Patients with complex chronic conditions: Health care use and clinical events associated with access to a patient portal

Patient portal registration and healthcare utilisation in general practices in England: a longitudinal cohort study

BACKGROUND

Patient portals introduced in most of England's general practices since 2015 have the potential to improve healthcare efficiency. There is a paucity of information on the use of patient portals within the NHS general practices and the potential impact on healthcare utilisation.

AIM

To investigate the association between patient portal registration and care utilisation (measured by the number of general practice consultations) among general practice patients.

DESIGN & SETTING

A longitudinal analysis using electronic health record data from the Clinical Practice Research Datalink (CPRD).

METHOD

We analysed patients registered for patient portals (n = 284 666), aggregating their consultations 1 year before and 1 year after registration. We ran a multilevel negative binomial regression model to examine patient portal registration's association with face-to-face and remote consultations.

RESULTS

Patients who registered to the portal had a small decrease in the total number of face-to-face consultations after registering to the patient portal (incidence rate ratio = 0.93, 95% confidence interval [CI] = 0.93 to 0.94). Patients who registered to the portal had an increase in the total number of remote consultations after registering to the portal (incidence rate ratio = 1.16, 95% CI = 1.15 to 1.18).

CONCLUSION

The study found minor changes in consultation numbers post-patient portal registration, notably with an increase in remote consultations. While causality between portal registration and consultation number remains unclear, the potential link between patient portal use and healthcare utilisation warrants further investigation, especially within the NHS, where portal impacts are not well-studied. Detailed portal utilisation data could clarify this relationship.

Patient Perspectives on Portal-Based Anxiety and Depression Screening in HIV Care: A Qualitative Study Using the Consolidated Framework for Implementation Research

Electronic patient portals represent a promising means of integrating mental health assessments into HIV care where anxiety and depression are highly prevalent. Patient attitudes toward portal-based mental health screening within HIV clinics have not been well described. The aim of this formative qualitative study is to characterize the patient-perceived facilitators and barriers to portal-based anxiety and depression screening within HIV care in order to inform implementation strategies for mental health screening. Twelve adult HIV clinic patients participated in semi-structured interviews that were audio recorded and transcribed. The transcripts were coded using constructs from the Consolidated Framework for Implementation Research and analyzed thematically to identify the barriers to and facilitators of portal-based anxiety and depression screening. Facilitators included an absence of alternative screening methods, an approachable design, perceived adaptability, high compatibility with HIV care, the potential for linkage to treatment, an increased self-awareness of mental health conditions, the ability to bundle screening with clinic visits, and communicating an action plan for results. The barriers included difficulty navigating the patient portal system, a lack of technical support, stigmatization from the healthcare system, care team response times, and the novelty of using patient portals for communication. The patients in the HIV clinic viewed the use of a portal-based anxiety and depression screening tool as highly compatible with routine HIV care. Technical difficulties, follow-up concerns, and a fear of stigmatization were commonly perceived as barriers to portal use. The results of this study can be used to inform implementation strategies when designing or incorporating portal-based mental health screening into other HIV care settings.

Disparities in Patient Portal Engagement Among Patients With Hypertension Treated in Primary Care

Importance

Patient portals are increasingly used for patient-clinician communication and to introduce interventions aimed at improving blood pressure control.

Objective

To characterize patient portal use among patients with hypertension managed in primary care.

Design, Settings, and Participants

This retrospective cohort study used electronic health records linked with patient portal log file data from a large, diverse Midwestern health care system. Patients with hypertension who had a primary care visit from January 1, 2021, to December 31, 2021, were included. The first visit in 2021 was considered the baseline visit; patient portal engagement was evaluated during the following year. Multivariate logistic regressions, presented as odds ratios (ORs) and 95% CIs, were used to evaluate associations between patient characteristics and patient portal engagement, adjusting for potential confounders.

Exposures

Primary exposures included 4 sociodemographic factors routinely collected in the electronic health record: race and ethnicity, insurance, preferred language, and smoking status.

Main Outcomes and Measures

Indicators of patient engagement with the patient portal included accessing the patient portal at least once, accessing the portal within 7 days of at least 50.0% of primary care physician (PCP) visits, frequent logins (<28 vs ≥28), messaging (<2 vs ≥2), and sharing home blood pressure readings.

Results

Among 366 871 patients (mean [SD], 63.5 [12.6] years), 52.8% were female, 3.4% were Asian, 7.8% were Hispanic, 19.7% were non-Hispanic Black, 66.9% were non-Hispanic White, and 2.3% were of other race or ethnicity. During the 1-year study period starting in 2021, 70.5% accessed the patient portal at least once, 60.2% accessed around the time of their PCP visits, 35.7% accessed the portal frequently, 28.9% engaged in messaging, and 8.7% shared home blood pressure readings. Compared with White patients, non-Hispanic Black and Hispanic patients had lower odds of any access (Black: OR, 0.53; 95% CI, 0.52-0.54; Hispanic: OR, 0.66; 95% CI, 0.64-0.68), access around PCP visit time (Black: OR, 0.49; 95% CI, 0.48-0.50; Hispanic: OR, 0.62; 95% CI, 0.60-0.64), frequent access (Black: OR, 0.56; 95% CI, 0.55-0.57; Hispanic: OR, 0.71; 95% CI, 0.69-0.73), and messaging (Black: OR, 0.63; 95% CI, 0.61-0.64); Hispanic: OR, 0.71; 95% CI, 0.69-0.73).

Conclusions and Relevance

This cohort study of patients with hypertension found clear sociodemographic disparities in patient portal engagement among those treated in primary care. Without special efforts to engage patients with portals, interventions that use patient portals to target hypertension may exacerbate disparities.

Association of Remote Patient Monitoring with Mortality and Healthcare Utilization in Hypertensive Patients: a Medicare Claims-Based Study

BACKGROUND

Hypertension management is complex in older adults. Recent advances in remote patient monitoring (RPM) have warranted evaluation of RPM use and patient outcomes.

OBJECTIVE

To study associations of RPM use with mortality and healthcare utilization measures of hospitalizations, emergency department (ED) utilization, and outpatient visits.

DESIGN

A retrospective cohort study.

PATIENTS

Medicare beneficiaries aged ≥65 years with an outpatient hypertension diagnosis between July 2018 and September 2020. The first date of RPM use with a corresponding hypertension diagnosis was recorded (index date). RPM non-users were documented from those with an outpatient hypertension diagnosis; a random visit was selected as the index date. Six months prior continuous enrollment was required.

MAIN MEASURES

Outcomes studied within 180 days of index date included (i) all-cause mortality, (ii) any hospitalization, (iii) cardiovascular-related hospitalization, (iv) non-cardiovascular-related hospitalization, (v) any ED, (vi) cardiovascular-related ED, (vii) non-cardiovascular-related ED, (viii) any outpatient, (ix) cardiovascular-related outpatient, and (x) non-cardiovascular-related outpatient. Patient demographics and clinical variables were collected from baseline and index date. Propensity score matching (1:4) and Cox regression were performed. Hazard ratios (HR) and 95% confidence intervals (CI) are reported.

