Shared Access to Patient Portals and Digital Health Equity (Preprint)

Characteristics of Patients Using Different Patient Portal Functions and the Impact on Primary Care Service Utilization and Appointment Adherence: Retrospective Observational Study

Journal of Medical Internet Research ◽

10.2196/14410 ◽

2020 ◽

Vol 22 (2) ◽

pp. e14410 ◽

Cited By ~ 6

Author(s):

Xiang Zhong ◽

Jaeyoung Park ◽

Muxuan Liang ◽

Fangyun Shi ◽

Pamela R Budd ◽

...

Keyword(s):

Primary Care ◽

Service Utilization ◽

Care Delivery ◽

Care Service ◽

Primary Care Service ◽

Patient Portal ◽

Patient Portals ◽

Appointment Adherence ◽

Primary Care Patients ◽

The Impact

Background Patient portals are now widely available and increasingly adopted by patients and providers. Despite the growing research interest in patient portal adoption, there is a lack of follow-up studies describing the following: whether patients use portals actively; how frequently they use distinct portal functions; and, consequently, what the effects of using them are, the understanding of which is paramount to maximizing the potential of patient portals to enhance care delivery. Objective To investigate the characteristics of primary care patients using different patient portal functions and the impact of various portal usage behaviors on patients’ primary care service utilization and appointment adherence. Methods A retrospective, observational study using a large dataset of 46,544 primary care patients from University of Florida Health was conducted. Patient portal users were defined as patients who adopted a portal, and adoption was defined as the status that a portal account was opened and kept activated during the study period. Then, users were further classified into different user subgroups based on their portal usage of messaging, laboratory, appointment, and medication functions. The intervention outcomes were the rates of primary care office visits categorized as arrived, telephone encounters, cancellations, and no-shows per quarter as the measures of primary care service utilization and appointment adherence. Generalized linear models with a panel difference-in-differences study design were then developed to estimate the rate ratios between the users and the matched nonusers of the four measurements with an observational window of up to 10 quarters after portal adoption. Results Interestingly, a high propensity to adopt patient portals does not necessarily imply more frequent use of portals. In particular, the number of active health problems one had was significantly negatively associated with portal adoption (odds ratios [ORs] 0.57-0.86, 95% CIs 0.51-0.94, all P<.001) but was positively associated with portal usage (ORs 1.37-1.76, 95% CIs 1.11-2.22, all P≤.01). The same was true for being enrolled in Medicare for portal adoption (OR 0.47, 95% CI 0.41-0.54, P<.001) and message usage (OR 1.44, 95% CI 1.03-2.03, P=.04). On the impact of portal usage, the effects were time-dependent and specific to the user subgroup. The most salient change was the improvement in appointment adherence, and patients who used messaging and laboratory functions more often exhibited a larger reduction in no-shows compared to other user subgroups. Conclusions Patients differ in their portal adoption and usage behaviors, and the portal usage effects are heterogeneous and dynamic. However, there exists a lack of match in the patient portal market where patients who benefit the most from patient portals are not active portal adopters. Our findings suggest that health care delivery planners and administrators should remove the barriers of adoption for the portal beneficiaries; in addition, they should incorporate the impact of portal usage into care coordination and workflow design, ultimately aligning patients’ and providers’ needs and functionalities to effectively deliver patient-centric care.

Novel use of existing technology: A preliminary study of patient portal use for telerehabilitation

Journal of Telemedicine and Telecare ◽

10.1177/1357633x20950172 ◽

2020 ◽

pp. 1357633X2095017

Author(s):

Susan S Conroy ◽

Stacey Harcum ◽

Linda Keldsen ◽

Christopher T Bever

Keyword(s):

