; (2) emotional response when viewing the results and uncertainty about their implications; (3) understanding test results; (4) preferences for mode and timing of result release; (5). information seeking and patients' actions motivated by viewing results via a portal; (6) contemplating changes in behavior and managing own health; (7) benefits of accessing test results via a portal; (8) limitations of accessing test results via a portal; and (9) suggestions for portal improvement. Health care provider perspectives (7 papers) were synthetized into six themes: (1) providers' view of benefits of patient access to results via the portal; (2) effects on health care provider workload; (3) concerns about patient anxiety; (4) timing of result release into the patient portal; (5) the method of result release into the patient portal: manual versus automatic release; and (6) the effects of hospital health information technology system on patient quality outcomes.

CONCLUSIONS

The timing of the release of test results emerged as a particularly important topic. In some countries, the policy context may motivate immediate release of most tests directly into patient portals. However, our findings aim to make policy makers, health administrators, and other stakeholders aware of factors to consider when making decisions about the timing of result release. This review is sensitive to the characteristics of patient populations and portal technology and can inform result release framework policies. The findings are timely, as patient portals have become more common internationally.

Tablet distribution to veterans: an opportunity to increase patient portal adoption and use

OBJECTIVE

Examine whether distribution of tablets to patients with access barriers influences their adoption and use of patient portals.

MATERIALS AND METHODS

This retrospective cohort study included Veterans Affairs (VA) patients (n = 28 659) who received a VA-issued tablet between November 1, 2020 and April 30, 2021. Tablets included an app for VA's My HealtheVet (MHV) portal. Veterans were grouped into 3 MHV baseline user types (non-users, inactive users, and active users) based on MHV registration status and feature use pre-tablet receipt. Three multivariable models were estimated to examine the factors predicting (1) MHV registration among non-users, (2) any MHV feature use among inactive users, and (3) more MHV use among active users post-tablet receipt. Differences in feature use during the 6 months pre-/post-tablet were examined with McNemar chi-squared tests of proportions.

RESULTS

In the 6 months post-tablet, 1298 (8%) non-users registered for MHV, 525 (24%) inactive users used at least one MHV feature, and 4234 (46%) active users increased feature use. Across veteran characteristics, there were differences in registration and feature use post-tablet, particularly among older adults and those without prior use of video visits (P < .01). Among active users, use of all features increased during the 6 months post-tablet, with the greatest differences in viewing prescription refills and scheduling appointments (P < .01).

CONCLUSION

Providing patients who experience barriers to in-person care with a portal-enabled device supports engagement in health information and management tasks. Additional strategies are needed to promote registration and digital inclusion among inactive and non-users of portals.

Factors Enhancing Trust in Electronic Communication Among Patients from an Internal Medicine Clinic: Qualitative Results of the RECEPT Study

BACKGROUND

Electronic health records are now the norm in US healthcare. Bidirectional patient portals allow frequent communication between patients and their healthcare team. Many studies have examined the importance of patient engagement and trust between patients and their healthcare team, typically in the context of face-to-face interactions. Little is known about how patient trust and engagement are built or enhanced through electronic communications. COVID-19 provided a unique time in history for this novel exploration.

OBJECTIVE

Our objective was to learn how patients experience trust formation through electronic communication (patient messaging and video visits) with their healthcare team.

DESIGN

Our research was guided by grounded theory methodology. Qualitative interviews were conducted between February and December 2020 with patients or their caregivers from an internal medicine clinic in Colorado.

PARTICIPANTS

Fifty-one participants were recruited by age group and gender to represent the clinic's adult ambulatory care demographics. Seven were patients' caregivers who were purposefully recruited. Average age was 53 with an educated, middle class, and largely white predominance in our eventual sample.

APPROACH

Thirty-minute semi-structured interviews were conducted using an interview guide informed by a validated physician-patient trust scale. Interviews were conducted by telephone, recorded via Zoom, and transcribed. Results were analyzed and coded in ATLAS.ti utilizing the constant comparative method, with two coders.

KEY RESULTS

Patients experienced enhanced trust in their healthcare team through electronic communications. Interpersonal and system factors contributed to trust formation. Promptness of reply was the most salient factor in trust formation with a majority desiring same day response.

CONCLUSIONS

Patients now rely on electronic communication with their healthcare team. Opportunities exist to leverage this to improve health outcomes. Important research in expanded demographic groups, along with ambulatory healthcare redesign, will be necessary to optimize benefits of electronic communication with patients and meet patient expectations.

Direct Access for Patients to Diagnostic Testing and Results Using eHealth: Systematic Review on eHealth and Diagnostics

BACKGROUND

The number of people with chronic diseases and the subsequent pressure on health care is increasing. eHealth technology for diagnostic testing can contribute to more efficient health care and lower workload.

OBJECTIVE

This systematic review examines the available methods for direct web-based access for patients to diagnostic testing and results in the absence of a health care professional in primary care.

METHODS

We searched the PubMed, Embase, Web of Sciences, Cochrane Library, Emcare, and Academic Search Premier databases in August 2019 and updated in July 2021. The included studies focused on direct patient access to web-based triage leading to diagnostic testing, self-sampling or testing, or web-based communication of test results. A total of 45 studies were included. The quality was assessed using the Mixed Methods Appraisal Tool.