KEY RESULTS

The matched sample had 16,339 and 63,333 users and non-users, respectively. Cumulative incidences of mortality outcome were 2.9% (RPM) and 4.3% (non-RPM), with a HR (95% CI) of 0.66 (0.60-0.74). RPM users had lower hazards of any [0.78 (0.75-0.82)], cardiovascular-related [0.79 (0.73-0.87)], and non-cardiovascular-related [0.79 (0.75-0.83)] hospitalizations. No significant association was observed between RPM use and the three ED measures. RPM users had higher hazards of any [1.10 (1.08-1.11)] and cardiovascular-related outpatient visits [2.17 (2.13-2.19)], while a slightly lower hazard of non-cardiovascular-related outpatient visits [0.94 (0.93-0.96)].

CONCLUSIONS

RPM use was associated with substantial reductions in hazards of mortality and hospitalization outcomes with an increase in cardiovascular-related outpatient visits.

People with diabetes who read their clinicians' visit notes: Behaviors and attitudes

OBJECTIVES

To understand behaviors and attitudes of adults with diabetes who read their clinicians' visit notes.

METHODS

By linking a large 2017 patient survey involving three institutions with administrative and portal use data, we identified patients with diabetes mellitus from outpatient records and examined reading behaviors related to eligible notes-initial, follow-up, history and physical, and progress notes. We analyzed patients' perceived benefits of reading notes.

RESULTS

2104 respondents had diagnoses of diabetes mellitus and had read ≥1 note in the 12-month period. Patients had an average of 8.7 eligible notes available and read 59% of them. The strongest predictor of reading more notes was having more notes available; the specialties of the authoring clinicians were not correlated with note reading rates. Patients reported understanding notes by primary care clinicians and specialists equally well; more than 90% of patients reported understanding everything or almost everything in a self-selected note. Across visit types, 73-80% of patients reported that note reading was extremely important for taking care of their health.

DISCUSSION

People with diabetes want to read their clinicians' notes, are accessing them at high rates, and report understanding the notes and benefiting from reading them.

Continuity of care in primary healthcare settings among patients with chronic diseases in Saudi Arabia

Introduction

Maintaining continuity of care is one of the most critical components of providing great care in primary health care. This study aimed to explore continuity of care and its predictors in primary healthcare settings among patients with chronic diseases in Saudi Arabia.

Method

Face-to-face cross-sectional interviews were conducted with patients with chronic diseases who had at least four visits to primary care facilities in Riyadh, Saudi Arabia, between November 1, 2022 and March 3, 2023. We determined patients' continuity of care levels using the Bice-Boxerman continuity of care index. A Tobit regression model was used to determine the effects of several factors on the continuity of care index.

Results

The interviews were conducted with 193 respondents with chronic diseases of interest. The mean continuity of care index of the entire sample was 0.54. Those with asthma had the highest median continuity of care index at 0.75 (interquartile range, 0.62-0.75), whereas those diagnosed with thyroid disease had a much lower continuity of care index (0.47) (interquartile range, 0.3-0.62). Tobit regression model findings showed that employed respondents with poorer general health had a negative effect on continuity of care index levels. By contrast, a higher continuity of care index was significantly associated with elderly respondents, urban residents, and those diagnosed with dyslipidemia, diabetes, hypertension, or asthma.

Conclusions

According to our findings, the continuity of care level in Saudi Arabia's primary healthcare setting is low. The data demonstrate how continuity of care varies among study group characteristics and that improving continuity of care among chronic disease patients in Saudi Arabia is multifaceted and challenging, necessitating a coordinated and integrated healthcare delivery approach.

Cross-sectional analyses of online appointment booking and repeat prescription ordering user characteristics in general practices of England in the years 2018-2020

OBJECTIVES

To explore the characteristics of the General Practice Patient Survey (GPPS) respondents using the different functionalities of the online services in the context of England's National Health Service General Practices. We hypothesised that respondents who are older, with lower socioeconomic status and non-white ethnicity would be less likely to use online services, while long-term conditions might increase their usage.

DESIGN

Cross-sectional study using respondent-level data from the GPPS in England of the years 2018, 2019 and 2020. We assessed the association between online services use and respondent characteristics using two-level mixed-effects logistic regression.

PARTICIPANTS

Survey respondents of the GPPS 2018-2020.

PRIMARY OUTCOME MEASURES

Online appointment booking and online repeat prescription ordering.

RESULTS

1 807 049 survey respondents were included in this study. 15% (n=263 938) used online appointment booking in the previous 12 months, and 19% (n=339 449) had ordered a repeat prescription in the previous 12 months. Respondents with a long-term condition, on regular multiple medications, who have deafness or hearing loss and who are from the lowest deprivation quintile were more likely to have used online services. Male respondents (compared with females) and respondents with black and other ethnicity compared with white ethnicity were less likely to use online services. Respondents over 85 years old were less likely to use online appointment booking and online repeat prescription ordering compared with the younger age groups.

CONCLUSIONS

Specific groups of respondents were more likely to use online services such as patients with long-term conditions or those with deafness or hearing loss. While online services could provide efficiency to patients and practices it is essential that alternatives continue to be provided to those that cannot use or choose not to use online services. Understanding the different patients' needs could inform solutions to increase the uptake and use of the services.

An Evidence-Based Framework for Creating Inclusive and Personalized mHealth Solutions-Designing a Solution for Medicaid-Eligible Pregnant Individuals With Uncontrolled Type 2 Diabetes

Mobile health (mHealth) apps can be an evidence-based approach to improve health behavior and outcomes. Prior literature has highlighted the need for more research on mHealth personalization, including in diabetes and pregnancy. Critical gaps exist on the impact of personalization of mHealth apps on patient engagement, and in turn, health behaviors and outcomes. Evidence regarding how personalization, engagement, and health outcomes could be aligned when designing mHealth for underserved populations is much needed, given the historical oversights with mHealth design in these populations. This viewpoint is motivated by our experience from designing a personalized mHealth solution focused on Medicaid-enrolled pregnant individuals with uncontrolled type 2 diabetes, many of whom also experience a high burden of social needs. We describe fundamental components of designing mHealth solutions that are both inclusive and personalized, forming the basis of an evidence-based framework for future mHealth design in other disease states with similar contexts.

Mobilizing registry data for quality improvement: A convergent mixed-methods analysis and application to spinal cord injury

Introduction

The rising prevalence of complex chronic conditions and growing intricacies of healthcare systems emphasizes the need for interdisciplinary partnerships to advance coordination and quality of rehabilitation care. Registry databases are increasingly used for clinical monitoring and quality improvement (QI) of health system change. Currently, it is unclear how interdisciplinary partnerships can best mobilize registry data to support QI across care settings for complex chronic conditions.

