Growth of Secure Messaging Through a Patient Portal as a Form of Outpatient Interaction across Clinical Specialties

Team-based digital communication reduced patient-initiated phone calls to the hospital and improved patient satisfaction after orthopedic surgery: a randomized controlled trial in 70 patients

BACKGROUND AND PURPOSE

Post-discharge inquiries to the hospital are predominantly conducted through phone calls. The rigid timing of these calls is inconvenient for patients and disrupts the workflows of healthcare professionals. The aim of this study was to investigate the effect of a team-based digital communication intervention (eDialogue) facilitated through a messenger-like commercial solution on patient-initiated phone calls to the hospital after discharge. Secondarily, we investigated other patient-initiated contacts, patients' perception of continuity of care, and their perception of feeling safe and satisfied after hospital discharge.

METHODS

On the day of discharge, 70 surgically treated orthopedic patients were randomized to the intervention group with access to eDialogue (n = 35) or the control group with standard communication pathways by phone call (n = 35) for the following 8 weeks. Through eDialogue, the intervention group had access to team-based asynchronous digital communication in text and photos with healthcare professionals across disciplines and sectors. Inclusion criteria were discharge to own home and receipt of rehabilitation services from both hospital and primary care after discharge.

RESULTS

We found a significant reduction in the mean number of patient-initiated phone calls to the hospital from 2.3 (95% confidence interval [CI] 1.4-4.1) in the control group to 0.5 (CI 0.3-1.0) in the intervention group (P = 0.004). Across groups, patients reported similar perceptions of continuity of care; however, the participants in the intervention group expressed significantly improved perceptions of, and satisfaction with, access to healthcare after discharge.

CONCLUSION

Access to eDialogue reduced patient-initiated phone calls to the hospital, enhanced patient satisfaction with healthcare accessibility, and did not compromise patients' perception of continuity of care after discharge compared with standard communication pathways.

Patient Perspectives on Communication Pathways After Orthopedic Surgery and Discharge and Evaluation of Team-Based Digital Communication: Qualitative Exploratory Study

BACKGROUND

The transition from hospital to home after orthopedic surgery requires smooth communication and coordination between patients and their team of care to avoid fragmented care pathways. Digital communication is increasingly being used to facilitate easy and accessible asynchronous communication between patients and health care professionals across settings. A team-based approach to digital communication may provide optimized quality of care in the postoperative period following orthopedic surgery and hospital discharge.

OBJECTIVE

This study was divided into two phases that aimed to (1) explore the perspectives of patients undergoing orthopedic surgery on current communication pathways at a tertiary hospital in Denmark and (2) test and explore patients' experiences and use of team-based digital communication following hospital discharge (eDialogue).

METHODS

A triangulation of qualitative data collection techniques was applied: document analysis, participant observations (n=16 hours), semistructured interviews with patients before (n=31) and after (n=24) their access to eDialogue, and exploration of use data.

RESULTS

Findings show that patients experience difficult communication pathways after hospital discharge and a lack of information due to inadequate coordination of care. eDialogue was used by 84% (26/31) of the patients, and they suggested that it provided a sense of security, coherence, and proximity in the aftercare rearranging communication pathways for the better. Specific drivers and barriers to use were identified, and these call for further exploration of eDialogue.

CONCLUSIONS

In conclusion, patients evaluated eDialogue positively and suggested that it could support them after returning home following orthopedic surgery.

Health Care Professionals' Perspectives Before and After Use of eDialogue for Team-Based Digital Communication Across Settings: Qualitative Study

BACKGROUND

Orthopedic surgical treatment is a transversal task that requires the active involvement of patients, relatives, and health care professionals (HCPs) across various settings. However, after hospital discharge, communication is challenged and undertaken primarily by phone. New digital communication solutions have the potential to create a space for seamless and patient-centered dialogue across discipline and sector boundaries. When evaluating new communication solutions, knowledge about HCPs' needs and perspectives of use must be explored, as it is they who are responsible for implementing changes in practice.

OBJECTIVE

This study aimed to (1) investigate HCPs' perceptions of current communication pathways (phase 1) and (2) explore their experiences of using a simple messenger-like solution (eDialogue) for team-based digital communication across settings (phase 2).

METHODS

We used a triangulation of qualitative data collection techniques, including document analysis, observations, focus groups, and individual interviews of HCPs before (n=28) and after (n=12) their use of eDialogue. Data collection and analysis were inspired by the Consolidated Framework for Implementation Research (CFIR) to specifically understand facilitators and barriers to implementation as perceived by HCPs.

RESULTS

HCPs perceive current communication pathways as insufficient for both patients and themselves. Phone calls are disruptive, and there is a lack of direct communication modalities when communication crosses sector boundaries. HCPs experienced the use of eDialogue as a quick and easy way for timely interdisciplinary interaction with patients and other HCPs across settings; however, concerns were raised about time consumption.

CONCLUSIONS

eDialogue can provide needed support for interdisciplinary and cross-sectoral patient-centered communication. However, future studies of this solution should address its impact and the use of resources.

Physician Burnout: Evidence-Based Roadmaps to Prioritizing and Supporting Personal Wellbeing

Current literature validates the magnitude of physician burnout as a complex challenge affecting physicians, patients, and healthcare delivery that mandates science-informed intervention. Physician burnout affects both individual practitioners and patient care delivery. Interventions, defined as roadmaps, to prioritizing and supporting personal wellbeing encompass organizational, individual, and moral injury, with virtually no consensus on optimal approaches. The purpose of this conceptual review is to present evidence-based innovative insights on contributing factors, mitigation, and designing adaptive systems to combat and prevent burnout. Science-informed policy initiatives that support long-term organizational changes endorsed by both leadership and institutional stakeholders are keys to sustaining personal wellbeing and ending burnout.

Surgical Providers' Perceptions of the Patient Portal: Before and After the 21st Century Cures Act

INTRODUCTION

In April 2021, the Information Blocking Rule (IBR) of the 21st Century Cures Act went into effect giving patients immediate access to notes, radiology reports, lab results, and surgical pathology. We aimed to examine changes in surgical providers' perceptions of patient portal usage before and after its implementation.

METHODS

We administered a 37-question survey prior to the implementation of the IBR and a 39-question follow-up survey 3 mo later. The survey was sent to all surgeons, advanced practice providers, and clinic nurses in our surgical department.

RESULTS

The response rate to pre surveys and post surveys was 33.7% and 30.7%, respectively. Providers' preference for communication via the patient portal (compared to phone or in person) regarding lab, radiology, or pathology results remained similar. While there was an increase in messages received from patients, there was no difference in the self-reported time spent on the electronic health record (EHR). Prior to the implementation of the blocking rule, 75.8% of providers believed that the portal increased workload which decreased to 57.4% on our follow-up survey. About one-third of providers screened positive for burnout before (32%) which decreased slightly (27.4%).

CONCLUSIONS

Although 43.9% of providers reported the Cures Act had changed their practice, there was no difference in self-reported EHR usage, preferred method of interaction with patients, overall workload, or burnout. Initial concerns regarding the IBR's effect on job satisfaction, patient anxiety, and quality of care had lessened. Further exploration into how patients having immediate access to their EHRs has changed surgical practice is needed.

Evaluation of a Secure Messaging System in the Care of Children With Medical Complexity: Mixed Methods Study

BACKGROUND

The Connecting2gether (C2) platform is a web and mobile-based information-sharing tool that aims to improve care for children with medical complexity and their families. A key feature of C2 is secure messaging, which enables parental caregivers (PCs) to communicate with their child's care team members (CTMs) in a timely manner.

OBJECTIVE

The objectives of this study were to (1) evaluate the use of a secure messaging system, (2) examine and compare the content of messages to email and phone calls, and (3) explore PCs' and CTMs' perceptions and experiences using secure messaging as a method of communication.

METHODS

This is a substudy of a larger feasibility evaluation of the C2 platform. PCs of children with medical complexity were recruited from a tertiary-level complex care program to use the C2 platform for 6 months. PCs could invite CTMs involved in their child's care to register on the platform. Messages were extracted from C2, and phone and email data were extracted from electronic medical records. Quantitative data from the use of C2 were analyzed using descriptive statistics. Messaging content codes were iteratively developed through a review of the C2 messages and phone and email communication. Semistructured interviews were completed with PCs and CTMs. Communication and interview data were analyzed using thematic analysis.

RESULTS

A total of 36 PCs and 66 CTMs registered on the C2 platform. A total of 1861 messages were sent on C2, with PCs and nurse practitioners sending a median of 30 and 74 messages, respectively. Of all the C2 messages, 85.45% (1257/1471) were responded to within 24 hours. Email and phone calls focused primarily on clinical concerns and medications, whereas C2 messaging focused more on parent education, proactive check-ins, and nonmedical aspects of the child's life. Four themes emerged from the platform user interviews related to C2 messaging: (1) connection to the care team, (2) efficient communication, (3) clinical uses of secure messaging, and (4) barriers to use.