Care Delivery ◽

Health Service Delivery ◽

Patient Portal ◽

Significant Other ◽

Patient Portals ◽

Secure Messaging ◽

Exercise Time ◽

Stroke Population ◽

Therapist Communication ◽

Randomised Controlled

Patient portals (PPs) foster engagement and self-management of chronic disease and are emerging as extensions of the care continuum. Utilisation from a health service delivery perspective is growing; however, it is a relatively new model of care in the field of rehabilitation. This pilot, within a larger randomised controlled stroke rehabilitation trial, explored the feasibility and acceptance of secure messaging using an established nationwide PP system for e-visits. Fifteen participants with stroke-related arm disability were randomised to 6 weeks of home arm telerehabilitation. All were over the age of 60 and 73% lived with a spouse or significant other. Mean intervention time was 6.8 weeks, and participants sent 2.3 ± 1.4 messages per week to complete 15.1 h of reported therapy (prescribed therapy = 18 h). Portal use improved therapist efficiency and resulted in a 1:6 therapist to patient exercise time ratio compared with the conventional 1:1 ratio for in-person therapy. Low initial electronic health literacy, self-efficacy or cognitive scores did not prohibit utilisation, and satisfaction with secure messaging for patient–therapist communication was 3.5 ± 1.2 out of 5. Overall, PP-supported e-visits were a feasible and acceptable telerehabilitation care delivery method for this chronic stroke population. ClinicalTrials.gov Identifier NCT02665052. Registered 27 January 2016. https://clinicaltrials.gov/ct2/show/NCT02665052

Identifying and Overcoming Policy-Level Barriers to the Implementation of Digital Health Innovation: Qualitative Study

Journal of Medical Internet Research ◽

10.2196/14994 ◽

2019 ◽

Vol 21 (12) ◽

pp. e14994 ◽

Cited By ~ 3

Author(s):

Laura Desveaux ◽

Charlene Soobiah ◽

R Sacha Bhatia ◽

James Shaw

Keyword(s):

Health System ◽

Driving Forces ◽

Digital Health ◽

Critical Role ◽

Qualitative Description ◽

System Level ◽

Health Innovation ◽

Innovation Activities ◽

Challenges And Opportunities ◽

The Government

Background High-level policy barriers impede widespread adoption for even the most well-positioned innovations. Most of the work in this field assumes rather than analyzes the driving forces of health innovation. Objective: The aim of this study was to explore the challenges and opportunities experienced by health system stakeholders in the implementation of digital health innovation in Ontario. Objective The aim of this study was to explore the challenges and opportunities experienced by health system stakeholders in the implementation of digital health innovation in Ontario. Methods We completed semistructured interviews with 10 members of senior leadership across key organizations that are engaged in health care–related digital health activities. Data were analyzed using qualitative description. Results A total of 6 key policy priorities emerged, including the need for (1) a system-level definition of innovation, (2) a clear overarching mission, and (3) clearly defined organizational roles. Operationally, there is a need to (4) standardize processes, (5) shift the emphasis to change management, and (6) align funding structures. Conclusions These findings emphasize the critical role of the government in developing a vision and creating the foundation upon which innovation activities will be modeled.

The State of Evidence in Patient Portals: Umbrella Review

Journal of Medical Internet Research ◽

10.2196/23851 ◽

2020 ◽

Vol 22 (11) ◽

pp. e23851

Author(s):

Marcy G Antonio ◽

Olga Petrovskaya ◽

Francis Lau

Keyword(s):