Purpose

We employed spinal cord injury (SCI) as a case study of a highly disruptive and debilitating complex chronic condition, with existing registry data that is underutilized for QI. We aimed to compare and converge evidence from previous reports and multi-disciplinary experts in order to outline the major elements of a strategy to effectively mobilize registry data for QI of care for complex chronic conditions.

Methods

This study used a convergent parallel-database variant mixed design, whereby findings from a systematic review and a qualitative exploration were analyzed independently and then simultaneously. The scoping review used a three-stage process to review 282 records, which resulted in 28 articles reviewed for analysis. Concurrent interviews were conducted with multidisciplinary-stakeholders, including leadership from condition-specific national registries, members of national SCI communities, leadership from SCI community organizations, and a person with lived experience of SCI. Descriptive analysis was used for the scoping review and qualitative description for stakeholder interviews.

Results

There were 28 articles included in the scoping review and 11 multidisciplinary-stakeholders in the semi-structured interviews. The integration of the results allowed the identification of three key learnings to enhance the successful design and use of registry data to inform the planning and development of a QI initiative: enhance utility and reliability of registry data; form a steering committee lead by clinical champions; and design effective, feasible, and sustainable QI initiatives.

Conclusion

This study highlights the importance of interdisciplinary partnerships to support QI of care for persons with complex conditions. It provides practical strategies to determine mutual priorities that promote implementation and sustained use of registry data to inform QI. Learnings from this work could enhance interdisciplinary collaboration to support QI of care for rehabilitation for persons with complex chronic conditions.

A Multi-Level Analysis of Individual and Neighborhood Factors Associated with Patient Portal Use among Adult Emergency Department Patients with Multimorbidity

Background: Patient portals tethered to electronic health records (EHR) have become vital to patient engagement and better disease management, specifically among adults with multimorbidity. We determined individual and neighborhood factors associated with patient portal use (MyChart) among adult patients with multimorbidity seen in an Emergency Department (ED). Methods: This study adopted a cross-sectional study design and used a linked database of EHR from a single ED site to patients’ neighborhood characteristics (i.e., zip code level) from the American Community Survey. The study population included all adults (age > 18 years), with at least one visit to an ED and multimorbidity between 1 January 2019 to 31 December 2020 (N = 40,544). Patient and neighborhood characteristics were compared among patients with and without MyChart use. Random-intercept multi-level logistic regressions were used to analyze the associations of patient and neighborhood factors with MyChart use. Results: Only 19% (N = 7757) of adults with multimorbidity used the patient portal. In the fully adjusted multi-level model, at the patient level, having a primary care physician (AOR = 5.55, 95% CI 5.07−6.07, p < 0.001) and health insurance coverage (AOR = 2.41, 95% CI 2.23−2.61, p < 0.001) were associated with MyChart use. At the neighborhood level, 4.73% of the variation in MyChart use was due to differences in neighborhood factors. However, significant heterogeneity existed in patient portal use when neighborhood characteristics were included in the model. Conclusions: Among ED patients with multimorbidity, one in five adults used patient portals. Patient-level factors, such as having primary care physicians and insurance, may promote patient portal use.

Developing and testing an integrated patient mHealth and provider dashboard application system for type 2 diabetes management among Medicaid-enrolled pregnant individuals based on a user-centered approach: Mixed-methods study

Background

A tailored and integrated technology solution (patient mHealth application and provider dashboard) can provide a 360° view of Medicaid-enrolled patients with type 2 diabetes (T2D) during pregnancy that could improve health outcomes and address health inequities.

Objectives

To develop a set of user specifications for the mHealth and dashboard applications, develop prototypes based on user needs, and collect initial impressions of the prototypes to subsequently develop refined tools that are ready for deployment.

Methods

Study activities followed a double-diamond framework with a participatory design mindset. Activities were divided into two phases focused on a qualitative inquiry about participant needs and values (phase 1) and design, development, and usability testing of low and high-fidelity prototypes (phase 2).

Results

We identified themes that exemplified pregnancy experience among Medicaid-enrolled individuals with T2D. Patients (n  =  7) and providers (n  =  7) expressed a core set of expectations for the mHealth and dashboard applications. Participants provided feedback to improve the mHealth and dashboard. For both applications, participants reported scores for the NASA Task load Survey (TLX) that were in the 20th percentile of national TLX scores.

Conclusions

Digital health tools have the ability to transform health care among Medicaid-enrolled patients with T2D during pregnancy, with the goal of managing their blood glucose levels, which is a precursor to experiencing a successful pregnancy and birth. Distilling patient and provider needs and preferences-then using them, along with prior studies and theory, to develop applications-holds great potential in tackling complicated health care issues.

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.

Using a Machine Learning Algorithm to Predict Online Patient Portal Utilization: A Patient Engagement Study

Objective

There is a low rate of online patient portal utilization in the U.S. This study aimed to utilize a machine learning approach to predict access to online medical records through a patient portal.

Methods

This is a cross-sectional predictive machine learning algorithm-based study of Health Information National Trends datasets (Cycles 1 and 2; 2017-2018 samples). Survey respondents were U.S. adults (≥18 years old). The primary outcome was a binary variable indicating that the patient had or had not accessed online medical records in the previous 12 months. We analyzed a subset of independent variables using k-means clustering with replicate samples. A cross-validated random forest-based algorithm was utilized to select features for a Cycle 1 split training sample. A logistic regression and an evolved decision tree were trained on the rest of the Cycle 1 training sample. The Cycle 1 test sample and Cycle 2 data were used to benchmark algorithm performance.

Results

Lack of access to online systems was less of a barrier to online medical records in 2018 (14%) compared to 2017 (26%). Patients accessed medical records to refill medicines and message primary care providers more frequently in 2018 (45%) than in 2017 (25%).

Discussion

Privacy concerns, portal knowledge, and conversations between primary care providers and patients predict portal access.

Conclusion

Methods described here may be employed to personalize methods of patient engagement during new patient registration.

Occupational Therapy's Role in Chronic Conditions

It is the position of the American Occupational Therapy Association (AOTA) that occupational therapy practitioners are distinctly qualified to address the impact of chronic conditions on occupational performance and participation across the life span. The purpose of this position statement is twofold. First, it defines chronic conditions and describes the multiple factors associated with the development of one or more chronic conditions. Second, it provides an overview of how the field of occupational therapy has a distinct impact on improving the health and wellness of persons, groups, and populations with or at risk for chronic conditions through health promotion, disease prevention, and intervention.

Telemedicine Familiarity and Post-Disaster Utilization of Emergency and Hospital Services for Ambulatory Care Sensitive Conditions

INTRODUCTION

In this study, we examined the association between telemedicine use before a disaster and utilization of emergency or hospital services for ambulatory care sensitive conditions post-disaster.