CONCLUSIONS

Overall, our study provides valuable insight into the benefits of secure messaging in the care of children with medical complexity. Secure messaging provided the opportunity for continued family teaching, proactive check-ins from health care providers, and casual conversations about family and child life, which contributed to PCs feeling an improved sense of connection with their child's health care team. Secure messaging can be a beneficial additional communication method to improve communication between PCs and their care team, reducing the associated burden of care coordination and ultimately enhancing the experience of care delivery. Future directions include the evaluation of secure messaging when integrated into electronic medical records, as this has the potential to work well with CTM workflow, reduce redundancy, and allow for new features of secure messaging.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Efficacy and satisfaction of asynchronous TeleHealth care compared to in-person visits following colorectal surgical resection

BACKGROUND

The feasibility of remote visits following abdominal colorectal surgery has not been studied in relation to efficacy, patient satisfaction, and surgeon satisfaction. This study aims to assess reliability and satisfaction with a web-based questionnaire for post-operative visits following abdominal colorectal surgery.

METHODS

This was a prospective single-arm cohort study at single-tertiary care center during admission for abdominal colorectal surgery. Using a web-based patient portal, patients completed a questionnaire 48 h prior to their scheduled in-person follow-up visits and submitted photographs of their incisions. Surgeons reviewed patient-entered data and responded within 24 h. Following the subsequent in-person visit, surgeons completed questionnaires to compare the accuracy of the web-based vs. in-person evaluations. Lastly, patients and surgeons completed separate satisfaction surveys after the in-person visits.

RESULTS

A total of 33 patients were enrolled, of which 30 (90.9%) successfully completed the web questionnaire. Providers reported the online questionnaire to be concordant with the in-person visit in 90% of cases. Of the patients who completed the study, only half found the survey alone to be acceptable for follow-up. Patients spent significantly less time completing the online questionnaire (≤ 10 min) than in-person visits, including travel time (75 min, IQR 50-100). Only 12 patients (40%) uploaded photographs of their incisions. During in-person visits, management changes were employed in four patients (13.3%), of which 3 required treatment of superficial surgical site infections (10%).

CONCLUSION

This asynchronous web-based visit format was acceptable to colorectal surgeons but was only embraced by half of patients, despite considerable time savings. While patients preferred in-person visits, there may be opportunities to expand TeleHealth acceptance that focus on patient selection and education.

CLINICALTRIALS

gov: NCT05084131.

Scoping review protocol to map the use of text-based two-way communication between patients and healthcare professionals after hospital discharge and identify facilitators and barriers to implementation

INTRODUCTION

After discharge, patients face multiple risks where timely communication with healthcare professionals is required. eHealth has proposed new possibilities for asynchronous text-based two-way communication between patients and healthcare professionals during this time, and studies show positive effects on clinical outcomes, care coordination and patient satisfaction. However, there are challenges to the adoption of text-based two-way communication, potentially undermining the positive effects in clinical practice. Knowledge of these factors may inform future research and implementations. No reviews have provided an overview of the use of text-based two-way communication after discharge and the identified facilitators and barriers. Therefore, the objective of this scoping review is to systematically identify and map available research that assess the use of text-based two-way communication between patients and healthcare professionals after hospital discharge, including facilitators and barriers to implementation.

METHODS AND ANALYSIS

We will include all studies describing the use of text-based two-way communication between patients and healthcare professionals after discharge from hospital. A preliminary search of PubMed (PubMed.gov), EMBASE (Elsevier), CINAHL (EBSCO), PsycINFO (Ovid), Cochrane Library (Wiley), Web of Science (Clarivate) and Scopus (Elsevier) was undertaken on 9 November 2021. The search will be updated for the full scoping review, and reference lists of relevant papers reviewed. Two reviewers will independently screen the literature for inclusion. Data will be extracted and charted in accordance with a data extraction form developed from the research questions and inspired by Consolidated Framework Implementation Research. Findings will be presented in tabular format and a descriptive summary, and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist.

ETHICS AND DISSEMINATION

This scoping review will not require ethics approval. The dissemination strategy involves peer review publication and presentation at conferences.

Electronic Patient Portal Access, Retention in Care, and Viral Suppression Among People Living With HIV in Southeastern United States: Observational Study

BACKGROUND

Approximately 1.1 million people living with HIV live in the United States, and the incidence is highest in Southeastern United States. Electronic patient portal prevalence is increasing and can improve engagement in primary medical care. Retention in care and viral suppression-measures of engagement in HIV care-are associated with decreased HIV transmission, morbidity, and mortality.

OBJECTIVE

We aimed to determine if patient portal access among people living with HIV was associated with retention and viral suppression.

METHODS

We conducted an observational cohort study among people living with HIV in care at the Vanderbilt Comprehensive Care Clinic (Nashville, Tennessee) from 2011-2016. Individual access was defined as patient portal account registration at any point in the year prior. Retention was defined as ≥2 kept appointments or HIV lab measurements ≥3 months apart within a 12-month period. Viral suppression was defined as the last viral load in the calendar year <200 copies/mL. We calculated adjusted prevalence ratios (aPRs) and 95% CIs using modified Poisson regression with generalized estimating equations to estimate the association of portal access with retention and viral suppression.

RESULTS

We included 4237 people living with HIV contributing 16,951 person-years of follow-up (median 5, IQR 3-5 person-years). The median age was 43 (IQR 33-50) years. Of the 4237 people living with HIV, 78.1% (n=4237) were male, 40.8% (n=1727) were Black non-Hispanic, and 56.5% (n=2395) had access. Access was independently associated with retention (aPR 1.13, 95% CI 1.10-1.17) and viral suppression (aPR 1.18, 95% CI 1.14-1.22).

CONCLUSIONS

In this population, patient portal access was associated with retention and viral suppression. Future prospective studies should assess the impact of increasing portal access among people living with HIV on these HIV outcomes.

Adding Affordances and Communication Efficacy to the Technology Acceptance Model to Study the Messaging Features of Online Patient Portals among Young Adults

The use of messaging features within online patient portals could be beneficial to patients, but many patients do not utilize these features. Furthermore, it remains uncertain the reasons why patients may (or may not) use messaging features to communicate with a care provider. This study proposes and tests an extended Technology Acceptance Model (TAM), which incorporated perceived affordances (editability and persistence) and communication efficacy. An online survey was conducted with a sample of 525 young adults. Results showed that the editability affordance was conducted with perceived usefulness, while communication efficacy was associated with perceived ease of use of messaging. Editability and communication efficacy also were positively associated intention to use online patient portal messaging features, whereas persistence was negatively associated. Results suggest practitioners should emphasize editability and communication efficacy to increase patient intentions to use messaging features to communicate with a care provider.

Characterizing Patient-Clinician Communication in Secure Medical Messages: Retrospective Study

Background

Patient-clinician secure messaging is an important function in patient portals and enables patients and clinicians to communicate on a wide spectrum of issues in a timely manner. With its growing adoption and patient engagement, it is time to comprehensively study the secure messages and user behaviors in order to improve patient-centered care.

Objective

The aim of this paper was to analyze the secure messages sent by patients and clinicians in a large multispecialty health system at Mayo Clinic, Rochester.

Methods

We performed message-based, sender-based, and thread-based analyses of more than 5 million secure messages between 2010 and 2017. We summarized the message volumes, patient and clinician population sizes, message counts per patient or clinician, as well as the trends of message volumes and user counts over the years. In addition, we calculated the time distribution of clinician-sent messages to understand their workloads at different times of a day. We also analyzed the time delay in clinician responses to patient messages to assess their communication efficiency and the back-and-forth rounds to estimate the communication complexity.

Results

During 2010-2017, the patient portal at Mayo Clinic, Rochester experienced a significant growth in terms of the count of patient users and the total number of secure messages sent by patients and clinicians. Three clinician categories, namely “physician—primary care,” “registered nurse—specialty,” and “physician—specialty,” bore the majority of message volume increase. The patient portal also demonstrated growing trends in message counts per patient and clinician. The “nurse practitioner or physician assistant—primary care” and “physician—primary care” categories had the heaviest per-clinician workload each year. Most messages by the clinicians were sent from 7 AM to 5 PM during a day. Yet, between 5 PM and 7 PM, the physicians sent 7.0% (95,785/1,377,006) of their daily messages, and the nurse practitioner or physician assistant sent 5.4% (22,121/408,526) of their daily messages. The clinicians replied to 72.2% (1,272,069/1,761,739) patient messages within 1 day and 90.6% (1,595,702/1,761,739) within 3 days. In 95.1% (1,499,316/1,576,205) of the message threads, the patients communicated with their clinicians back and forth for no more than 4 rounds.

Conclusions

Our study found steady increases in patient adoption of the secure messaging system and the average workload per clinician over 8 years. However, most clinicians responded timely to meet the patients’ needs. Our study also revealed differential patient-clinician communication patterns across different practice roles and care settings. These findings suggest opportunities for care teams to optimize messaging tasks and to balance the workload for optimal efficiency.

Predicting Health Care Providers' Acceptance of a Personal Health Record Secure Messaging Feature

BACKGROUND

Personal health records (PHRs) can facilitate patient-centered communication through the secure messaging feature. As health care organizations in the Kingdom of Saudi Arabia implement PHRs and begin to implement the secure messaging feature, studies are needed to evaluate health care providers' acceptance.

