- Email: [email protected]
Patient Portals
[
Topics in Practice Management
]
Patient Portals An Underused Resource for Improving Patient Engagement Bengisu Tulu, PhD; John Trudel, MD; Diane M. Strong, PhD; Sharon A. Johnson, PhD; Devi Sundaresan, MS; and Lawrence Garber, MD
The potential of patient portals to improve patient engagement and health outcomes has been discussed for more than a decade. The slow growth in patient portal adoption rates among patients and providers in the United States, despite external incentives, indicates that this is a complex issue. We examined evidence of patient portal use and effects with a focus on the pulmonary domain. We found a paucity of studies of patient portal use in pulmonary practice, and highlight gaps for future research. We also report on the experience of a pulmonary department using a patient portal to highlight the potential of these systems. CHEST 2016; 149(1):272-277 KEY WORDS:
patient engagement; patient portals; personal health records; pulmonary
Patient portals are personal health record (PHR) systems tethered to a health organization’s electronic health record (EHR) system. They allow patients to track their medical history, access their medical records, and communicate with their healthcare providers, and in some cases, they record patient-entered data. The rate of patient portal adoption by patients and physicians has been slow in the United States despite their increasing availability due to meaningful use incentive requirements related to EHRs.1,2 Although the patient portal market is expected to boom between 2012 and 2017 as a result of providers trying to meet incentive requirements in the United States,3 surveys examining the adoption of patient portals indicate that only one-third of patients with access to a patient portal use it.4 The reasons for slow growth are likely complex, but engagement and commitment
ABBREVIATIONS:
EHR = electronic health record; PHR = personal
health record AFFILIATIONS: From the Robert A. Foisie School of Business (Drs Tulu, Strong, and Johnson), Worcester Polytechnic Institute; and Reliant Medical Group (Drs Trudel and Garber and Ms Sundaresan), Worcester, MA.
272 Topics in Practice Management
from both patients and providers are arguably important factors in accelerating adoption rates. We wanted to understand how specialists and their patients use patient portals. Many studies have evaluated the use of patient portals in general; by primary care physicians; or for specific chronic diseases, such as diabetes,2,5,6 but it is unclear how much work has been done to evaluate the use of patient portals by specialists. We chose pulmonologists as representative specialists because they commonly treat both acute and chronic illnesses with a diversity of interventions and order a wide variety of tests, the results of which need to be communicated to the patient. These characteristics are common to varying degrees with other medical and surgical specialists who would be expected to promote the value of patient portals.
CORRESPONDENCE TO:
Lawrence Garber, MD, Reliant Medical Group, 630 Plantation St, Worcester, MA 01605; e-mail: Lawrence. [email protected] Copyright Ó 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. DOI: http://dx.doi.org/10.1378/chest.14-2559
[
149#1 CHEST JANUARY 2016
]
We first reviewed the literature for studies on the use of patient portals or PHRs for pulmonary conditions or by pulmonologists to support patient engagement. We focused on patient portals used specifically for patient engagement because we believe that engaged patients participate more actively in their health-care management and related decisions and gain the
most value from portals. Next, we analyzed patient portal data in a multispecialty group practice to determine how pulmonologists and their teams use portal technology. This article thus summarizes the current knowledge regarding the use of patient portals by pulmonologists and determines gaps that future research should address.
Materials and Methods
for patients with chronic conditions or (2) the abstract mentioned the use of PHRs for pulmonary conditions. The abstract reviews identified 23 potentially relevant articles. We conducted full-text reviews of the 23 articles to better assess level of relevance and to categorize findings. To ensure that we did not miss any relevant publication, we implemented the same literature review strategy in PubMed. PubMed queries returned only four results, with two being unique hits. One of these was included as one of the aforementioned 23 articles from Google Scholar, whereas the other was identified as irrelevant based on review of the abstract.