METHODS

Difference-in-differences analyses were conducted in 2020‒2021 to assess pre- to post-fire changes in emergency or hospital utilization for 5 ambulatory care sensitive conditions: asthma, diabetes, hypertension, coronary artery disease, and heart failure across all Kaiser Permanente Santa Rosa patients (N=108,113) based on telemedicine utilization before the 2017 Tubbs wildfire. Inverse probability of treatment weighting was employed for cohort balancing across telemedicine familiar status.

RESULTS

Utilization for any ambulatory care sensitive condition increased from 9.03% pre-fire to 9.45% post-fire across the full cohort. Telemedicine familiarity (ref: not familiar) was associated with decreased absolute risk in pre- to post-fire inpatient and emergency department utilization for 4 conditions: asthma (absolute risk= -1.59%, 95% CI= -2.02%, -1.16%), diabetes (absolute risk= -0.68%, 95% CI= -0.89%, -0.47%), hypertension (absolute risk= -2.07%, 95% CI= -2.44%, -1.71%), and coronary artery disease (absolute risk= -0.43%, 95% CI= -0.61%, -0.24%). Telemedicine familiarity was associated with decreased relative change in pre- to post-fire utilization for 5 conditions: asthma (RRR=0.70, 95% CI=0.64, 0.75), diabetes (RRR=0.54, 95% CI=0.47, 0.63), hypertension (RRR=0.57, 95% CI=0.52, 0.62), heart failure (RRR=0.64, 95% CI=0.50, 0.82), and coronary artery disease (RRR=0.56, 95% CI=0.47, 0.67). Similar results were seen among patients residing in evacuation zones.

CONCLUSIONS

Telemedicine familiarity pre-fire was associated with decreased inpatient and emergency department utilization for certain ambulatory care sensitive conditions for 1-year post-fire. These results suggest a role for telemedicine in preventing unnecessary emergency and hospital utilization following disasters.

Changes in patient portal adoption due to the emergence of COVID-19 pandemic

Even though patient portals are recognized as a promising mechanism to support greater patient engagement, questions remain about access and utilization. This study aims to identify factors related to portal adoption in 2019 and 2020 (before and during the COVID-19). Cross-sectional data from the Health Information National Trends Survey (HINTS) cycles- 2019 HINTS 5 cycle 3 (N = 5,438) and 2020 HINTS 5 cycle 4 (N = 3,865) were analyzed using STATA-SE version 17 to factors predicting portal adoption. Next, HINTS 5 cycles 3 and 4 were pooled to identify changes in portal feature use and ease of usage among portal users, and barrier to portal use among non-users. Respondents who were college graduates, high income, and married were more likely to adopt patient portals during 2019 and 2020. Aged 75+ and Hispanic respondents reported less frequency of portal access in 2020 versus 2019. Men were more likely to adopt patient portals in 2019 versus women in 2020. Portal users were more likely to use the portal-system features in 2019 versus 2020. Portal non-users reported having multiple-health records as less of a barrier in 2020 compared to 2019. Patient engagement needs heightened attention during the COVID-19 pandemic.

Electronic Health Records and Heart Failure

Increasing the global adoption of electronic health records (EHRs) is transforming the delivery of clinical care. EHRs offer tools that are useful in the care of heart failure ranging from individualized risk stratification and decision support to population management. EHR tools can be combined to target specific areas of need such as the standardization of care, improved quality of care, and resource management. Leveraging EHR functionality has been shown to improve select outcomes including guideline-based therapies, reduction in adverse clinical outcomes, and improved cost-efficiency. Central to success is participation by clinicians and patients in the design and feedback of EHR tools.

Physician Practices With Robust Capabilities Spend Less On Medicare Beneficiaries Than More Limited Practices

No research has considered a range of physician practice capabilities for managing patient care when examining practice-level influences on quality of care, utilization, and spending. Using data from the 2017 National Survey of Healthcare Organizations and Systems linked to 2017 Medicare fee-for-service claims data from attributed beneficiaries, we examined the association of practice-level capabilities with process measures of quality, utilization, and spending. In propensity score-weighted mixed-effects regression analyses, physician practice locations with "robust" capabilities had lower total spending compared to locations with "mixed" or "limited" capabilities. Quality and utilization, however, did not differ by practice-level capabilities. Physician practice locations with robust capabilities spend less on Medicare fee-for-service beneficiaries but deliver quality of care that is comparable to the quality delivered in locations with low or mixed capabilities. Reforms beyond those targeting practice capabilities, including multipayer alignment and payment reform, may be needed to support larger performance advantages for practices with robust capabilities.

The Effect of an Automated Mobile Patient Engagement Application on Emergency Department Revisits: Prospective Observational Study

Background

Revisits within 30 days to an emergency department (ED), observation care unit, or inpatient setting following patient discharge continue to be a challenge, especially in urban settings. In addition to the consequences for the patient, these revisits have a negative impact on a health system’s finances in a value-based care or global budget environment. LifeBridge Health, a community health system in Maryland, United States, implemented an automated mobile patient engagement application as part of our enterprise-wide digital health strategy to improve patient engagement and reduce revisits to the ED.

Objective

The aim of this paper was to evaluate the effectiveness of a customized automated digital patient engagement application (GetWell Loop) to reduce 30-day revisits after home discharge from an ED.

Methods

The LifeBridge Health Innovation Department and ED staff from 2 participating health system hospitals collaborated with GetWellNetwork to customize their patient engagement application with automated check-in questions and other on-demand resources (eg, streaming content explaining aspects of self-care during COVID-19). An application link was emailed to adult patients discharged home from the ED. A study of ED visits for patients treated for general medicine and cardiology conditions between August 1, 2018, and July 31, 2019, was conducted using CRISP (Chesapeake Regional Information System for our Patients), Maryland’s state-designated health information exchange. We also used data within GetWell Loop (GetWellNetwork) to track patient activation and engagement. The primary outcome was the number of ED patients who experienced a 30-day revisit and who did or did not activate their GetWell Loop account. Secondary outcomes included the overall activation rate and the rate of engagement as measured by the number of logins, alerts, and comments generated by patients through the application. Bivariate analysis comparing outcomes among patients who activated the GetWell Loop application to patients who did not was conducted using the Fisher exact test. Multivariate logistic regression modeling with elastic net regularization was also performed to account for potential confounders and potential collinearity of covariates.

Results

During this 1-year study, 1062 (27.4%) of 3866 of all emergency patients treated for general medicine or cardiology conditions, who received an invite to use the digital application, activated their account. The patients discharged from the ED, who were treated for general medicine conditions (n=2087) and who activated their GetWell Loop account, experienced a 30-day revisit rate of 17.3% (n=101) compared with 24.6% (n=369) for those who did not activate their account (P<.001). Of the patients treated for cardiology conditions (n=1779), 12.8% (n=61) of those who activated their GetWell account experienced a 30-day revisit compared with 17.7% (n=231) of those who did not activate their account (P=.01). The significance of these findings persisted after adjustment for confounding variables including age, race, sex, and payor in logistic regression modeling (adjusted odds ratio 0.75, 95% CI 0.62-0.92; P=.006).