Knowledge Translation ◽

Systematic Reviews ◽

Business Models ◽

Digital Health ◽

Patient Portal ◽

Umbrella Review ◽

Patient Portals ◽

Meta Level ◽

Patient Reported ◽

Over Time

Background Patient portals have emerged as a recognized digital health strategy. To date, research on patient portals has grown rapidly. However, there has been limited evaluation of the growing body of evidence on portal availability, use, clinical or health behavior and outcomes, and portal adoption over time. Objective This paper aims to comprehensively consolidate the current state of evidence on patient portals using the umbrella review methodology, introduce our approach for evaluating evidence for quantitative and qualitative findings presented in included systematic reviews, and present a knowledge translation tool that can be used to inform all stages of patient portal adoption. Methods For this study, a modified version of the Joanna Briggs Institute umbrella review method was used. Multiple databases were searched for systematic reviews focused on patient portals, and the final sample included 14 reviews. We conducted a meta-level synthesis of findings from quantitative, qualitative, and mixed methods primary studies reported in systematic reviews. We organized the umbrella review findings according to the Clinical Adoption Meta-Model (CAMM). Vote-counting, GRADE (Grading of Recommendations, Assessment, Development, and Evaluations), and CERQual (Confidence in the Evidence from Review of Qualitative Research) were used to assess the umbrella review evidence. Results Our knowledge translation tool summarizes the findings in the form of an evidence map. Organized by the CAMM categories, the map describes the following factors that influence portal adoption and effects over time: patient contexts, patient's interest and satisfaction, portal design, facilitators and barriers, providers' attitudes, service utilization, behavioral effects, clinical outcomes, and patient-reported outcomes. The map lists the theories and mechanisms recognized in the included portal research while identifying the need for business models and organizational theories that can inform all stages of portal adoption. Our GRADE and CERQual umbrella review evaluation resulted in the majority of evidence being rated as moderate to low, which reflects methodological issues in portal research, insufficient number of studies, or mixed results in specific focus areas. The 2 findings with a high rating of evidence were patients' interest in using portals for communication and the importance of a simple display of information in the portals. Over 40 portal features were identified in the umbrella review, with communication through secure messaging and appointment booking mentioned in all systematic reviews. Conclusions Our umbrella review provides a meta-level synthesis to make sense of the evidence on patient portals from published systematic reviews. Unsystematic and variable reporting of portal features undermines the ability to evaluate and compare portal effects and overlooks the specific context of portal use. Research designs sensitive to the social, organizational, policy, and temporal dimensions are needed to better understand the underlying mechanisms and context that leverage the identified factors to improve portal use and effects.

Is research on patient portals attuned to health equity? A scoping review

Journal of the American Medical Informatics Association ◽

10.1093/jamia/ocz054 ◽

2019 ◽

Vol 26 (8-9) ◽

pp. 871-883 ◽

Cited By ~ 13

Author(s):

Marcy G Antonio ◽

Olga Petrovskaya ◽

Francis Lau

Keyword(s):

Health Equity ◽

Scoping Review ◽

Health Inequities ◽

Individual Responsibility ◽

Practice Research ◽

Patient Portal ◽

User Centered Design ◽

Patient Portals ◽

Search Terms ◽

The Impact

Abstract Objective Our scoping review examined how research on patient portals addresses health equity. Questions guiding our review were: 1) What health equity concepts are addressed in patient portal research—both explicitly and implicitly? 2) What are the gaps? 3) Is the potential for ehealth-related health inequities explicitly acknowledged in studies on patient portals? 4) What novel approaches and interventions to reduce health inequities are tested in patient portal research? Materials and Methods We searched 4 databases. Search terms included “patient portal” in combination with a comprehensive list of health equity terms relevant in ehealth context. Authors independently reviewed the papers during initial screening and full-text review. We applied the eHealth Equity Framework to develop search terms and analyze the included studies. Results Based on eHealth Equity Framework categories, the main findings generated from 65 reviewed papers were governance structures, ehealth policies, and cultural and societal values may further inequities; social position of providers and patients introduces differential preferences in portal use; equitable portal implementation can be supported through diverse user-centered design; and intermediary strategies are typically recommended to encourage portal use across populations. Discussion The predominant focus on barriers in portal use may be inadvertently placing individual responsibility in addressing these barriers on patients already experiencing the greatest health disparities. This approach may mask the impact of the socio-technical-economic-political context on outcomes for different populations. Conclusion To support equitable health outcomes related to patient portals we need to look beyond intermediary initiatives and develop equitable strategies across policy, practice, research, and implementation.