Figure 1 illustrates the literature review strategy. We determined two sets of search key words—one focused on capturing relevant articles about patient portals and the other focused on capturing articles about pulmonology—and combined the resulting search phrases with the term “patient engagement.” The literature review was conducted between July and December 2014, and the results consider articles published before July 2014. We started the literature review by searching for a given set of key words (Fig 1) anywhere in the text using Google Scholar. The combinations of the three key word sets identified in Figure 1 generated 317 unique results. Next, we conducted a relevance review of abstracts for all 317 articles. An article was considered potentially relevant if it satisfied either of the following conditions: (1) the abstract mentioned a study about the use of PHRs or patient portals
Results of the Literature Review Among the 23 articles reviewed, only one fully satisfied the relevance criteria.7 The authors argued that to realize
To illustrate the use of patient portals by pulmonologists and how their use compares with that by physicians in general, we conducted a review of messages in a patient portal used by a large multispecialty group practice in the northeastern United States. The analysis focused on the messages handled by the pulmonologists and their teams in this practice.
the benefits of PHRs for self-management of a complex chronic disease like COPD, either the patients need to have high levels of health literacy or the PHR system Step 3: Clean duplicates and identify unique papers
Step 1: Identify search key words
(n = 317) 1st Key word
2nd Key word
1.1 Personal Health Record 1.2 Personal Health Records 1.3 PHR 1.4 Patient Portal 1.5 Patient Portals
2.1 Pulmonology 2.2 Pulmonary 2.3 Pulmonologist 2.4 Respiratory 2.5 Asthma 2.6 Emphysema 2.7 COPD
3rd Key word Step 4: Determine relevant papers through abstract review
3. Patient Engagement
Relevance Criteria: a) the abstract mentions a study about the use of PHR for patients with chronic conditions; or b) the abstract mentions use of PHRs for pulmonary conditions (n = 23)
Step 2: Conduct literature search (eg, 1.1 (1.2, 1.3, 1.4, 1.5) + 2.1+ 3. = Pulmonology) Pulmonology n = 23 Pulmonary n = 232 Pulmonologist n = 23 Respiratory n = 167 Asthma n = 432 Emphysema n = 26 COPD n = 146
Step 5: Review full papers to determine study approach and findings of PHR use studies and their relevance to pulmonology domain
Figure 1 – Literature review strategy. PHR ¼ personal health record.
journal.publications.chestnet.org
273
needs to match the health literacy levels of its users. By going through the four levels of health literacy described in Nutbeam’s health literacy model8 and the selfmanagement needs of patients with COPD associated with each level of literacy in this model, the authors provided design suggestions for PHR systems. At functional, interactive, and critical health literacy levels, the authors suggested (1) the use of large icons, pictorial depictions, and talking touch screens; (2) the use of embedded Internet links; and (3) the conduct of usability testing for validation of an effective design.7 Although the article focused solely on patients with COPD as users of a PHR, it was a conceptual piece and did not present a research study. A second study that focused on patients with COPD mentioned only incidentally that most patients did not use the patient portal provided by the health system.9 The present review reveals a wide spectrum of factors affecting perceived value and adoption of PHRs. During early use of PHR systems, researchers concluded that patients with chronic diseases such as asthma and COPD are more likely to adopt and use PHRs.6,10 A more recent study of PHRs from the perspective of diffusion of innovation theory reported that when the outcome measure is not simply adoption but rather the value PHR systems offer in terms of improved communication between patients and providers, having chronic conditions was not a predictor of perceived value from these systems.5 Lack of motivation and lack of awareness by patients were reported as the main barriers to enrollment in patient portals, even among patients with chronic diseases.11 A study that tested the effects of a patient-centered care plan using an EHR and paper-based reporting on improving self-management among patients with chronic diseases concluded that the addition of patient portals would not only allow efficient implementation TABLE 1
of the plan but also increase patient engagement.12 However, perceived importance of self-management features provided by patient portals are reported to vary among race groups, with whites more likely to perceive this to be important than blacks.11 Several articles focused on the use of patient portals for chronic disease management. A qualitative study focusing on the effects of online chronic disease management portals on outcomes in patients with diabetes reported that such portals increase access to information and engagement in health care.13 Another article presented a model for using personally controlled health records based on the assumption that use of these systems will improve patterns of care and patient engagement among adolescents with diabetes.14 The remaining 16 articles were not related to the use of PHR or patient portal systems in pulmonology departments or for chronic pulmonary diseases, even though they mentioned PHRs and patients with chronic conditions in their abstracts and, hence, were considered for full review. However, they provided important insights into the acceptance and adoption of patient portals and health information technologies among all patients, including those with chronic diseases. One article presented several projects initiated through Project Health Design,15 which focused on bringing observations of daily living into the clinical workflow through mobile health technology. Articles that focused on the factors affecting acceptance and adoption of patient portals showed that a satisfactory patientprovider relationship,16 higher levels of selfdetermination in managing health,17 and better usability13 are positively associated with PHR acceptance. Studying how PHRs are implemented and deployed led to other interesting findings on PHR use. For example,
] Distributions of Messages Sent From Pulmonary Department to Patients (June 1, 2013, to May 31, 2014)