Conclusions

Our results suggest that a significant percentage of patients are willing to utilize a digital application following ED discharge to better engage in their own care, and that usage of such digital applications may significantly reduce 30-day revisit rates. LifeBridge Health’s experience demonstrates that health care systems can leverage automated mobile apps to improve patient engagement and successfully impact clinical outcomes at scale.

Patient portals for the adolescent and young adult population: Benefits, risks and guidance for use

Patient portals are the primary means by which electronic health information (EHI) is shared with patients and families. The use of patient portals increased during the COVID-19 pandemic and may continue to rise with the implementation and enforcement of the 21^st Century Cures Act that encourages facilitation of access to EHI and prohibits information blocking. Research on the use of patient portals by adolescents and their families is limited. Potential benefits of portal use to adolescents include increased engagement in their own health care, direct communication with their health care clinicians, and facilitation of transition of care to new clinicians in adulthood. Clinicians need to educate adolescents on the functions available through the portal, appropriate use and expectations for messaging through the portal, and the pros and cons of viewing EHI such as test results independently. Parental proxy access to the adolescent's portal should be carefully and thoughtfully implemented, because it poses a potential breach to confidential care via disclosure of sensitive or protected information. Adolescents who choose to deny their parents proxy access to the portal should be supported in that decision. It is important that all clinicians understand portal functionality and have strategies to optimize use within their practice. This paper provides the reader considerations and tips for portal use within this population.

Implementation Strategies to Improve Engagement With a Multi-Institutional Patient Portal: Multimethod Study

Background

Comprehensive multi-institutional patient portals that provide patients with web-based access to their data from across the health system have been shown to improve the provision of patient-centered and integrated care. However, several factors hinder the implementation of these portals. Although barriers and facilitators to patient portal adoption are well documented, there is a dearth of evidence examining how to effectively implement multi-institutional patient portals that transcend traditional boundaries and disparate systems.

Objective

This study aims to explore how the implementation approach of a multi-institutional patient portal impacted the adoption and use of the technology and to identify the lessons learned to guide the implementation of similar patient portal models.

Methods

This multimethod study included an analysis of quantitative and qualitative data collected during an evaluation of the multi-institutional MyChart patient portal that was deployed in Southwestern Ontario, Canada. Descriptive statistics were performed to understand the use patterns during the first 15 months of implementation (between August 2018 and October 2019). In addition, 42 qualitative semistructured interviews were conducted with 18 administrative stakeholders, 16 patients, 7 health care providers, and 1 informal caregiver to understand how the implementation approach influenced user experiences and to identify strategies for improvement. Qualitative data were analyzed using an inductive thematic analysis approach.

Results

Between August 2018 and October 2019, 15,271 registration emails were sent, with 67.01% (10,233/15,271) registered for an account across 38 health care sites. The median number of patients registered per site was 19, with considerable variation (range 1-2114). Of the total number of sites, 55% (21/38) had ≤30 registered patients, whereas only 2 sites had over 1000 registered patients. Interview participants perceived that the patient experience of the portal would have been improved by enhancing the data comprehensiveness of the technology. They also attributed the lack of enrollment to the absence of a broad rollout and marketing strategy across sites. Participants emphasized that provider engagement, change management support, and senior leadership endorsement were central to fostering uptake. Finally, many stated that regional alignment and policy support should have been sought to streamline implementation efforts across participating sites.

Conclusions

Without proper management and planning, multi-institutional portals can suffer from minimal adoption. Data comprehensiveness is the foundational component of these portals and requires aligned policies and a key base of technology infrastructure across all participating sites. It is important to look beyond the category of the technology (ie, patient portal) and consider its functionality (eg, data aggregation, appointment scheduling, messaging) to ensure that it aligns with the underlying strategic priorities of the deployment. It is also critical to establish a clear vision and ensure buy-ins from organizational leadership and health care providers to support a cultural shift that will enable a meaningful and widespread engagement.

Dismantling internet-based cognitive behavioral therapy for tinnitus. The contribution of applied relaxation: A randomized controlled trial

BACKGROUND

Internet-based cognitive behavioral therapy (ICBT) for tinnitus is an evidence-based intervention. The components of ICBT for tinnitus have, however, not been dismantled and thus the effectiveness of the different therapeutic components is unknown. It is, furthermore, not known if heterogeneous tinnitus subgroups respond differently to ICBT.

AIMS

This dismantling study aimed to explore the contribution of applied relaxation within ICBT for reducing tinnitus distress and comorbidities associated with tinnitus. A secondary aim was to assess whether outcomes varied for three tinnitus subgroups, namely those with significant tinnitus severity, those with low tinnitus severity, and those with significant depression.

METHODS

A parallel randomized controlled trial design (n = 126) was used to compare audiologist-guided applied relaxation with the full ICBT intervention. Recruitment was online and via the intervention platform. Assessments were completed at four-time points including a 2-month follow-up period. The primary outcome was tinnitus severity as measured by the Tinnitus Functional Index. Secondary outcomes were included for anxiety, depression, insomnia, negative tinnitus cognitions, health-related quality of life, hearing disability, and hyperacusis. Treatment engagement variables including the number of logins, number of modules opened, and the number of messages sent. Both an intention-to-treat analysis and completer's only analysis were undertaken.

RESULTS

Engagement was low which compromised results as the full intervention was undertaken by few participants. Both the ICBT and applied relaxation resulted in large reduction of tinnitus severity (within-group effect sizes d = 0.87 and 0.68, respectively for completers only analysis), which were maintained, or further improved at follow-up. These reductions in tinnitus distress were greater for the ICBT group, with a small effect size differences (between-group d = 0.15 in favor of ICBT for completers only analysis). Tinnitus distress decreased the most at post-intervention for those with significant depression at baseline. Both ICBT and applied relaxation contributed to significant reductions on most secondary outcome measures, with no group differences, except for a greater reduction of hyperacusis in the ICBT group.

CONCLUSION

Due to poor compliance partly attributed to the COVID-19 pandemic results were compromised. Further studies employing strategies to improve compliance and engagement are required. The intervention's effectiveness increased with initial level of tinnitus distress; those with the highest scores at intake experienced the most substantial changes on the outcome measures. This may suggest tailoring of interventions according to tinnitus severity. Larger samples are needed to confirm this.