OBJECTIVE

The aim of this study was to identify predictors of health care providers' behavioral intention to support the addition of a secure messaging feature in PHRs using an adapted model of the Unified Theory of Acceptance and Use of Technology as the theoretical framework.

METHODS

Using a cross-sectional survey design, data on acceptance of secure messaging features in PHRs were collected from health care providers working at the Ministry of National Guard Health Affairs between April and May 2021. The proposed model was tested using partial least squares structural equation modeling in SmartPLS.

RESULTS

There were 224 participants: female (66.5%), 40 to 49 years of age (39.9%), nurses (45.1%), and those working more than 10 years in the organization (68.8%). Behavioral intention to support the addition of a secure messaging feature was significantly influenced by performance expectancy (β = 0.21, p = 0.01) and attitude (β = 0.50, p < 0.01), while other predicting factors, such as effort expectancy, social influence, and facilitating condition, did not significantly affect the intention. Furthermore, age, years of experience, and professional role did not moderate the relationships.

CONCLUSION

Health care professionals will support introducing a secure messaging feature in the PHRs if they serve the intended purpose. Considering attitude also plays a significant role in acceptance, it is necessary to arrange for training and support, so that caregivers, health care providers, and the patients become familiar with the benefits and expected outcomes of using the feature.

Assessing the impact of the COVID-19 pandemic on clinician ambulatory electronic health record use

Objective

The COVID-19 pandemic changed clinician electronic health record (EHR) work in a multitude of ways. To evaluate how, we measure ambulatory clinician EHR use in the United States throughout the COVID-19 pandemic.

Materials and Methods

We use EHR meta-data from ambulatory care clinicians in 366 health systems using the Epic EHR system in the United States from December 2019 to December 2020. We used descriptive statistics for clinician EHR use including active-use time across clinical activities, time after-hours, and messages received. Multivariable regression to evaluate total and after-hours EHR work adjusting for daily volume and organizational characteristics, and to evaluate the association between messages and EHR time.

Results

Clinician time spent in the EHR per day dropped at the onset of the pandemic but had recovered to higher than prepandemic levels by July 2020. Time spent actively working in the EHR after-hours showed similar trends. These differences persisted in multivariable models. In-Basket messages received increased compared with prepandemic levels, with the largest increase coming from messages from patients, which increased to 157% of the prepandemic average. Each additional patient message was associated with a 2.32-min increase in EHR time per day (P < .001).

Discussion

Clinicians spent more total and after-hours time in the EHR in the latter half of 2020 compared with the prepandemic period. This was partially driven by increased time in Clinical Review and In-Basket messaging.

Conclusions

Reimbursement models and workflows for the post-COVID era should account for these demands on clinician time that occur outside the traditional visit.

Associations Between Patient-Provider Secure Message Content and Patients' Health Care Visits

Background: Between-visit communications can play a vital role in improving intermediate patient outcomes such as access to care and satisfaction. Secure messaging is a growing modality for these communications, but research is limited about the influence of message content on those intermediate outcomes. We examined associations between secure message content and patients' number of health care visits. Methods: Our study included 2,111 adult patients with hypertension and/or diabetes and 18,309 patient- and staff-generated messages. We estimated incident rate ratios (IRRs) for associations between taxonomic codes assigned to message content, and the number of office, emergency department, and inpatient visits. Results: Patients who initiated message threads in 2017 had higher numbers of outpatient visits (p < 0.001) compared with patients who did not initiate threads. Among patients who initiated threads, we identified an inverse relationship between outpatient visits and preventive care scheduling requests (IRR = 0.92; 95% confidence interval [CI]: 0.86-0.98) and requests for appointments for new conditions (IRR = 0.95; 95% CI: 0.92-0.99). Patients with higher proportions of request denials or more follow-up appointment requests had more emergency department visits compared with patients who received or sent other content (IRR = 1.18; 95% CI: 1.03-1.34 and IRR = 1.14; 95% CI: 1.07-1.23, respectively). We identified a positive association between outpatient visits and the proportion of threads that lacked a clinic response (IRR = 1.02; 95% CI: 1.00-1.03). Discussion: We report on the first analyses to examine associations between message content and health care visits. Conclusions: Our findings are relevant to understanding how to better use secure messaging to support patients and their care.

Analyzing Patient Secure Messages Using a Fast Health Care Interoperability Resources (FIHR)-Based Data Model: Development and Topic Modeling Study

Background

Patient portals tethered to electronic health records systems have become attractive web platforms since the enacting of the Medicare Access and Children’s Health Insurance Program Reauthorization Act and the introduction of the Meaningful Use program in the United States. Patients can conveniently access their health records and seek consultation from providers through secure web portals. With increasing adoption and patient engagement, the volume of patient secure messages has risen substantially, which opens up new research and development opportunities for patient-centered care.

Objective

This study aims to develop a data model for patient secure messages based on the Fast Healthcare Interoperability Resources (FHIR) standard to identify and extract significant information.

Methods

We initiated the first draft of the data model by analyzing FHIR and manually reviewing 100 sentences randomly sampled from more than 2 million patient-generated secure messages obtained from the online patient portal at the Mayo Clinic Rochester between February 18, 2010, and December 31, 2017. We then annotated additional sets of 100 randomly selected sentences using the Multi-purpose Annotation Environment tool and updated the data model and annotation guideline iteratively until the interannotator agreement was satisfactory. We then created a larger corpus by annotating 1200 randomly selected sentences and calculated the frequency of the identified medical concepts in these sentences. Finally, we performed topic modeling analysis to learn the hidden topics of patient secure messages related to 3 highly mentioned microconcepts, namely, fatigue, prednisone, and patient visit, and to evaluate the proposed data model independently.

Results

The proposed data model has a 3-level hierarchical structure of health system concepts, including 3 macroconcepts, 28 mesoconcepts, and 85 microconcepts. Foundation and base macroconcepts comprise 33.99% (841/2474), clinical macroconcepts comprise 64.38% (1593/2474), and financial macroconcepts comprise 1.61% (40/2474) of the annotated corpus. The top 3 mesoconcepts among the 28 mesoconcepts are condition (505/2474, 20.41%), medication (424/2474, 17.13%), and practitioner (243/2474, 9.82%). Topic modeling identified hidden topics of patient secure messages related to fatigue, prednisone, and patient visit. A total of 89.2% (107/120) of the top-ranked topic keywords are actually the health concepts of the data model.

Conclusions

Our data model and annotated corpus enable us to identify and understand important medical concepts in patient secure messages and prepare us for further natural language processing analysis of such free texts. The data model could be potentially used to automatically identify other types of patient narratives, such as those in various social media and patient forums. In the future, we plan to develop a machine learning and natural language processing solution to enable automatic triaging solutions to reduce the workload of clinicians and perform more granular content analysis to understand patients’ needs and improve patient-centered care.

Classification and analysis of asynchronous communication content between care team members involved in breast cancer treatment

OBJECTIVE

A growing research literature has highlighted the work of managing and triaging clinical messages as a major contributor to professional exhaustion and burnout. The goal of this study was to discover and quantify the distribution of message content sent among care team members treating patients with breast cancer.

MATERIALS AND METHODS

We analyzed nearly two years of communication data from the electronic health record (EHR) between care team members at Vanderbilt University Medical Center. We applied natural language processing to perform sentence-level annotation into one of five information types: clinical, medical logistics, nonmedical logistics, social, and other. We combined sentence-level annotations for each respective message. We evaluated message content by team member role and clinic activity.

RESULTS

Our dataset included 81 857 messages containing 613 877 sentences. Across all roles, 63.4% and 21.8% of messages contained logistical information and clinical information, respectively. Individuals in administrative or clinical staff roles sent 81% of all messages containing logistical information. There were 33.2% of messages sent by physicians containing clinical information-the most of any role.

DISCUSSION AND CONCLUSION

Our results demonstrate that EHR-based asynchronous communication is integral to coordinate care for patients with breast cancer. By understanding the content of messages sent by care team members, we can devise informatics initiatives to improve physicians' clerical burden and reduce unnecessary interruptions.

Classification of patient- and clinician-generated secure messages using a theory-based taxonomy

BACKGROUND

As secure electronic message exchange increases between patients and clinicians, we must explore and understand how patients and clinicians use those messages to communicate between clinical visits.

OBJECTIVE

To present the application of a taxonomy developed specifically to code secure message content in a way that allows for identification of patient and clinician communication functions demonstrated to be associated with patients' intermediate and health outcomes.

METHOD

We randomly sampled 1031 patients who sent and received 18 309 messages and coded those messages with codes from our taxonomy. We present the prevalence of each taxon (ie, code) within the sample.

RESULTS

The most common taxon among initial patient-generated messages were Information seeking (29.09%), followed by Scheduling requests (27.91%), and Prescription requests (23.09%). Over half of subsequent patient-generated messages included responses to clinic staffs' questions (58.31%). Six in 10 clinic staff responses included some form of Information sharing with process-based responses being most common (32.81%). A third of all clinician-generated messages (36.28%) included acknowledgement or some level of fulfilment of a patient's task-oriented request. Clinic staff sought information from patients in 20.54% of their messages.