Patient Portal Message Type Response to patient medical advice request
Pulmonary Message Count
Pulmonary Message %
Group Practice Message %
517
50
40
57
6
9
Messages originated by pulmonary department
313
31
40
Response to patient appointment schedule request
120
12
8
3
<1
1
Response to patient medication renewal request
Response to patient customer service request about an appointment Response to an appointment request for health maintenance Total of all message types
274 Topics in Practice Management
14
1
2
1,024
100
100
[
149#1 CHEST JANUARY 2016
]
TABLE 2 ]
Distribution of Messages Sent From Patients to Pulmonary Department (June 1, 2013, to May 31, 2014)
Patient Portal Message Type
Pulmonary Message Count
Pulmonary Message %
Group Practice Message %
Patient medical advice request
556
60
51
Patient medication renewal request
180
19
27
Response to a message started by a pulmonologist
110
12
9
Patient appointment schedule request Total of all message types
the communication tactics used during PHR rollout were reported to significantly affect acceptance of the system.16 Other researchers determined that a mismatch exists between provider perceptions about the characteristics of patients who are early adopters and the characteristics reported by the actual users.18 Providers expected to see a difference in computer skills; demographics, such as young age; and personality characteristics, such as being organized and proactive, between early adopters and nonusers of the system, but the results of patient surveys from both groups revealed no such difference. On the other hand, in relation to the most commonly used features in a patient portal, other studies reported differences in terms of demographics.19 These findings indicate the importance of more granular
84
9
13
930
100
100
studies when it comes to understanding patient portal use and its effect on health outcomes. Finally, some articles did not provide directly relevant information for pulmonologists, pulmonary diseases, or chronic diseases but, rather, focused on the value of PHRs from a financial perspective,20 the role nurses play in supporting coordination of care through the use of patient portals,21 the potential benefits of patients facing technologies within the context of meaningful use requirements,22 the potential of mobile health-care technology,23,24 how patients can use the new health information technology to receive better health care,25 and the effects of making provider visit notes available to patients online.26 Other articles focused on patient
Figure 2 – Medical advice request screen from patient portal. PCP ¼ primary care physician.
journal.publications.chestnet.org
275
portals as an advanced health information exchange application,27 how portals can provide decision support to improve patient engagement,28 the impact of tablet computer use on patient engagement for inpatient settings,29 and the role of patient engagement in prevention within the context of primary care.30 From the present review, it is clear that although PHRs could offer great value to providers and patients, research shows very rare use of PHR systems or patient portals among patients with pulmonary conditions, an important gap for future research. This gap may be due to low patient and provider use of PHRs. To better understand whether lack of research in this area might be due to lack of use, we conducted a case study.
Use of a Patient Portal by Pulmonologists in a Group Practice We looked at the use of a patient portal implemented in early 2009 in a multispecialty group practice in the northeastern United States. As of May 31, 2014, 51,770 active patients in this practice had activated their access to the patient portal. The pulmonary department comprised six pulmonologists who served 2,099 patients with access to the patient portal, corresponding to 35.2% of the patient panel for the department. This participation rate is similar to that of the group practice as a whole, which was 37.8%, but contrasted cardiology and obstetrics and gynecology participation, which was significantly different at 33.2% and 46.9%, respectively (two-tailed, one-sample t test P < .001). Since 2009, > 500,000 messages were received and a little > 400,000 messages were sent by the group practice through the patient portal. Messages sent and received by the pulmonologists and their teams corresponded to 1.5% and 0.7%, respectively, of all the messages handled by the portal across the practice. Among the 2,099 portal users in pulmonology, 19.5% (411 unique patients) received a message from and 12.6% (264 unique patients) sent a message to the pulmonologists and their teams between June 1, 2013, and May 31, 2014, compared with 50% and 41%, respectively, through any provider in the group practice. Tables 1 and 2 present the distribution of the message types sent and received by the pulmonologists and their teams, compared with the group practice experience as a whole. This comparison illuminates some interesting characteristics that are more prevalent in the pulmonary specialty. For example, pulmonologists originated fewer messages than the group practice average (31% vs 40%, respectively). Chart review revealed that the majority of physician-originated messages were regarding
276 Topics in Practice Management
test results. It is likely that pulmonologists order fewer tests and thus reported fewer test results compared with, for example, internal medicine physicians and neurologists who originated 44% and 60%, respectively, of the patient portal messages in their practices. In contrast, hematologists and cardiologists originated only 14% and 21% of their patient portal messages, respectively. Some of these variations may also be explained by variability in patient needs and desire to ask questions through the portal. In contrast, pulmonologists addressed more patient problems through the patient portal than the group practice average. This is seen both for medical advice requests (Fig 2 shows the patient portal screen for this feature) from patients (60% vs 51%) and responses from the pulmonologists and their teams (50% vs 40%). Overall, this case study demonstrates that pulmonologists and a significant number of their patients are using the patient portal, with more messages characterized as being related to health issues than to administrative tasks.