Democratizing epilepsy care: Utility and usability of an electronic patient portal

OBJECTIVES

Electronic patient portals (ePortals) can facilitate greater healthcare democratization by providing patients and/or their authorized care partners with secure access to their medical records when and where needed. Such democratization can promote effective healthcare provider-patient partnerships, shared decision-making, and greater patient engagement in managing their health condition. This study examined the usefulness of providing individualized services and care in epilepsy (PiSCES), an epilepsy ePortal, as an enabler of more democratized epilepsy care.

METHODS

Seventy-two individuals with epilepsy and 18 care partners were invited to report on their experience of interacting via PiSCES with clinical documents (epilepsy care summary record; epilepsy clinic letters) authored about them by healthcare providers. The OpenNotes reporting tool was adapted to capture participant experience.

RESULTS

Twenty-five percent of invited patients and 44% of invited care partners reported on interacting with their epilepsy care summary; 14% of patients and 67% of care partners invited reported on their epilepsy clinic letters. Participant testimonials illustrate the value of PiSCES in: promoting autonomy, aiding memory, developing the knowledgeable patient, and enhancing healthcare partnerships. Ninety-six percent and 100% of respondents, respectively, reported understanding their epilepsy care summary and epilepsy clinic letter; 77% said the summary described their epilepsy history to date; 96% indicated that the letter provided an accurate description of their clinical encounter; 92% and 96%, respectively, valued access to their summary record and clinic letters; 77% of summary record and 73% clinic letter respondents reported learning something about their epilepsy or the healthcare service via PiSCES. Illustrating their potential patient and care partner safety role, 42% respondents identified inaccuracies in their clinical documents which were subsequently resolved by a clinician.

SIGNIFICANCE

In the post-digital world highly customized on-demand products and services have come to be expected. Similarly, in epilepsy care, technologies such as PiSCES can enable more personalized, transparent, and engaging services.

Association between Patient Portal use and Office Visits

Extant research on the relationship between portal use and office visits is mixed. Some researchers have stated that there is no correlation between the two events, others have found a positive correlation, and still others have found a negative correlation between portal use and office visits. Through the use of system-generated data from two different portal systems, we demonstrate the correlation between portal visits and office visits. We also demonstrate how this correlation differs between two institutions and across three demographic attributes. We performed a retrospective bivariate correlation analysis between portal visits and office visits. The correlation analysis was followed by an application of Fisher's z transformation of the correlation coefficients to determine significant differences in correlation across ethnicity, gender, and age. We found a positive and statistically significant correlation between portal visits and office visits among both hospital patients (n = 2,594, r = .239, p < .000) and university health service patients (n = 1,233, r = .596, p < .000). This correlation varies significantly across the dimensions of ethnicity, gender, and age. Our findings support the importance of portal use in the care continuum. Future research should aim to better understand the nuance of personal characteristics on the relationship between portal visits and office visits. Knowing these nuances can assist practitioners with further promoting patient self-engagement through portal use.

Association between 30-day readmission rates and health information technology capabilities in US hospitals

ABSTRACT

Health information technology (IT) is often proposed as a solution to fragmentation of care, and has been hypothesized to reduce readmission risk through better information flow. However, there are numerous distinct health IT capabilities, and it is unclear which, if any, are associated with lower readmission risk.To identify the specific health IT capabilities adopted by hospitals that are associated with hospital-level risk-standardized readmission rates (RSRRs) through path analyses using structural equation modeling.This STROBE-compliant retrospective cross-sectional study included non-federal U.S. acute care hospitals, based on their adoption of specific types of health IT capabilities self-reported in a 2013 American Hospital Association IT survey as independent variables. The outcome measure included the 2014 RSRRs reported on Hospital Compare website.A 54-indicator 7-factor structure of hospital health IT capabilities was identified by exploratory factor analysis, and corroborated by confirmatory factor analysis. Subsequent path analysis using Structural equation modeling revealed that a one-point increase in the hospital adoption of patient engagement capability latent scores (median path coefficient ß = -0.086; 95% Confidence Interval, -0.162 to -0.008), including functionalities like direct access to the electronic health records, would generally lead to a decrease in RSRRs by 0.086%. However, computerized hospital discharge and information exchange capabilities with other inpatient and outpatient providers were not associated with readmission rates.These findings suggest that improving patient access to and use of their electronic health records may be helpful in improving hospital performance on readmission; however, computerized hospital discharge and information exchange among clinicians did not seem as beneficial - perhaps because of the quality or timeliness of information transmitted. Future research should use more recent data to study, not just adoption of health IT capabilities, but also whether their usage is associated with lower readmission risk. Understanding which capabilities impact readmission risk can help policymakers and clinical stakeholders better focus their scarce resources as they invest in health IT to improve care delivery.

Coproducing health and well-being in partnership with patients, families, and healthcare providers: A qualitative study exploring the role of an epilepsy patient portal

BACKGROUND

Coproduced epilepsy care sees people with epilepsy (PwE), their care-proxies, and healthcare providers (HCPs), working together as partners to build strong relationships, improve communication, trust, and share decision-making. Coproduction underpins good quality patient- and family-centered care (PFCC) that is responsive to individual patient needs, preferences, and values. By facilitating information sharing and exchange between partners, electronic patient portals (ePortal) can enable coproduction. This paper explores what HCPs, PwE, and their care-proxies value from their user experience of PiSCES, the Irish epilepsy ePortal.

METHODS

A purposeful sample of actors involved in the receipt and delivery of epilepsy care and services were recruited via adult epilepsy centers at St James's and Beaumont Hospitals in Dublin. Interactive codesign sessions, surveys, and focus groups were used to elicit perspectives from PwE, care-proxies, and HCPs to understand their perception of how PiSCES could enhance or inhibit the epilepsy care process.

RESULTS

Results illustrate that participants welcome the role PiSCES can play in: empowering PwE/care-proxies, strengthening confidence in the healthcare system; aiding memory; advancing health literacy, motivating PwE to understand their condition better; acting as a passport of care between different clinical settings; and creating a foundation for stronger coproduction partnerships. PiSCES was generally embraced; however, some HCPs expressed plausible concerns about how clinical implementation might impact their work practices.

CONCLUSION

"Nothing about me without me" is a core value of the PiSCES initiative, recognizing that people need to be included in the planning of their own treatment and care. Our data show that PwE, their care-proxies, and HCPs value PiSCES potential, particularly in bolstering healthcare partnerships that foster inclusion, confidence, and trust.

The Causal Relationship Between Portal Usage and Self-Efficacious Health Information-Seeking Behaviors: Secondary Analysis of the Health Information National Trends Survey Data

Background

Patient portals have drawn much attention, as they are considered an important tool for health providers in facilitating patient engagement. However, little is known about whether the intensive use of patient portals contributes to improved management of patients’ health in terms of their confidence in acquiring health information and exercising self-care. There is a lack of randomized trials with these outcomes measured both pre- and postadoption of patient portals.

Objective

The aim of this study was to examine the causal relationship between the usage of patient portals and patients’ self-efficacy toward obtaining health information and performing self-care.