CONCLUSION

This taxonomy is the first step toward examining whether secure messaging communication can be associated with patients' health outcomes. Knowing which content is positively associated with outcomes can support training of, and targeted responses from, clinicians with the goal of generating message content designed to improve outcomes.

PATIENT CONTRIBUTION

This study is based on analyses of patient-initiated secure message threads.

Perspectives on team communication challenges in caring for children with medical complexity

BACKGROUND

Children with medical complexity (CMC) require the expertise of many care providers spanning different disciplines, institutions, and settings of care. This leads to duplicate health records, breakdowns in communication, and limited opportunities to provide comprehensive, collaborative care. The objectives of this study were to explore communication challenges and solutions/recommendations from multiple perspectives including (i) parents, (ii) HCPs - hospital and community providers, and (iii) teachers of CMC with a goal of informing patient care.

METHODS

This qualitative study utilized an interpretive description methodology. In-depth semi-structured interviews were conducted with parents and care team members of CMC. The interview guides targeted questions surrounding communication, coordination, access to information and roles in the health system. Interviews were conducted until thematic saturation was reached. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed using thematic analysis.

RESULTS

Thirty-two individual interviews were conducted involving parents (n = 16) and care team members (n = 16). Interviews revealed 2 main themes and several associated subthemes (in parentheses): (1) Communication challenges in the care of CMC (organizational policy and technology systems barriers, inadequate access to health information, and lack of partnership in care) (2) Communication solutions (shared systems that can be accessed in real-time, universal access to health information, and partnered contribution to care).

CONCLUSION

Parents, HCPs, and teachers face multiple barriers to communication and information accessibility in their efforts to care for CMC. Parents and care providers in this study suggested potential strategies to improve communication including facilitating communication in real-time, universal access to health information and meaningful partnerships.

How clinician-patient communication affects trust in health information sources: Temporal trends from a national cross-sectional survey

Background

Understanding patients’ trust in health information sources is critical to designing work systems in healthcare. Patient-centered communication during the visit might be a major factor in shaping patients’ trust in information sources.

Objective

The purpose of this paper is to explore relationships between patient ratings of clinician communication during the visit and patient trust in health information sources.

Methodology

We conducted a secondary analysis of the nationally-representative Health Information National Trends Surveys; HINTS4 Cycle1 (2011), HINTS4 Cycle4 (2014), and HINTS5 Cycle1 (2017), and HINTS5 Cycle2 (2018). We created a composite score of patient-centered communication from five questions and dichotomized at the median. We created multivariable logistic regression models to see how patient-centered communication influenced trust in different information sources across cycles. Consecutively, we used hierarchical analysis for aggregated data.

Results

We analyzed data from 14,425 individuals. In the adjusted logistic models for each cycle and the hierarchical model, clinicians’ perceived patient-centered communication skills were significantly associated with increased trust in the clinicians as an information source.

Conclusion

Clinicians still represent an essential source of trustworthy information reinforced by patient-centered communication skills. Given that trust helps build healing relationships that lead to better healthcare outcomes, communication sets an essential foundation to establish necessary trust. Interpreting information from the internet sources for patients is likely to remain a vital clinician function.

How technology impacts communication between cancer patients and their health care providers: A systematic literature review

OBJECTIVE

To ensure the well-being of their patients, health care providers (HCPs) are putting more effort into the quality of the communication they provide in oncology clinics. With the emergence of Health Information Technology (HIT), the dynamics between doctors and patients in oncology settings have changed. The purpose of this literature review is to explore and demonstrate how various health information technologies impact doctor-patient communication in oncology settings.

METHOD

A systematic literature review was conducted in 4 databases (PubMed, Cochrane, Web of Science, IEEE Xplore) to select publications that are in English, published between January 2009 and September 2020. This review reports outcomes related to the impacts of using health information technologies on doctor-patient communication according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Reviews and Meta-Analysis guidelines (PRISMA).

RESULTS

We identified 31 studies which satisfied the selection and eligibility criteria. The review revealed a diverse range of HIT used to support communication between cancer patients and their HCPs in oncology settings. Outcomes related to communication were examined to demonstrate how technology can improve access to care in clinical settings and online. When technology is used effectively to support patient knowledge and shared understanding, this increases the patient's satisfaction and ability to manage emotions, make decisions, and progress in their treatment, in addition to increasing social support and building a stronger therapeutic alliance based on shared knowledge and transparency between clinicians and patients.

CONCLUSION

Technology-based solutions can help strengthen the relationship and communication between patients and their doctors. They can empower the patient's well-being, help doctors make better decisions and enhance the therapeutic alliance between them. Thus, using technology to enhance communication in healthcare settings remains beneficial if its use is structured and target oriented. Future studies should focus on comparing in-depth the difference between outpatient and inpatient settings in terms of the efforts required and the extent of the impacts from both clinicians' and cancer patients' perspectives.

Twenty-first Century Bedside Manner: Exploring Patient-Centered Communication in Secure Messaging with Cancer Patients

Patient-centered communication (PCC) is integral to providing high-quality health care and is recommended to be incorporated during face-to-face consultations. Electronic communication, such as the use of secure messaging (SM) within patient portals, is a popular form of patient-provider communication, but preliminary studies have shown that PCC is rarely utilized by providers in SM. As a consequence, the patient-provider relationship can be negatively affected, especially for cancer patients who have greater electronic health information needs than the general population. Therefore, our objective was to determine the importance of SM to cancer patients and to identify which attributes of PCC are preferred to be incorporated into secure messages. Five focus groups were conducted, comprised of patients with a current or previous cancer diagnosis (three all-female; two all-male). Participants recalled their own experiences and reviewed simulated messages. Three main topics emerged from the thematic analysis: (1) the normalization of SM, (2) SM quality can affect perceptions of care, and (3) patients need guidance. Overall, participants valued the ability to communicate with their care team using SM and indicated that electronic communication may have the potential to have just as big of an impact on a patient's care than in-person communication.

Predictors and patterns of portal use in patients with multiple chronic conditions

OBJECTIVE

To explore predictors of portal use by patients (registered portal users) with multiple chronic conditions according to demographic characteristics and use of specific features hypothesized to support self-management.

METHODS

Two data sources were used in this analysis: electronic health records and 12 months of data from web server log files. Patients (n = 500) included in the analysis were 45 years or older, registered portal users, and diagnosed with at least two chronic conditions. We fit a negative binomial regression model to predict portal use (number of logins) based on practice size and location, demographic characteristics, and use of specific portal features (secure messaging and patient-entered data).

RESULTS

Among patients with one or more logins, age, distance separating the patient from his or her primary care provider, and having a diagnosis of heart failure were significant predictors of portal use (p < .05). No significant differences in portal use were found according to gender, ethnicity, or practice size and location.

CONCLUSION

Considering the extraordinary investment on implementation and meaningful use of portal technology, low overall use and the large number of registered non-users is especially troubling. Regardless, our results demonstrate potential opportunities to leverage portal technology especially for patients living in rural and underserved areas to improve self-management of chronic illness.

Descriptive examination of secure messaging in a longitudinal cohort of diabetes patients in the ECLIPPSE study

The substantial expansion of secure messaging (SM) via the patient portal in the last decade suggests that it is becoming a standard of care, but few have examined SM use longitudinally. We examined SM patterns among a diverse cohort of patients with diabetes (N = 19 921) and the providers they exchanged messages with within a large, integrated health system over 10 years (2006-2015), linking patient demographics to SM use. We found a 10-fold increase in messaging volume. There were dramatic increases overall and for patient subgroups, with a majority of patients (including patients with lower income or with self-reported limited health literacy) messaging by 2015. Although more physicians than nurses and other providers messaged throughout the study, the distribution of health professions using SM changed over time. Given this rapid increase in SM, deeper understanding of optimizing the value of patient and provider engagement, while managing workflow and training challenges, is crucial.

Utilization of Secure Messaging to Primary Care Departments

INTRODUCTION

Secure messaging is a platform for email communication between patients and their physicians. Although patient-generated emails are associated with increased use of clinical services, greater member retention, and improved quality of care, secure messaging has a marked impact on primary care physicians' workload.

OBJECTIVE

To understand how the email topic and volume vary by demographics and clinical factors among members of a managed care organization.

METHODS

We analyzed all secure messages sent to primary care departments by adult members of Kaiser Permanente Southern California (KPSC) in 2017.

RESULTS

Members with a higher volume of office visits and telephone appointment visits generated a higher volume of emails to primary care physician. Members with a Centers of Medicare and Medicaid Services Hierarchical Condition Category diagnosis history sent 3 times as many emails as those without such a diagnosis history. Women accounted for nearly two-thirds of emails despite making up only half of the KPSC member population. Less than one-fourth (21.4%) of members sent 2.3 million total emails to their physician. Medical advice was the most common reason for sending secure messages (24.7%) in a sample studied (n = 2397).