Conclusions PHRs have value to providers and patients in numerous health-care settings and scenarios; however, this review of the literature reveals that in the PHR and patient portal knowledge base accumulated to date, very few studies have addressed the use of PHRs for pulmonary conditions or by pulmonologists. As shown in the example presented herein, use of a patient portal is a significant form of communication between providers and patients, and pulmonologists use the portal differently than other physicians. The example studied provides important insights into how adoption of patient portals can be energized. Further studies are needed to explore opportunities and to elucidate changes in quality, safety, satisfaction, and financial outcomes related to the use of PHRs.
Acknowledgments Financial/nonfinancial disclosures: None declared. Other contributions: The authors thank graduate students Xinrui Che, MS-IT, and Yun Lin, MS-ODL, for help in conducting the literature search.
References 1. Furukawa MF, King J, Patel V, Hsiao C-J, Adler-Milstein J, Jha AK. Despite substantial progress in EHR adoption, health information exchange and patient engagement remain low in office settings. Health Aff (Millwood). 2014;33(9):1672-1679.
[
149#1 CHEST JANUARY 2016
]
2. Emont S. Measuring the Impact of Patient Portals: What the Literature Tells Us. Oakland, CA: California Healthcare Foundation; 2011. 3. Market disruption imminent as hospitals and physicians aggressively adopt patient portal technology. Frost & Sullivan website. http:// www.frost.com/prod/servlet/press-release.pag?docid¼285477570. Accessed June 11, 2015. 4. Patient portal preferences: IndustryView 2014. Software Advice website. http://www.softwareadvice.com/medical/industryview/ patient-portals-2014. Accessed June 11, 2015. 5. Emani S, Yamin CK, Peters E, et al. Patient perceptions of a personal health record: a test of the diffusion of innovation model. J Med Internet Res. 2012;14(6):e150. 6. Miller H, Vandenbosch B, Ivanov D, Black P. Determinants of personal health record use: a large population study at Cleveland Clinic. J Healthc Inf Manag. 2007;21(3):44-48. 7. Mitchell B, Begoray DL. Electronic personal health records that promote self-management in chronic illness. OJIN. 2010;15(3). http://www.nursingworld.org/MainMenuCategories/ ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152 010/No3-Sept-2010/Articles-Previously-Topic/Electronic-PersonalHealth-Records-and-Chronic-Illness.aspx. Accessed June 11, 2015. 8. Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promot Int. 2000;15(3):259-267. 9. Panos RJ, Krywkowski-Mohn SM, Sherman SN, Lach LA. Patient reported determinants of health: a qualitative analysis of veterans with chronic obstructive pulmonary disease. COPD. 2013;10(3): 333-347. 10. Hsu J, Huang J, Kinsman J, et al. Use of e-Health services between 1999 and 2002: a growing digital divide. J Am Med Inform Assoc. 2005;12(2):164-171. 11. Goel MS, Brown TL, Williams A, Cooper AJ, Hasnain-Wynia R, Baker DW. Patient reported barriers to enrolling in a patient portal. J Am Med Inform Assoc. 2011;18(suppl 1):i8-i12.