Methods

This study was a secondary data analysis that used data from a US national survey, the National Cancer Institute’s Health Information National Trends Survey 5 Cycle 1. Patient portal usage frequency was used to define the treatment. Survey items measuring self-efficacy on a Likert-type scale were selected as the main outcomes, including patients’ confidence in obtaining health information and performing self-care. To establish causality using survey data, we adopted the instrumental variables method. To determine the direction of the causal relationship in the presence of high-dimensional confounders, we further proposed a novel testing framework that employs conditional independence tests in a directed acyclic graph. The average causal effect was measured using the two-stage least squares regression method.

Results

We showed that frequently using patient portals improves patients’ confidence in obtaining health information. The estimand of the weighted average causal effect was 0.14 (95% CI 0.06-0.23; P<.001). This means that when increasing the portal usage intensity, for instance, from 1-2 times to 3-5 times per year, the expected average increase in confidence level measured on a Likert-type scale would be 0.14. However, we could not conclusively determine the causal effect between patient portal usage and patients’ confidence in exercising self-care.

Conclusions

The results support the use of patient portals and encourage better support and education to patients. The proposed statistical method can be used to exploit the potential of national survey data for causal inference studies.

"Will you hear my voice?": to engage older patients online, listen to them about their lives offline

The scope of health information and health care services available online is rapidly expanding. At the same time, COVID-19 is causing vulnerable elders to reconsider in-person provider visits. In that context, recently published research by Y. Mizrachi et al. examining obstacles to the use of online health services (OHS) among adults age 50 and up takes on new importance. An iconic Israeli song begins, “Will you hear my voice?” (Hebrew Songs. Zemer Nugeh (Hatishmah Koli), 2020). What makes Mizrachi et al.’s findings particularly intriguing, despite several caveats, is the manner in which they demonstrated a commitment to genuinely listen to individual voices. The researchers spoke “openly and bluntly” with interviewees as peers and were rewarded with “specific, well-defined and applicable answers with the potential to be used.” The most striking findings came in candid answers that went beyond the factors intrinsic to the online offerings and addressed important factors in what regular Internet users often refer to as IRL (“in real life”), such as support from family. The necessity of avoiding preconceptions about the most effective manner to engage patients underscores the importance of patient and family advisory councils (PFACs). PFACs, increasingly being adopted by health care organizations globally, provide an ongoing ability to listen and respond to the “patient voice.” Effectively addressing obstacles to older adults’ use of the full range of online health resources will require the involvement not just of health plans and government, but also of voluntary organizations, providers, families and others integral to users’ offline “real lives.” Sustained, focused listening must be a central part of that effort.

Readiness and Implementation of Quality Improvement Strategies Among Small- and Medium-Sized Primary Care Practices: an Observational Study

BACKGROUND

Little is known about what determines strategy implementation around quality improvement (QI) in small- and medium-sized practices. Key questions are whether QI strategies are associated with practice readiness and practice characteristics.

OBJECTIVE

Grounded in organizational readiness theory, we examined how readiness and practice characteristics affect QI strategy implementation. The study was a component of a larger practice-level intervention, Heart of Virginia Healthcare, which sought to transform primary care while improving cardiovascular care.

DESIGN

This observational study analyzed practice correlates of QI strategy implementation in primary care at 3 and 12 months. Data were derived from surveys completed by clinicians and staff and from assessments by practice coaches.

PARTICIPANTS

A total of 175 small- and medium-sized primary care practices were included.

MAIN MEASURES

Outcome was QI strategy implementation in three domains: (1) aspirin, blood pressure, cholesterol, and smoking cessation (ABCS); (2) care coordination; and (3) organizational-level improvement. Coaches assessed implementation at 3 and 12 months. Readiness was measured by baseline member surveys, 1831 responses from 175 practices, a response rate of 73%. Practice survey assessed practice characteristics, a response rate of 93%. We used multivariate regression.

KEY RESULTS

QI strategy implementation increased from 3 to 12 months: the mean for ABCS from 1.20 to 1.59, care coordination from 2.15 to 2.75, organizational improvement from 1.37 to 1.78 (95% CI). There was no statistically significant association between readiness and QI strategy implementation across domains. Independent practice implementation was statistically significantly higher than hospital-owned practices at 3 months for ABCS (95% CI, P = 0.01) and care coordination (95% CI, P = 0.03), and at 12 months for care coordination (95% CI, P = 0.04).

CONCLUSION

QI strategy implementation varies by practice ownership. Independent practices focus on patient care-related activities. FQHCs may need additional time to adopt and implement QI activities. Practice readiness may require more structural and organizational changes before starting a QI effort.

Patient Portal Functionalities and Patient Outcomes Among Patients With Diabetes: Systematic Review

BACKGROUND

Patient portal use could help improve the care and health outcomes of patients with diabetes owing to functionalities, such as appointment booking, electronic messaging (e-messaging), and repeat prescription ordering, which enable patient-centered care and improve patient self-management of the disease.

OBJECTIVE

This review aimed to summarize the evidence regarding patient portal use (portals that are connected to electronic health care records) or patient portal functionality use (eg, appointment booking and e-messaging) and their reported associations with health and health care quality outcomes among adult patients with diabetes.

METHODS

We searched the MEDLINE, Embase, and Scopus databases and reported the review methodology using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three independent reviewers screened titles and abstracts, and two reviewers assessed the full texts of relevant studies and performed data extraction and quality assessments of the included studies. We used the Cochrane Collaboration Risk of Bias Tool and the National Heart, Lung and Blood Institute (NHLBI) Study Quality Assessment Tool to assess the risk of bias of the included studies. Data were summarized through narrative synthesis.

RESULTS

Twelve studies were included in this review. Five studies reported overall patient portal use and its association with diabetes health and health care quality outcomes. Six studies reported e-messaging or email use-associated outcomes, and two studies reported prescription refill-associated outcomes. The reported health outcomes included the associations of patient portal use with blood pressure, low-density lipoprotein cholesterol, and BMI. Few studies reported health care utilization outcomes such as office visits, emergency department visits, and hospitalizations. A limited number of studies reported overall quality of care for patients with diabetes who used patient portals.

CONCLUSIONS

The included studies mostly reported improved glycemic control outcomes for patients with diabetes who used patient portals. However, limitations of studying the effects of patient portals exist, which do not guarantee whether the outcomes reported are completely the result of patient portal use or if confounding factors exist. Randomized controlled trials and mixed-methods studies could help understand the mechanisms involved in health outcome improvements and patient portal use among patients with diabetes.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) CRD42019141131; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019141131.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/14975.

Impact of Digital Divide on the Adoption of Online Patient Portals for Self-Motivated Patients

OBJECTIVE

Our study aimed to determine the effect of the digital divide in the adoption of online patient portals by motivated patients who wish to improve their health outcomes through the use of the Internet and information technology to assess determinants of low adoption rates of online portals and to explore social media use as a correlation to patient portal use.