DISCUSSION

These findings confirm the need for additional research to more accurately quantify the additional burden from secure message utilization on primary care physicians. Knowing the factors associated with secure messaging usage and message content could assist in building more efficient staffing models and creating more efficient routing that matches the message content with a physician's scope of practice.

Automating the Classification of Complexity of Medical Decision-Making in Patient-Provider Messaging in a Patient Portal

BACKGROUND

Patient portals are consumer health applications that allow patients to view their health information. Portals facilitate the interactions between patients and their caregivers by offering secure messaging. Patients communicate different needs through portal messages. Medical needs contain requests for delivery of care (e.g. reporting new symptoms). Automating the classification of medical decision complexity in portal messages has not been investigated.

MATERIALS AND METHODS

We trained two multiclass classifiers, multinomial Naïve Bayes and random forest on 500 message threads, to quantify and label the complexity of decision-making into four classes: no decision, straightforward, low, and moderate. We compared the performance of the models to using only the number of medical terms without training a machine learning model.

RESULTS

Our analysis demonstrated that machine learning models have better performance than the model that did not use machine learning. Moreover, machine learning models could quantify the complexity of decision-making that the messages contained with 0.59, 0.45, and 0.58 for macro, micro, and weighted precision and 0.63,0.41, and 0.63 for macro, micro, and weighted recall.

CONCLUSIONS

This study is one of the first to attempt to classify patient portal messages by whether they involve medical decision-making and the complexity of that decision-making. Machine learning classifiers trained on message content resulted in better message thread classification than classifiers that employed medical terms in the messages alone.

Associations Between Patient Health Outcomes and Secure Message Content Exchanged Between Patients and Clinicians: Retrospective Cohort Study

Background

The number of electronic messages securely exchanged between clinic staff and patients has risen dramatically over the last decade. A variety of studies explored whether the volume of messages sent by patients was associated with outcomes. None of these studies, however, examined whether message content itself was associated with outcomes. Because secure messaging is a significant form of communication between patients and clinic staff, it is critical to evaluate the context of the communication to best understand its impact on patient health outcomes.

Objective

To examine associations between patients’ and clinicians’ message content and changes in patients’ health outcomes.

Methods

We applied a taxonomy developed specifically for secure messages to 14,394 patient- and clinic staff–generated messages derived from patient-initiated message threads. Our study population included 1602 patients, 50.94% (n=816) of whom initiated message threads. We conducted linear regression analyses to determine whether message codes were associated with changes in glycemic (A1C) levels in patients with diabetes and changes in systolic (SBP) and diastolic (DBP) blood pressure in patients with hypertension.

Results

Patients who initiated threads had larger declines in A1Cs (P=.01) compared to patients who did not initiate threads. Clinic nonresponse was associated with decreased SBP (β=–.30; 95% CI –0.56 to –0.04), as were staffs’ action responses (β=–30; 95% CI –0.58 to –0.02). Increased DBP, SBP, and A1C levels were associated with patient-generated appreciation and praise messages and staff encouragement with effect sizes ranging from 0.51 (A1C) to 5.80 (SBP). We found improvements in SBP associated with patients’ complaints (β=–4.03; 95% CI –7.94 to –0.12). Deferred information sharing by clinic staff was associated with increased SBP (β=1.29; 95% CI 0.4 to 2.19).

Conclusions

This is the first research to find associations between message content and patients’ health outcomes. Our findings indicate mixed associations between patient message content and patient outcomes. Further research is needed to understand the implications of this work; in the meantime, health care providers should be aware that their message content may influence patient health outcomes.

A Retrospective Analysis of Provider-to-Patient Secure Messages: How Much Are They Increasing, Who Is Doing the Work, and Is the Work Happening After Hours?

BACKGROUND

Patient portal registration and the use of secure messaging are increasing. However, little is known about how the work of responding to and initiating patient messages is distributed among care team members and how these messages may affect work after hours.

OBJECTIVE

This study aimed to examine the growth of secure messages and determine how the work of provider responses to patient-initiated secure messages and provider-initiated secure messages is distributed across care teams and across work and after-work hours.

METHODS

We collected secure messages sent from providers from January 1, 2013, to March 15, 2018, at Mayo Clinic, Rochester, Minnesota, both in response to patient secure messages and provider-initiated secure messages. We examined counts of messages over time, how the work of responding to messages and initiating messages was distributed among health care workers, messages sent per provider, messages per unique patient, and when the work was completed (proportion of messages sent after standard work hours).

RESULTS

Portal registration for patients having clinic visits increased from 33% to 62%, and increasingly more patients and providers were engaged in messaging. Provider message responses to individual patients increased significantly in both primary care and specialty practices. Message responses per specialty physician provider increased from 15 responses per provider per year to 53 responses per provider per year from 2013 to 2018, resulting in a 253% increase. Primary care physician message responses increased from 153 per provider per year to 322 from 2013 to 2018, resulting in a 110% increase. Physicians, nurse practitioners, physician assistants, and registered nurses, all contributed to the substantial increases in the number of messages sent.

CONCLUSIONS

Provider-sent secure messages at a large health care institution have increased substantially since implementation of secure messaging between patients and providers. The effort of responding to and initiating messages to patients was distributed across multiple provider categories. The percentage of message responses occurring after hours showed little substantial change over time compared with the overall increase in message volume.

Uptake and patient and provider communication modality preferences of virtual visits in primary care: a retrospective cohort study in Canada

OBJECTIVES

To evaluate the uptake of a platform for virtual visits in primary care, examine patient and physician preferences for virtual communication methods and report on characteristics of visits and patients experience of care.

DESIGN

A retrospective cohort study.

SETTING

Primary care practices within five regions in Ontario, Canada after 18 months of access to virtual care services.

PARTICIPANTS

326 primary care providers and 14 291 registered patients.

INTERVENTIONS

Providers used a platform that allowed them to connect with their patients through synchronous (audio/video) and/or asynchronous (secure messaging) communication.

MAIN OUTCOME MEASURES

User-level data from the platforms including patient demographics, practice characteristics, communication modality used, visit characteristics and patients' satisfaction.

RESULTS

Among the participants, 44% of registered patients and 60% of registered providers used the platform at least once. Among patient users, 51% completed at least one virtual visit. The majority of virtual visits (94%) involved secure messaging. The most common patient requests were for medication prescriptions (24%) and follow-up from previous appointment (22%). The most common provider request was to follow-up on test results (59%). Providers indicated that 81% of virtual visits required no follow-up for that issue and 99% of patients reported that they would use virtual care services again.

CONCLUSIONS

While there are a growing number of primary care video visit services, our study found that both patients and providers in rostered practices prefer secure messaging over video. Despite fears that virtual visits would be overused by patients, when patients connected with their own primary care provider, many virtual visits appeared to replace in-person visits, and patients did not overwhelm physicians with requests. This approach may improve access and continuity in primary care.

Analysis of Employee Patient Portal Use and Electronic Health Record Access at an Academic Medical Center

BACKGROUND

Patient portals provide patients and their caregivers online access to limited health results. Health care employees with electronic health record (EHR) access may be able to view their health information not available in the patient portal by looking in the EHR.

OBJECTIVE

In this study, we examine how employees use the patient portal when they also have access to the tethered EHR.

METHODS

We obtained patient portal and EHR usage logs corresponding to all employees who viewed their health data at our institution between January 1, 2013 and November 1, 2017. We formed three cohorts based on the systems that employees used to view their health data: employees who used the patient portal only, employees who viewed health data in the EHR only, and employees who used both systems. We compared system accesses and usage patterns for each employee cohort.

RESULTS

During the study period, 35,172 employees accessed the EHR as part of patients' treatment and 28,631 employees accessed their health data: 25,193 of them used the patient portal and 13,318 accessed their clinical data in EHR. All employees who accessed their records in the EHR viewed their clinical notes at least once. Among EHR accesses, clinical note accesses comprised more than 42% of all EHR accesses. Provider messaging and appointment scheduling were the most commonly used functions in the patient portal. Employees who had access to their health data in both systems were more likely to engage with providers through portal messages.

CONCLUSION

Employees at a large medical center accessed clinical notes in the EHR to obtain information about their health. Employees also viewed other health data not readily available in the patient portal.

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

PURPOSE

The aim of the study was to incorporate the perspectives of both patients and providers into the development of training to improve the exchange of secure messages through a patient portal as well as to identify management strategies that support patient engagement.

METHODOLOGY

Three patient focus groups (17 patients) and interviews with 21 ambulatory physicians across 17 outpatient clinics at a large Midwestern academic medical center using Epic MyChart were performed. Rigorous thematic analysis was guided by the Systems Engineering Initiative for Patient Safety 2.0 framework adapted to patient portal implementation.

RESULTS

Patients and physicians identified strategies at the patient, portal, physician, and health system levels that could help each group navigate the portal to communicate via secure messages more efficiently. Patient-focused training strategies included multimodal materials addressing how to navigate portal features and direction on when, what, and how to message. Changes to the format of the messaging feature and pop-ups with communication tips were also frequently mentioned. Physician and clinic-level strategies focused on how the clinic and health system management could enhance physician training on the patient-facing portal features and on how to manage patient care within the portal. Physicians also requested that the health system administration standardize physician and care team work processes related to secure messages within the portal and communicate clear management expectations of physician portal management.