The State of Evidence in Patient Portals: Umbrella Review (Preprint)

10.2196/preprints.23851 ◽

2020 ◽

Author(s):

Marcy G Antonio ◽

Olga Petrovskaya ◽

Francis Lau

Keyword(s):

Knowledge Translation ◽

Systematic Reviews ◽

Business Models ◽

Digital Health ◽

Patient Portal ◽

Umbrella Review ◽

Patient Portals ◽

Meta Level ◽

Patient Reported ◽

Over Time

BACKGROUND Patient portals have emerged as a recognized digital health strategy. To date, research on patient portals has grown rapidly. However, there has been limited evaluation of the growing body of evidence on portal availability, use, clinical or health behavior and outcomes, and portal adoption over time. OBJECTIVE This paper aims to comprehensively consolidate the current state of evidence on patient portals using the umbrella review methodology, introduce our approach for evaluating evidence for quantitative and qualitative findings presented in included systematic reviews, and present a knowledge translation tool that can be used to inform all stages of patient portal adoption. METHODS For this study, a modified version of the Joanna Briggs Institute umbrella review method was used. Multiple databases were searched for systematic reviews focused on patient portals, and the final sample included 14 reviews. We conducted a meta-level synthesis of findings from quantitative, qualitative, and mixed methods primary studies reported in systematic reviews. We organized the umbrella review findings according to the Clinical Adoption Meta-Model (CAMM). Vote-counting, GRADE (Grading of Recommendations, Assessment, Development, and Evaluations), and CERQual (Confidence in the Evidence from Review of Qualitative Research) were used to assess the umbrella review evidence. RESULTS Our knowledge translation tool summarizes the findings in the form of an evidence map. Organized by the CAMM categories, the map describes the following factors that influence portal adoption and effects over time: patient contexts, patient's interest and satisfaction, portal design, facilitators and barriers, providers' attitudes, service utilization, behavioral effects, clinical outcomes, and patient-reported outcomes. The map lists the theories and mechanisms recognized in the included portal research while identifying the need for business models and organizational theories that can inform all stages of portal adoption. Our GRADE and CERQual umbrella review evaluation resulted in the majority of evidence being rated as moderate to low, which reflects methodological issues in portal research, insufficient number of studies, or mixed results in specific focus areas. The 2 findings with a high rating of evidence were patients' interest in using portals for communication and the importance of a simple display of information in the portals. Over 40 portal features were identified in the umbrella review, with communication through secure messaging and appointment booking mentioned in all systematic reviews. CONCLUSIONS Our umbrella review provides a meta-level synthesis to make sense of the evidence on patient portals from published systematic reviews. Unsystematic and variable reporting of portal features undermines the ability to evaluate and compare portal effects and overlooks the specific context of portal use. Research designs sensitive to the social, organizational, policy, and temporal dimensions are needed to better understand the underlying mechanisms and context that leverage the identified factors to improve portal use and effects.

Feasibility of an Interactive Patient Portal for Monitoring Physical Activity, Remote Symptom Reporting, and Patient Education in Oncology: Qualitative Study (Preprint)

10.2196/preprints.15539 ◽

2019 ◽

Author(s):

Michael Marthick ◽

Anna Janssen ◽

Birinder S Cheema ◽

Jennifer Alison ◽

Tim Shaw ◽

...

Keyword(s):