RESULTS

Most studies had a quantitative descriptive design and discussed a combination of services. Diagnostic test services mainly focused on sexually transmitted infections. Overall, the use was high for web-based triage (3046/5000, >50%, who used a triage booked a test), for self-sampling or self-testing kits (83%), and the result service (85%). The acceptability of the test services was high, with 81% preferring home-based testing over clinic-based testing. There was a high rate of follow-up testing or treatment after a positive test (93%).

CONCLUSIONS

The results show that direct access to testing and result services had high use rates, was positively evaluated, and led to high rates of follow-up treatment. More research on cost-effectiveness is needed to determine the potential for other diseases. Direct access to diagnostic testing can lower the threshold for testing in users, potentially increase efficiency, and lower the workload in primary care.

Patient portal engagement and diabetes management among new portal users in the Veterans Health Administration

OBJECTIVE

The study sought to investigate whether consistent use of the Veterans Health Administration's My HealtheVet (MHV) online patient portal is associated with improvement in diabetes-related physiological measures among new portal users.

MATERIALS AND METHODS

We conducted a retrospective cohort study of new portal users with type 2 diabetes that registered for MHV between 2012 and 2016. We used random-effect linear regression models to examine associations between months of portal use in a year (consistency) and annual means of the physiological measures (hemoglobin A1c [HbA1c], low-density lipoproteins [LDLs], and blood pressure [BP]) in the first 3 years of portal use.

RESULTS

For patients with uncontrolled HbA1c, LDL, or BP at baseline, more months of portal use in a year was associated with greater improvement. Compared with 1 month of use, using the portal 12 months in a year was associated with annual declines in HbA1c of -0.41% (95% confidence interval [CI], -0.46% to -0.36%) and in LDL of -6.25 (95% CI, -7.15 to -5.36) mg/dL. Twelve months of portal use was associated with minimal improvements in BP: systolic BP of -1.01 (95% CI, -1.33 to -0.68) mm Hg and diastolic BP of -0.67 (95% CI, -0.85 to -0.49) mm Hg. All associations were smaller or not present for patients in control of these measures at baseline.

CONCLUSIONS

We found consistent use of the patient portal among new portal users to be associated with modest improvements in mean HbA1c and LDL for patients at increased risk at baseline. For patients with type 2 diabetes, self-management supported by online patient portals may help control HbA1c, LDL, and BP.

Impact of patient access to their electronic health record: systematic review

Patient access to their own electronic health records (EHRs) is likely to become an integral part of healthcare systems worldwide. It has the potential to decrease the healthcare provision costs, improve access to healthcare data, self-care, quality of care, and health and patient-centered outcomes. This systematic literature review is aimed at identifying the impact in terms of benefits and issues that have so far been demonstrated by providing patients access to their own EHRs, via providers' secure patient portals from primary healthcare centers and hospitals. Searches were conducted in PubMed, MEDLINE, CINHAL, and Google scholar. Over 2000 papers were screened and were filtered based on duplicates, then by reading the titles and finally based on their abstracts or full text. In total, 74 papers were retained, analyzed, and summarized. Papers were included if providing patient access to their own EHRs was the primary intervention used in the study and its impact or outcome was evaluated. The search technique used to identify relevant literature for this paper involved input from five experts. While findings from 54 of the 74 papers showed positive outcome or benefits of patient access to their EHRs via patient portals, 10 papers have highlighted concerns, 8 papers have highlighted both and 2 have highlighted absence of negative outcomes. The benefits range from re-assurance, reduced anxiety, positive impact on consultations, better doctor-patient relationship, increased awareness and adherence to medication, and improved patient outcomes (e.g., improving blood pressure and glycemic control in a range of study populations). In addition, patient access to their health information was found to improve self-reported levels of engagement or activation related to self-management, enhanced knowledge, and improve recovery scores, and organizational efficiencies in a tertiary level mental health care facility. However, three studies did not find any statistically significant effect of patient portals on health outcomes. The main concerns have been around security, privacy and confidentiality of the health records, and the anxiety it may cause amongst patients. This literature review identified some benefits, concerns, and attitudes demonstrated by providing patients' access to their own EHRs. This access is often part of government strategies when developing patient-centric self-management elements of a sustainable healthcare system. The findings of this review will give healthcare providers a framework to analyze the benefits offered by promoting patient access to EHRs and decide on the best approach for their own specialties and clinical setup. A robust cost-benefit evaluation of such initiatives along with its impact on major stakeholders within the healthcare system would be essential in understanding the overall impact of such initiatives. Implementation of patient access to their EHRs could help governments to appropriately prioritize the development or adoption of national standards, whilst taking care of local variations and fulfilling the healthcare needs of the population, e.g., UK Government is aiming to make full primary care records available online to every patient. Ultimately, increasing transparency and promoting personal responsibility are key elements of a sustainable healthcare system for future generations.

Capturing the Impact of Patient Portals Based on the Quadruple Aim and Benefits Evaluation Frameworks: Scoping Review

Background

Despite extensive and continuing research in the area of patient portals, measuring the impact of patient portals remains a convoluted process.