CONCLUSION

As communication via secure messaging has become more common, our study identified patient, physician, portal and health system-level management and training strategies to enhance patient portal use.

PRACTICE IMPLICATIONS

Health system administrators and outpatient clinic management could implement these strategies to clarify the rules of engagement in the collaborative work of incorporating a patient portal into the primary care workflow and facilitating provider and patient use.

Disparities in Secure Messaging Uptake Between Patients and Physicians: Longitudinal Analysis of Two National Cross-Sectional Surveys

Background

Emails securely exchanged between patients and clinicians offer the promise of improved access to care and indirectly improved health outcomes. Yet research to date is mixed on who—among both patients and clinicians—is using secure messaging.

Objective

Using data from two large nationally representative cross-sectional surveys, this study aimed to compare the prevalence of secure messaging use among patients and their access to the functionality through their physicians, and to explore the clinical practice and physician characteristics and patient sociodemographic characteristics associated with the use of secure messaging.

Methods

We conducted regression analyses to identity statistical associations between self-reported secure messaging use and access, and the patient, practice, and physician characteristics from the National Health Interview Survey (NHIS) and the National Ambulatory Medical Care Survey (NAMCS). The NHIS data collected between 2013 and 2018, with approximately 150,000 adult individuals, were used to evaluate patient characteristics associated with email communication with clinicians. The NAMCS data included 7340 physicians who reported on secure messaging use between 2013 and 2016 and provided context on physician specialty, use of certified health information technology (IT), and practice size and ownership associated with secure messaging access and use.

Results

By 2016, two-thirds of ambulatory care visits were conducted by a physician who reported using secure messaging, up from 40.70% in 2013. The percentage of US residents who reported sending an email to their clinician, however, only increased from 7.22% to 16.67% between 2013 and 2018. We observed a strong positive association between certified health IT use and secure messaging use (odds ratio [OR] 11.46, 95% CI 7.55-17.39). Individuals who were black, had lower levels of education, had Medicaid or other public payer insurance, or those who were uninsured had reduced odds for using email to communicate with clinicians. No differences were observed in secure messaging use based on physician specialty, but significant differences were observed by practice size (OR 0.46, 95% CI 0.35-0.60 in solo practices vs nonsolo practices) and practice ownership (P<.001 for the different categories).

Conclusions

This study is the first to use two large nationally representative surveys to produce longitudinal estimates on the access and use of patient-clinician email communication in the United States. The survey findings complement each other: one provides the patient perspective of their use and the other indicates potential patient access to secure messaging based on the use of the functionality by the physicians providing treatment. This study provides nationally representative data on the characteristics of patients and physicians who have access to and are using secure messaging. This information can be used to target interventions to promote adoption and use of secure messaging.

Interprofessional Collaboration in the Assessment and Management of Substance Use Risk

Substance use disorder assessment strategies are increasingly being employed by dentistry, while adequate evaluation requires reaching out to other cotreating providers and collaborating on patient care. The field of dentistry has a range of barriers often not experienced in other professions, including limitations on e-record communication and clinical practice setting often isolated from the patient's general medical care. Barriers can be overcome if the dentist facilitates communication.

Look Who's Talking: Application of a Theory-Based Taxonomy to Patient-Clinician E-mail Messages

Background: Patient-clinician communication between office visits may improve patient outcomes by increasing patients' information retention and offering opportunities for patient-centered communication. Secure electronic messaging offers one such communication modality, but evidence of associations between its use and patient outcomes is mixed. To date, no study has examined the relationship between message content and patient outcomes. Introduction: Secure message content provides context around patients' requests and whether clinicians responded in ways that improve care and outcomes. This study evaluates the use of a theory-based taxonomy to classify patients' and clinicians' message content and describes characteristics associated with coded content. Methods: We coded message threads initiated in 2017 by 73 randomly selected patients with hypertension and/or diabetes. Multiple codes could be applied to each message. Chi-square analyses identified differences by patients' demographics and health condition. Results: We analyzed 658 message threads composed of 1,751 clinician- and patient-generated messages, to which 2,055 taxonomic codes were assigned. Eighteen percent of patients' threads were unanswered. Most codes assigned to patient-generated messages were task-oriented (46%) or information seeking (26%) requests; 30% of clinician responses left those requests unfulfilled or unaddressed. Clinicians were more likely to recommend a patient be seen in the office based on patients' sex, age, and health condition. Furthermore, white patients were more likely to send, and receive from their clinicians, messages with praise and appreciation content compared with black patients. Conclusion: Further research is needed to better understand how and why these differences exist so that patient-clinician electronic messaging is optimized to improve patient outcomes.

Parents' Use of Technologies for Health Management: A Health Literacy Perspective

OBJECTIVE

Parent use of technology to manage child health issues has the potential to improve access and health outcomes. Few studies have examined how parent health literacy affects usage of Internet and cell phone technologies for health management.

METHODS

Cross-sectional analysis of data collected as part of a randomized controlled experiment in 3 urban pediatric clinics. English- and Spanish-speaking parents (n = 858) of children ≤8 years answered questions regarding use of and preferences related to Internet and cell phone technologies. Parent health literacy was measured using the Newest Vital Sign.

RESULTS

The majority of parents were high Internet (70.2%) and cell phone (85.1%) users (multiple times a day). A total of 75.1% had limited health literacy (32.1% low, 43.0% marginal). Parents with higher health literacy levels had greater Internet and cell phone use (adequate vs low: adjusted odds ratio [AOR], 1.7 [confidence interval, 1.2-2.5]) and were more likely to use them for health management (AOR, 1.5 [confidence interval, 1.2-1.8]); those with higher health literacy levels were more likely to use the Internet for provider communication (adequate vs marginal vs low: 25.0% vs 18.0% vs 12.0%, P = .001) and health-related cell phone apps (40.6% vs 29.7% vs 16.4%, P < .001). Overall preference for using technology for provider communication was high (∼70%) and did not differ by health literacy, although Internet and cell phone apps were preferred by higher literacy parents; no differences were seen for texting.

CONCLUSIONS

Health literacy-associated disparities in parent use of Internet and cell phone technologies exist, but parents' desire for use of these technologies for provider communication was overall high and did not differ by health literacy.

Characterizing the impact of health literacy, computer ability, patient demographics, and portal usage on patient satisfaction with a patient portal

OBJECTIVE

We sought to measure patient portal satisfaction with patient portals and characterize its relationship to attitude towards computers, health literacy, portal usage, and patient demographics.

MATERIALS AND METHODS

We invited 13 040 patients from an academic medical center to complete a survey measuring satisfaction, perceived control over computers, and health literacy using validated instruments (End User Computing Satisfaction, Computer Attitude Measure, and Brief Health Literacy Screen). We extracted portal usage and demographic information from the medical center data warehouse.

RESULTS

A total of 6026 (46.2%) patients completed the survey. The median (IQR) scores for satisfaction, computer control, and health literacy were 87% (20%), 86% (22%), and 95% (15%), respectively. The normalized mean (SD) usage of messaging, lab, appointment, medication, and immunization functions were 6.6 (2.6), 4.6 (2.4), 3.1 (1.7), 1.5 (1.2), and 0.88 (0.91) times, respectively. Logistic regression yielded significant odds ratios [99% CI] for computer control (3.6 [2.5-5.2]), health literacy (12 [6.9-23]), and immunization function usage (0.84 [0.73-0.96]).

DISCUSSION

Respondents were highly satisfied and had high degrees of computer control and health literacy. Statistical analysis revealed that higher computer control and health literacy predicted higher satisfaction, whereas usage of the immunization function predicted lower satisfaction. Overall, the analytical model had low predictive capability, suggesting that we failed to capture the main drivers of satisfaction, or there was inadequate variation in satisfaction to delineate its contributing factors.

CONCLUSION

This study provides insight into patient satisfaction with and usage of a patient portal. These data can guide the development of the patient portal, with the ultimate goal of increasing functionality and usability to enhance the patient experience.

Policies and procedures governing patient portal use at an Academic Medical Center

BACKGROUND AND OBJECTIVE

Patient portal use has increased over the last two decades in response to consumer demand and government regulation. Despite growing adoption, few guidelines exist to direct successful implementation and governance. We describe the policies and procedures that have governed over a decade of continuous My Health at Vanderbilt (MHAV) patient portal use.

METHODS

We examined MHAV usage data between May 2007 and November 2017. We classified patient portal activity into eight functional categories: Appointment, Billing, Document Access, Genetics, Health Result, Immunization, Medication, and Messaging. We describe our operating policies and measure portal uptake, patient account activity, and function use over time.

RESULTS

By the end of the study period, there were 375 517 registered accounts. Policies made MHAV available to competent adults and adolescents 13 and over. Patients signed up for a limited access account online, which could be upgraded to a full-access account after identity verification. Patients could assign proxy accounts to family and caregivers, which permitted nonpatient access to select MHAV functions. Laboratory and radiology results were accessible via MHAV. Results were classified into three groups based on sensitivity, which govern the length of delay before results appeared in MHAV.