METHODS

We utilized data from the Health Information National Trends Survey (HINTS) 2017 and 2018. We performed a cross-sectional study analyzing the outcome variable of patient portal use with several predictor variables, namely, age, marital status, gender, mental health, education, Medicaid, income, number of people in household, trust, social media, chronic disease, and health app use. Basic descriptive statistics and logistic regression were performed using SPSS version 25.

RESULTS

Our study found that low adoption rates go beyond the digital divide. A correlation exists between social media use and patient portal use, and the impact of previously identified factors on patients with self-motivation for health improvement.

CONCLUSION

Self-motivation is an important factor in patient portal use and access. Behavioral and motivational interventions geared towards the adoption of health information technology tools, such as online portals, can assist with improving the public health significance of these tools.

The development of an epilepsy electronic patient portal: Facilitating both patient empowerment and remote clinician-patient interaction in a post-COVID-19 world

Objectives

The current coronavirus disease 2019 (COVID‐19) pandemic stresses an urgency to accelerate much‐needed health service reform. Rapid and courageous changes being made to address the immediate impact of the pandemic are demonstrating that the means and technology to enable new models of health care exist. For example, innovations such as electronic patient portals (ePortal) can facilitate (a) radical reform of outpatient care; (b) cost containment in the economically constrained aftermath of the pandemic; (c) environmental sustainability by reduction of unnecessary journeys/transport. Herein, the development of Providing Individualised Services and Care in Epilepsy (PiSCES), an ePortal to the Irish National Epilepsy Electronic Patient Record, is demonstrated. This project, which pre‐dates the COVID‐19 crisis, aims to facilitate better patient‐ and family‐centered epilepsy care.

Methods

A combination of ethnographic research, document analysis, and joint application design sessions was used to elicit PiSCES requirements. From these, a specification of desired modules of functionality was established and guided the software development.

Results

PiSCES functional features include “My Epilepsy Care Summary,” “My Epilepsy Care Goals,” “My Epilepsy Clinic Letters,” “Help Us Measure Your Progress,” “Prepare For Your Clinic Visit,” “Information for Your Healthcare Provider.” The system provides people with epilepsy access to, and engages them as co‐authors of, their own medical record. It can promote improved patient‐clinician partnerships and facilitate patient self‐management.

Significance

In the aftermath of COVID‐19, it is highly unlikely that the healthcare sector will return to a “business as usual” way of delivering services. The pandemic is expected to accelerate adoption of innovations like PiSCES. It is therefore a catalyst for change that will deliver care that is more responsive to individual patient needs and preferences.

Electronic patient portal utilization by neurology patients and association with outcomes

Existing literature on electronic patient portals demonstrates mixed findings for portal user demographic patterns and relationships between portal usage and clinical outcomes. This study sought to determine characteristics of portal users specific to a neurology patient population and examine whether usage predicted decreased clinic visits and risk of hospitalization. A cross-sectional analysis on 13,483 patients seen at a tertiary neurology outpatient clinic over a 1-year period found significant associations between demographics, and interactions between age, sex, and race. Black and Hispanic patients were less likely to be portal users. While females had higher odds of portal usage overall, their probability decreased with increasing age. Portal users had higher rates of clinic utilization but no difference in hospitalization risk. These results highlight demographics that may need strategic targeting to increase portal uptake and the need for other interventions for populations more likely to experience health events resulting in hospitalization.

Heart Failure Management Innovation Enabled by Electronic Health Records

Patients with congestive heart failure (CHF) require complex medical management across the continuum of care. Electronic health records (EHR) are currently used for traditional tasks of documentation, reviewing and managing test results, computerized order entry, and billing. Unfortunately many clinicians view EHR as merely digitized versions of paper charts, which create additional work and cognitive burden without improving quality or efficiency of care. In fact, EHR are revolutionizing the care of chronic diseases such as CHF. This review describes how appropriate use of technologies offered by EHR can help standardize CHF care, promote adherence to evidence-based guidelines, optimize workflow efficiency, improve performance metrics, and facilitate patient engagement. This review discusses a number of tools including documentation templates, telehealth and telemedicine, health information exchange, order sets, clinical decision support, registries, and analytics. Where available, evidence of their potential utility in management of CHF is presented. Together these EHR tools can also be used to enhance quality improvement, patient management, and clinical research as part of a learning health care system model. This review describes how existing EHR tools can support patients, cardiologists, and care teams to deliver consistent, high-quality, coordinated, patient-centered, and guideline-concordant care of CHF.

Care Experiences of Patients with Multiple Chronic Conditions in a Payer-Based Patient-Centered Medical Home

Individuals with multiple chronic health conditions require additional support and medical services, incur higher health care costs, and often have a higher risk of hospitalization. The goal of this study was to examine care experiences of patients with multiple chronic conditions in the CareFirst patient-centered medical home (PCMH). The study used a repeated cross-sectional research design and included 1308 adult CareFirst plan members with multiple chronic conditions. Patient care experiences were collected using a structured telephone survey in 2015 and 2017. Composite scores and individual question responses for patient-provider communication, coordination of care, access to care, and self-management support were analyzed to determine differences between survey years. Overall, patients reported positive care experiences with communication, self-management support, and care coordination. Access to care indicators received lower composite scores. Between 2015 and 2017, patients reported higher ratings for appointment reminders, communicating test results, providers listening carefully, and care plan effectiveness. Patients who completed their CareFirst PCMH care plan had higher care experience scores than patients who did not. A key finding of this study is that care plan completion is associated with positive care experiences, indicating the importance of the care plan to this PCMH model. Lower scores on access to care measures suggest a need for improved pathways for patients to obtain care during nontraditional office hours. Payer-based PCMH models that include enhanced care coordination and additional provider payments to support these activities may be beneficial to patients with multiple chronic conditions.

Gateless communication: A concept analysis

The movement toward the use of electronic technologies in everyday life has also impacted healthcare. Patient portals allow patients to send messages to their healthcare team from the comfort of their own homes and even on mobile devices. With responses typically sent within 24 business hours, some patients are looking for more timely feedback to their health questions. This is true in behavioral health, where real-time communication between psychologist-patient is valued. It is not uncommon for psychiatric providers including psychiatrists and nurse practitioners to provide personal cell phone numbers or secure-texting services to their patients. The real-time texting that occurs between patients and providers is emerging as a new way in which information is shared. A literature review in PubMed and CINAHL revealed a plethora of research conducted on information exchanged via the patient portal; however, there appears to be a gap in the information known about direct patient-provider communication that utilizes other types of technology. This concept analysis looks at this type of communication and proposes that a new concept be developed to perform future research studies. "Gateless communication" will be explored using a previous paper eight-step method for conceptualizing this new concept.