Objective

This study aims to explore what is known about patient portal evaluations and to provide recommendations for future endeavors. The focus is on mapping the measures used to assess the impact of patient portals on the dimensions of the Quadruple Aim (QA) framework and the Canada Health Infoway’s Benefits Evaluation (BE) framework.

Methods

A scoping review was conducted using the methodological framework of Arksey and O’Malley. Reporting was guided by the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) extension for scoping reviews. A systematic and comprehensive search was conducted using the Ovid platform, and the following databases were searched: Ovid MEDLINE (R) ALL (including epub ahead of print, in-process, and other nonindexed citations), EMBASE, and PsycINFO. CINAHL on the EBSCO platform and Web of Science were searched for studies published between March 2015 and June 2020. A systematic gray literature search was conducted using the Google search engine. Extracted data were tabulated based on a coding template developed to categorize the literature into themes and areas of interest.

Results

A total of 96 studies were included for data extraction. The studies were categorized based on the QA dimensions, with strict adherence to the definitions for each dimension. From the patients’ perspective, it was determined that most evaluations focused on benefits and barriers to access, access to test results, medication adherence, condition management, medical notes, and secure messaging. From the population perspective, the evaluations focused on the increase in population outreach, decrease in disparities related to access to care services, and improvement in quality of care. From the health care workforce perspective, the evaluations focused on the impact of patients accessing medical records, impact on workflow, impact of bidirectional secure messaging, and virtual care. From the health system perspective, the evaluations focused on decreases in no-show appointments, impact on office visits and telephone calls, impact on admission and readmission rates and emergency department visits, and impact on health care use. Overall, 77 peer-reviewed studies were mapped on the expanded version of the BE framework. The mapping was performed using subdimensions to create a more precise representation of the areas that are currently explored when studying patient portals. Most of the studies evaluated more than one subdimension.

Conclusions

The QA and BE frameworks provide guidance in identifying gaps in the current literature by providing a way to show how an impact was assessed. This study highlights the need to appropriately plan how the impact will be assessed and how the findings will be translated into effective adaptations.

Effects of Electronic Health Record Implementation and Barriers to Adoption and Use: A Scoping Review and Qualitative Analysis of the Content

Despite the great advances in the field of electronic health records (EHRs) over the past 25 years, implementation and adoption challenges persist, and the benefits realized remain below expectations. This scoping review aimed to present current knowledge about the effects of EHR implementation and the barriers to EHR adoption and use. A literature search was conducted in PubMed, Web of Science, IEEE Xplore Digital Library and ACM Digital Library for studies published between January 2005 and May 2020. In total, 7641 studies were identified of which 142 met the criteria and attained the consensus of all researchers on inclusion. Most studies (n = 91) were published between 2017 and 2019 and 81 studies had the United States as the country of origin. Both positive and negative effects of EHR implementation were identified, relating to clinical work, data and information, patient care and economic impact. Resource constraints, poor/insufficient training and technical/educational support for users, as well as poor literacy and skills in technology were the identified barriers to adoption and use that occurred frequently. Although this review did not conduct a quality analysis of the included papers, the lack of uniformity in the use of EHR definitions and detailed contextual information concerning the study settings could be observed.

Can patients contribute to enhancing the safety and effectiveness of test-result follow-up? Qualitative outcomes from a health consumer workshop

Background

Missed test‐results and failure to follow‐up test‐results are major patient safety concerns. Strategies to improve test‐results management have predominantly focused on clinician‐based interventions, with patients principally involved in studies of test‐result communication preferences, the impact of patient portals or experiences with reporting processes in primary care.

Objective

To identify consumer perspectives and experiences of the challenges they have faced with test‐results management, through consumer participation in qualitative data analysis.

Design and participants

Volunteers (n = 10) were recruited to participate in a health consumer reference group workshop on test‐results management. Prior to the workshop, consumers selected topics for discussion using a preference poll. During the workshop, consumers participated in qualitative data analysis of de‐identified excerpts of previously collected interview data discussing hospital test‐results management. Researchers (n = 5) guided consumers through the analytical process and discussion of themes. Discussions were audio‐recorded and transcribed for qualitative analysis.

Results

Consumer‐selected topics for discussion were ‘Transitions of Care’ and ‘Access’. Consumer data analysis prompted broader discussion including lived experiences. Following the workshop, a second level of content analysis pinpointed issues with implications for patient safety highlighting that consumers were astutely aware of macrolevel ‘Systems Factors’ relating to ‘Emergency Departments’ and the health system, as well as microlevel ‘Patient Factors’ (eg patient preferences and circumstances) which impact a patient's understanding during the ‘Communication’ (clinician to patient/between clinicians) of test‐results ‘Information’ (or lack thereof).

Conclusions

Consumers identified the challenges patients experience with test‐results management, and our findings highlight areas for potential improvement in patient safety.

Patient or public contribution

Ten health consumer volunteers actively participated in the test‐results management data analysis workshop conducted in this study. Two health consumers also volunteered to read and comment on the draft manuscript.