DISCUSSION AND CONCLUSION

Patient portals offer significant opportunity to engage patients in their healthcare. However, there remains a need to understand how policies can promote uptake and use. We anticipate that other institutions can apply concepts from our policies to support meaningful patient portal engagement.

Communication Preferences and Satisfaction of Secure Messaging Among Patients and Providers in the Military Healthcare System

Introduction

Use of electronic secure messaging (SM) is rapidly growing in various healthcare settings. However, there is a large number of patients that choose not use SM or use it minimally. Thus, understanding preferences for patient-provider communication modalities is critically important, particularly among military healthcare beneficiaries. The purpose of this study was to assess preferences for patient-provider communication modalities (in person, telephone, SM, or mail) among a sample of patients, providers, and staff located at five Air Force military treatment facilities across the USA.

Methods

We recruited patients, providers, and staff, from five family health clinics to complete a short survey. We measured participants' preferences for communication modality for various healthcare concerns, such as responses to non-urgent medical questions, test results, and medication renewal information. We also measured satisfaction with MiCare, the Air Force's SM system. We conducted chi-square analyses and Fisher's exact tests to assess differences in communication preferences by patients, providers, and staff and we computed frequencies in satisfaction responses.

Results

We found that while providers and staff (N = 70) prefer to communicate with patients about various healthcare concerns online through MiCare, patients (N = 1,260) prefer to communicate in-person or through the telephone. Patients were generally satisfied with MiCare; however, there was a large proportion of patients who were undecided about MiCare's impact on the quality of care they received (40.3%). Additionally, although the majority of providers and staff believed MiCare improved their efficiency (58.0%) and communication with patients (72.3%), 65.7% of providers and staff believed MiCare had increased their workload.

Conclusion

MiCare is a promising tool to improve patient-provider communication. However, future studies are needed to better understand why patients within the military healthcare system prefer communication modalities other than MiCare and to identify strategies to decrease provider and staff workloads while using MiCare.

Text Messaging and Type 1 Diabetes Management: Qualitative Study Exploring Interactions Among Patients and Health Care Professionals

BACKGROUND

The diffusion of information and communication technologies (ICTs) in type 1 diabetes (T1D) management has generated a debate on the ways in which ICTs can support the patient-provider relationship. Several studies have focused on text messages. Most of the literature proposes quantitative analysis of the impact of text messaging on the clinical conditions of patients and/or their satisfaction with the technology, while the qualitative studies have focused mainly on patients' perceptions about strengths and weaknesses of this technology.

OBJECTIVE

In contrast to past studies, we adopted a qualitative approach for the in-depth examination of patient-health care professionals' interactions in text messaging.

METHODS

The study focused on the use of the Trento Cartella Clinica del Cittadino Diabetes System (TreC-DS), a digital platform with a built-in messaging system, in two diabetes centers, integrating message analysis with interviews with patients and health care professionals. Each center focused on a specific patient profile: the first one focused on pregnant women with T1D and the second one focused on adult patients with poorly controlled diabetes.

RESULTS

The main results of the study were as follows: (1) Health care professionals and patients perceived the messaging system as useful for sharing information (ie, pregnant women for prescriptions and adults with poorly controlled diabetes for advice); (2) The content and communication styles of the two centers differed: in the case of pregnant women, interactions via text messaging were markedly prescriptive, while in the case of adult patients with poorly controlled diabetes, they were conceived as open dialogues; and (3) Conversations were initiated mainly by professionals; in the cases considered, it was mainly the diabetes center that decided whether a messaging conversation was needed.

CONCLUSIONS

The results show how the features of interactions of text messaging changed based on the patient profiles in two different centers. In addition, in both diabetes centers that were involved, the system seems to have laid a foundation for a closer relationship between patients and health care professionals.

Secure Messaging Through PositiveLinks: Examination of Electronic Communication in a Clinic-Affiliated Smartphone App for Patients Living with HIV

Purpose: Secure messaging between patients and their health care team can facilitate chronic care management. PositiveLinks^® (PL) is a clinic-affiliated smartphone application designed for patients living with HIV that includes a secure messaging feature for patients, PL staff, and clinic providers to communicate. Our aim was to examine the content and function of messaging within PL.

Methodology: We examined messages exchanged through PL from November 2017 through January 2018. Qualitative analysis included categorization of topics as: related to the app, medical care, or social needs. Messaging functions were categorized as information exchange or rapport building.

Results: Of the 1,474 PL messages analyzed, 44% were sent by PL staff, 38% by patients, and 18% by providers, whereas 61% were received by patients, 22% by providers, and 17% by PL staff. Message topics included app-related (57.6%), medical care (34.3%), and social concerns (12.4%). App-related messages addressed technical difficulties, software updates, or coordinating phone payments. Medical messages included medical information, medications, appointments, outreach, and care coordination for physical and mental health. Social messages related to insurance, transportation, housing, food, utilities, disability, finances, and work absences. Message function coding showed that 87.3% of messages contained information exchange and 33.8% contained rapport building. Messages sent by providers were most likely to contain rapport building at 54.8%.

Conclusion: PL messaging was used to handle medical and social needs with potential impact on patients' health and offers an opportunity to strengthen patient–provider relationships through responsiveness and rapport building. Secure messaging through a clinic-affiliated smartphone app could enhance patient-centered care between clinical visits.

Detecting Hypoglycemia Incidents Reported in Patients' Secure Messages: Using Cost-Sensitive Learning and Oversampling to Reduce Data Imbalance

BACKGROUND

Improper dosing of medications such as insulin can cause hypoglycemic episodes, which may lead to severe morbidity or even death. Although secure messaging was designed for exchanging nonurgent messages, patients sometimes report hypoglycemia events through secure messaging. Detecting these patient-reported adverse events may help alert clinical teams and enable early corrective actions to improve patient safety.

OBJECTIVE

We aimed to develop a natural language processing system, called HypoDetect (Hypoglycemia Detector), to automatically identify hypoglycemia incidents reported in patients' secure messages.

METHODS

An expert in public health annotated 3000 secure message threads between patients with diabetes and US Department of Veterans Affairs clinical teams as containing patient-reported hypoglycemia incidents or not. A physician independently annotated 100 threads randomly selected from this dataset to determine interannotator agreement. We used this dataset to develop and evaluate HypoDetect. HypoDetect incorporates 3 machine learning algorithms widely used for text classification: linear support vector machines, random forest, and logistic regression. We explored different learning features, including new knowledge-driven features. Because only 114 (3.80%) messages were annotated as positive, we investigated cost-sensitive learning and oversampling methods to mitigate the challenge of imbalanced data.

RESULTS

The interannotator agreement was Cohen kappa=.976. Using cross-validation, logistic regression with cost-sensitive learning achieved the best performance (area under the receiver operating characteristic curve=0.954, sensitivity=0.693, specificity 0.974, F1 score=0.590). Cost-sensitive learning and the ensembled synthetic minority oversampling technique improved the sensitivity of the baseline systems substantially (by 0.123 to 0.728 absolute gains). Our results show that a variety of features contributed to the best performance of HypoDetect.

CONCLUSIONS

Despite the challenge of data imbalance, HypoDetect achieved promising results for the task of detecting hypoglycemia incidents from secure messages. The system has a great potential to facilitate early detection and treatment of hypoglycemia.

Determinants of mobile technology use and smartphone application interest in cancer patients

BACKGROUND

Supportive care is a critical component of the treatment of cancer patients that is underutilized; patient lack of information about these services is an important barrier. Mobile technologies may be useful tools for delivering information, but cancer patient use of and interest in using them to learn about supportive care services have not been described. This study evaluates factors associated with cancer patient use of mobile technologies and interest in smartphone applications for information delivery about supportive care.

METHODS

We conducted a cross-sectional survey among cancer patients from one urban academic hospital and 11 community hospitals. Patients self-reported use of mobile technologies and interest in smartphone applications. Multivariate logistic analysis was used to identify determinants of mobile technology use and smartphone interest.

RESULTS

Among 631 participants, 466 (74%) reported regular use of mobile devices and 242 (39%) expressed an interest in supportive care information via smartphone applications. Patients under 45 were more likely to use a mobile device (Adjusted Odds Ratio [AOR] 6.8, 2.8-16.9 95% CI, P < 0.001) and were interested in smartphone applications for delivery of information (AOR 3.2, 1.8-5.9 95% CI, P < 0.001). Non-white patients had similar use of mobile technology compared to whites but reported greater interest in smartphone application-based information (AOR 3.4, 2.1-5.5 95% CI, P < 0.001).

CONCLUSION

Many patients expressed interest in smartphone application-based information about supportive care services, especially those who are younger and non-white. Future studies should investigate the characteristics of patients and smartphones applications that will optimize information delivery through a mobile technology platform.

On the effect of electronic patient portal on primary care utilization and appointment adherence

BACKGROUND

The objective of this study was to investigate the impact of patient portal adoption on patients' primary care utilization and appointment adherence.