Physical Activity ◽

Digital Health ◽

Symptom Reporting ◽

Patient Portal ◽

Semistructured Interview ◽

Web Portal ◽

Patient Portals ◽

Web Based ◽

Qualitative Thematic Analysis ◽

The Web

BACKGROUND Digital health interventions, such as the use of patient portals, have been shown to offer benefits to a range of patients including those with a diagnosis of cancer. OBJECTIVE This study aimed to explore the participant experience and perception of using an interactive Web-based portal for monitoring physical activity, remote symptom reporting, and delivering educational components. METHODS Participants who were currently under treatment or had recently completed intensive treatment for cancer were recruited to three cohorts and invited to join a Web-based portal to enhance their physical activity. Cohort 1 received Web portal access and an activity monitor; cohort 2 had additional summative messaging; and cohort 3 had additional personalized health coaching messaging. Following the 10-week intervention, participants were invited to participate in a semistructured interview. Interview recordings were transcribed and evaluated using qualitative thematic analysis. RESULTS A total of 17 semistructured interviews were carried out. Participants indicated that using the Web portal was feasible. Personalized messaging improved participant perceptions of the value of the intervention. There was a contrast between cohorts and levels of engagement with increasing health professional contact leading to an increase in engagement. Educational material needs to be tailored to the participants’ cancer treatment status, health literacy, and background. CONCLUSIONS Participants reported an overall positive experience using the Web portal and that personalized messaging positively impacted on their health behaviors. Future studies should focus more on design of interventions, ensuring appropriate tailoring of information and personalization of behavioral support messaging.

Using Human-Centered Design to Build a Digital Health Advisor for Patients With Complex Needs: Persona and Prototype Development (Preprint)

10.2196/preprints.10318 ◽

2018 ◽

Author(s):

Onil Bhattacharyya ◽

Kathryn Mossman ◽

Lovisa Gustafsson ◽

Eric C Schneider

Keyword(s):

Health System ◽

Care Delivery ◽

Digital Health ◽

Business Case ◽

Cultural Barriers ◽

Multiple Chronic Conditions ◽

Complex Needs ◽

Prototype Development ◽

System Leaders ◽

Key Features

BACKGROUND Twenty years ago, a “Guardian Angel” or comprehensive digital health advisor was proposed to empower patients to better manage their own health. This is now technically feasible, but most digital applications have narrow functions and target the relatively healthy, with few designed for those with the greatest needs. OBJECTIVE The goal of the research was to identify unmet needs and key features of a general digital health advisor for frail elderly and people with multiple chronic conditions and their caregivers. METHODS In-depth interviews were used to develop personas and use cases, and iterative feedback from participants informed the creation of a low-fidelity prototype of a digital health advisor. Results were shared with developers, investors, regulators, and health system leaders for suggestions on how this could be developed and disseminated. RESULTS Patients highlighted the following goals: “live my life,” “love my life,” “manage my health,” and “feel understood.” Patients and caregivers reported interest in four functions to address these goals: tracking and insights, advice and information, providing a holistic picture of the patient, and coordination and communication. Experts and system stakeholders felt the prototype was technically feasible, and that while health care delivery organizations could help disseminate such a tool, it should be done in partnership with consumer-focused organizations. CONCLUSIONS This study describes the key features of a comprehensive digital health advisor, but to spur its development, we need to clarify the business case and address the policy, organizational, and cultural barriers to creating tools that put patients and their goals at the center of the health system.

Defining Empowerment and Supporting Engagement Using Patient Views From the Citizen Health Information Portal: Qualitative Study (Preprint)

10.2196/preprints.8828 ◽

2017 ◽

Author(s):

Tracie Risling ◽

Juan Martinez ◽

Jeremy Young ◽

Nancy Thorp-Froslie

Keyword(s):

Qualitative Methodology ◽

Digital Health ◽

Patient Empowerment ◽

Primary Objective ◽

Patient Portal ◽

Interpretive Description ◽

Patient Portals ◽

Information Portal ◽

Use Of Technology ◽

Self Reported Health Status

BACKGROUND The increasing presence of technology in health care has created new opportunities for patient engagement and with this, an intensified exploration of patient empowerment within the digital health context. While the use of technology, such as patient portals, has been positively received, a clear linkage between digital health solutions, patient empowerment, and health outcomes remains elusive. OBJECTIVE The primary objective of this research was to explore the views of participants enrolled in an electronic health record portal access trial regarding the resultant influence of this technology on their feelings of patient empowerment. METHODS The exploration of patient empowerment within a digital health context was done with participants in a tethered patient portal trial using interpretive description. Interpretive description is a qualitative methodology developed to pragmatically address clinical health questions. Patient demographics, self-reported health status, and self-identified technology adaptation contributed to the assessment of empowerment in this qualitative approach. RESULTS This research produced a view of patient empowerment within the digital health context summarized in two overarching categories: (1) Being Heard and (2) Moving Forward. In each of these, two subcategories further delineate the aspects of empowerment, as viewed by these participants: Knowing More and Seeing What They See under Being Heard, and Owning Future Steps and Promoting Future Care under Moving Forward. This work also highlighted an ongoing interconnectedness between the concepts of patient empowerment, engagement, and activation and the need to further articulate the unique aspects of each of these. CONCLUSIONS The results of this study contribute needed patient voice to the ongoing evolution of the concept of patient empowerment. In order to move toward more concrete and accurate measure of patient empowerment and engagement in digital health, there must be further consideration of what patients themselves identify as essential aspects of these complex concepts. This research has revealed relational and informational elements as two key areas of focus in the ongoing evolution of patient empowerment operationalization and measure.

Health System Stakeholders’ Perspective on the Role of Mobile Health and Its Adoption in the Swiss Health System: Qualitative Study (Preprint)

10.2196/preprints.17315 ◽

2019 ◽

Author(s):

Myriam Lingg ◽

Verena Lütschg

Keyword(s):

Health Care ◽

Health System ◽

Mobile Health ◽

Care Delivery ◽

Digital Health ◽

Full Potential ◽

Semistructured Interview ◽

Swiss Health ◽

Recommendations For Action

BACKGROUND Digital health solutions have great potential to change the way health care is delivered, including better clinical outcomes and improved processes and access to health services. However, the adoption of mobile health (mHealth) solutions for patient monitoring has been rather slow in Switzerland. The reasons are complex, and a better understanding is needed to leverage the full potential of mHealth. OBJECTIVE This study aimed to deepen the understanding of the potential relevance and influence of mHealth for the health system and health care provision, and factors influencing its adoption. The findings will be used to provide an outlook on feasible recommendations for action. METHODS We conducted a qualitative survey using a maximum variation sample of a heterogeneous group of stakeholders (N=50) in the Swiss health care system with a profound knowledge of digital health and medical devices. A semistructured interview guide including open- and closed-ended questions was used to address questions around mHealth relevance and its influence on the health system, the relevance of selected determinants for mHealth adoption, and important influencing factors. A content analysis method was applied. RESULTS Overall, respondents thought that mHealth would have a beneficial impact on the Swiss health system but that its adoption would evolve slowly. We derived 23 key opportunities regarding patient and patient pathway, treatment of disease, and diseases and health conditions. High consistency in answers among respondents was observed for treatment of disease. Stakeholders’ attitudes toward mHealth adoption along the relevance of 23 preselected determinants were relatively consistent. However, we obtained diverging attitudes regarding the influence of trends, enablers, and restraints in Switzerland and translated them into 26 key themes influencing mHealth adoption. Relevant trends comprise changing needs and expectations of patients, a rising need for efficient health care delivery, growing interest in improved outpatient care, and emerging technologies and progressing digitization. Important enablers include growing demand for new financing schemes and incentive concepts, rising demand for comprehensive information on and stronger body of evidence for mHealth use cases, and increasing need for easy to use alternate care approaches. Challenging restraints are rigidness of thinking and siloed actions of health system actors, complexity of changing the existing regulations and structures, little understanding of mHealth use and the role of clinicians, and risk of further polarization of the population. CONCLUSIONS This study provides a comprehensive look at mHealth in the Swiss health system. It becomes apparent that strong governance is inevitable to foster a sustainable data strategy and to reconcile the different interests of stakeholders. The use of mHealth will add value but will not necessarily reduce the burden on the system caused by emerging societal needs and changing disease prevalence.