METHODS

We conducted a retrospective observational study using a panel difference-in-differences (DID) framework to investigate the use of primary care services by patients, adjusting for their disease burden and allowing for time-dependent portal effect. A large dataset with 46,544 patients of University of Florida (UF) Health during the study period July 2013 - June 2016 was used. The main outcome measures are disease burden adjusted rates of office visits arrived, no-show, and cancellation to primary care physicians (PCPs) per quarter between patient portal adopters (denoted as users) and non-users.

RESULTS

At the time of adoption, the quarterly PCP office visit rate ratio (RR) of patient portal users to non-users was 1.33 (95% CI, 1.27-1.39; p < 0.001). The RRs were between 0.94 to 0.99 up to four quarters after portal adoption (p = 0.749, 0.100, 0.131, and 0.091, respectively), and were significantly less than one at the seventh (RR =0.82; 95% CI, 0.73-0.91; p < 0.001) and the eighth (RR = 0.80; 95% CI, 0.70-0.90; p < 0.001) quarters post adoption. The quarterly no-show rates of the users were significantly smaller (RRs were between 0.60 and 0.83) except for the seventh, eighth and tenth quarters post adoption. In these three quarters, the no-show rates were not significantly changed (p = 0.645, 0.295, and 0.436, respectively). Quarterly cancellation rates were not significantly affected by portal adoption (p > 0.05 for all cases).

CONCLUSIONS

Patient portal users' disease burden adjusted PCP office visit rate was significantly reduced in one and a half year and thereafter post portal adoption. PCP appointment no-show rate was also significantly reduced and cancellation rate was not affected, implying improved care engagement of patients.

Care Delivered by Pediatric Surgical Specialties Through Patient Portal Messaging

BACKGROUND

Patient portals are online applications that typically allow users to interact with providers using secure messaging. Portal messaging use and content have not been studied in pediatric surgical specialties.

MATERIALS AND METHODS

We obtained all message threads initiated by pediatric patients/caregivers and sent to pediatric surgical providers through the Vanderbilt University Medical Center patient portal from June 1, 2014 to December 31, 2014. We collected patient demographics and providers' surgical specialties. We determined the number of message threads and individual messages sent by patients/caregivers and providers by specialty. Message content was analyzed by semantic types using a validated consumer health taxonomy.

RESULTS

Most threads were about male (176, 60.3%), white (239, 81.8%), non-Hispanic (278, 95.2%) patients with a median age of 6 y (range: 0-21 y). A total of 292 message threads containing 1679 individual messages were sent with mean 5.8 (standard deviation [SD] 5.0) messages per thread. Messages were sent more frequently regarding younger patients (P = 0.001). Physicians directly contributed to 161 (55%) message threads. Otolaryngology received the most threads (123, 42.1%) and messages (790, 47.1%). Specialties exchanging the most messages per thread were cardiac surgery (mean 7.0, SD 11.7), and dermatology (7.0, SD 6.9). Most message threads (273, 93.5%) involved delivery of medical care with 123 (42.1%) involving appointments/scheduling; 99 (33.9%) medical problems; 81 (27.7%) treatments; 68 (23.3%) testing; and 29 (9.9%) referrals.

CONCLUSIONS

Pediatric surgeons deliver substantial care within portal messages exchanged with pediatric patients and caregivers. Institutions adopting portals should consider effects on provider workload and potential disparities in access to care.

Examining the Complexity of Patient-Outpatient Care Team Secure Message Communication: Qualitative Analysis

BACKGROUND

The value of secure messaging in streamlining routine patient care activities is generally agreed upon. However, the differences in how patients use secure messaging, including for communicating both routine and nonroutine issues, and the implications of these differences in use are less well understood.

OBJECTIVE

The purpose of this study was to examine secure messaging use to extend current knowledge of how this tool is being used in outpatient care settings and generate new research questions to improve our understanding of the role of secure messaging in the patient-provider communication toolbox.

METHODS

We conducted an in-depth qualitative analysis of secure message threads in 12 US Department of Veterans Affairs outpatient clinics in south Texas. We analyzed 70 secure message threads with a total of 179 unique communications between patients and their outpatient teams for patterns in communication and secure message content. We used theories from information systems and complexity science in organizations to explain our observations.

RESULTS

Analysis identified content relating to 3 main themes: (1) information management, (2) uncertainty management, and (3) patient safety and engagement risks and opportunities. Within these themes, we identified 2 subcategories of information management (information exchange and problem solving), 2 subcategories of uncertainty management (relationship building and sensemaking), and 3 subcategories of patient safety and engagement risks and opportunities (unresolved issues, tone mismatch, and urgent medical issues). Secure messages were most often used to communicate routine issues (eg, information exchange and problem solving). However, the presence of subcategories pertaining to nonroutine issues (eg, relationship building, sensemaking, tone mismatch, urgent issues, and unresolved issues) requires attention, particularly for improving opportunities in outpatient care settings using secure messaging.

CONCLUSIONS

Patients use secure messaging for both routine and nonroutine purposes. Our analysis sheds light on potentially new patient safety concerns, particularly when using secure messaging to address some of the more complex issues patients are communicating with providers. Secure messaging is an asynchronous communication information system operated by patients and providers who are often characterized as having significant differences in knowledge, experience and expectations. As such, justification for its use beyond routine purposes is limited-yet this occurs, presenting a multifaceted dilemma for health care organizations. Secure messaging use in outpatient care settings may be more nuanced, and thus more challenging to understand and manage than previously recognized. New information system designs that acknowledge the use of secure messaging for nonroutine and complex health topics are needed.

Usability Assessment of Secure Messaging for Clinical Document Sharing between Health Care Providers and Patients

BACKGROUND

Web-based patient portals feature secure messaging systems that enable health care providers and patients to communicate information. However, little is known about the usability of these systems for clinical document sharing.

OBJECTIVE

This article evaluates the usability of a secure messaging system for providers and patients in terms of its ability to support sharing of electronic clinical documents.

METHODS

We conducted usability testing with providers and patients in a human-computer interaction laboratory at a Midwestern U.S. hospital. Providers sent a medication list document to a fictitious patient via secure messaging. Separately, patients retrieved the clinical document from a secure message and returned it to a fictitious provider. We collected use errors, task completion, task time, and satisfaction.

RESULTS

Twenty-nine individuals participated: 19 providers (6 physicians, 6 registered nurses, and 7 pharmacists) and 10 patients. Among providers, 11 (58%) attached and sent the clinical document via secure messaging without requiring assistance, in a median (range) of 4.5 (1.8-12.7) minutes. No patients completed tasks without moderator assistance. Patients accessed the secure messaging system within 3.6 (1.2-15.0) minutes; retrieved the clinical document within 0.8 (0.5-5.7) minutes; and sent the attached clinical document in 6.3 (1.5-18.1) minutes. Although median satisfaction ratings were high, with 5.8 for providers and 6.0 for patients (scale, 0-7), we identified 36 different use errors. Physicians and pharmacists requested additional features to support care coordination via health information technology, while nurses requested features to support efficiency for their tasks.

CONCLUSION

This study examined the usability of clinical document sharing, a key feature of many secure messaging systems. Our results highlight similarities and differences between provider and patient end-user groups, which can inform secure messaging design to improve learnability and efficiency. The observations suggest recommendations for improving the technical aspects of secure messaging for clinical document sharing.

The Perceived Ease of Use and Usefulness of Loop: Evaluation and Content Analysis of a Web-Based Clinical Collaboration System

BACKGROUND

Patients with complex health care needs require the expertise of many health care providers. Communication, collaboration, and patient-centered care positively impact care quality and patient outcomes. Few technologies exist that facilitate collaboration between providers across settings of care and also engage the patient. We developed a Web-based clinical collaboration system, Loop, to address this gap. The likelihood of a technological system's uptake is associated with its perceived ease of use and perceived usefulness. We engaged stakeholders in the conceptualization and development of Loop in an effort to maximize its intuitiveness and utility.

OBJECTIVE

This study aimed to report end users' perceptions about the ease of use and usefulness of Loop captured during usability tests of Loop.

METHODS

Participants represented three user types (patients, caregivers, and health care providers) recruited from three populations (adults with cancer, adolescents and young adults with cancer, and children with medical complexity). We conducted usability testing over three iterative cycles of testing and development in both laboratory-based and off-site environments. We performed a content analysis of usability testing transcripts to summarize and describe participant perceptions about the ease of use and usefulness of Loop.

RESULTS

Participants enjoyed testing Loop and were able to use the core functions-composing, posting, and reading messages-with little difficulty. They had difficulty interpreting certain visual cues and design elements or the purpose of some features. This difficulty negatively impacted perceived ease of use but was primarily limited to auxiliary features. Participants predicted that Loop could improve the efficiency and effectiveness of communication between care team members; however, this perceived usefulness could be compromised by disruptions to personal workflow such as additional time or task requirements.

CONCLUSIONS

Loop was perceived to have value as a collaboration system; however, usability testing findings indicate that some design and functional elements need to be addressed to improve ease of use. Additionally, participant concerns highlight the need to consider how a system can be implemented so as to minimize impact on workflow and optimize usefulness.