16. Agarwal R, Anderson C, Zarate J, Ward C. If we offer it, will they accept? Factors affecting patient use intentions of personal health records and secure messaging. J Med Internet Res. 2013;15(2):e43. 17. Assadi V. Adoption of Integrated Personal Health Record Systems: A Self-Determination Theory Perspective [dissertation]. Hamilton, ON: McMaster University; 2013. 18. Butler JM, Carter M, Hayden C, et al. Understanding adoption of a personal health record in rural health care clinics: revealing barriers and facilitators of adoption including attributions about potential patient portal users and self-reported characteristics of early adopting users. AMIA Annu Symp Proc. 2013;2013:152-161. 19. Sue VM, Griffin MT, Allen JY. Beyond adoption: individual differences in the use of personal health record features in an integrated healthcare organisation. Int J Biomed Eng Technol. 2013;11(3):252-269. 20. Kaelber DC, Shah S, Vincent A, et al. The Value of Personal Health Records. Charlestown, MA: Center for Information Technology Leadership; 2008. 21. Wilson ML, Murphy LS, Newhouse RP. Patients’ access to their health information: a meaningful-use mandate. J Nurs Adm. 2012;42(11):493-496. 22. Ahern DK, Woods SS, Lightowler MC, Finley SW, Houston TK. Promise of and potential for patient-facing technologies to enable meaningful use. Am J Prev Med. 2011;40(5 suppl 2):S162-S172. 23. Stylianou A, McCormack H, Kokmotou R. Editorial: applying mHealth solutions. Eur J ePractice. 2013;20:2-4. 24. Chiarini G, Ray P, Akter S, Masella C, Ganz A. mHealth technologies for chronic diseases and elders: a systematic review. IEEE J Selected Areas Commun. 2013;31(9):6-18. 25. Finn NB. e-Patients Live Longer: The Complete Guide to Managing Health Care Using Technology. Bloomington, IN: iUniverse; 2011. 26. Kind EA, Fowles JB, Craft CE, Kind AC, Richter SA. No change in physician dictation patterns when visit notes are made available online for patients. Mayo Clin Proc. 2011;86(5):397-405.
12. Chunchu K, Mauksch L, Charles C, Ross V, Pauwels J. A patient centered care plan in the EHR: improving collaboration and engagement. Fam Syst Health. 2012;30(3):199-209.
27. McCarthy DB, Propp K, Cohen A, Sabharwal R, Schachter AA, Rein AL. Learning from Health Information Exchange Technical Architecture and Implementation in Seven Beacon Communities. EGEMS (Wash DC). 2014;2(1):1060.
13. Urowitz S, Wiljer D, Dupak K, et al. Improving diabetes management with a patient portal: a qualitative study of diabetes self-management portal. J Med Internet Res. 2012;14(6):e158.
28. Haddad M, Chetty G. Development of a smart e-health portal for chronic disease management. Algorithms and Architectures for Parallel Processing. 2012;7440:284-291.
14. Weitzman ER, Kaci L, Quinn M, Mandl KD. Helping high-risk youth move through high-risk periods: personally controlled health records for improving social and health care transitions. J Diabetes Sci Tech. 2011;5(1):47-54.
29. Greysen SR, Khanna RR, Jacolbia R, Lee HM, Auerbach AD. Tablet computers for hospitalized patients: a pilot study to improve inpatient engagement. J Hosp Med. 2014;9(6):396-399.
15. Casper GR, Brennan PF. Project HealthDesign: a preliminary program-level report. AMIA Annu Symp Proc. 2013;2013:192-199.
journal.publications.chestnet.org
30. Gorin SNS, Senathirajah Y. The future of prevention in primary care. In: Gorin SS, ed. Prevention Practice in Primary Care. New York, NY: Oxford University Press; 2013:268-306.
277
Topics in Practice Management
]
Patient Portals An Underused Resource for Improving Patient Engagement Bengisu Tulu, PhD; John Trudel, MD; Diane M. Strong, PhD; Sharon A. Johnson, PhD; Devi Sundaresan, MS; and Lawrence Garber, MD
The potential of patient portals to improve patient engagement and health outcomes has been discussed for more than a decade. The slow growth in patient portal adoption rates among patients and providers in the United States, despite external incentives, indicates that this is a complex issue. We examined evidence of patient portal use and effects with a focus on the pulmonary domain. We found a paucity of studies of patient portal use in pulmonary practice, and highlight gaps for future research. We also report on the experience of a pulmonary department using a patient portal to highlight the potential of these systems. CHEST 2016; 149(1):272-277 KEY WORDS:
patient engagement; patient portals; personal health records; pulmonary
Patient portals are personal health record (PHR) systems tethered to a health organization’s electronic health record (EHR) system. They allow patients to track their medical history, access their medical records, and communicate with their healthcare providers, and in some cases, they record patient-entered data. The rate of patient portal adoption by patients and physicians has been slow in the United States despite their increasing availability due to meaningful use incentive requirements related to EHRs.1,2 Although the patient portal market is expected to boom between 2012 and 2017 as a result of providers trying to meet incentive requirements in the United States,3 surveys examining the adoption of patient portals indicate that only one-third of patients with access to a patient portal use it.4 The reasons for slow growth are likely complex, but engagement and commitment
ABBREVIATIONS:
EHR = electronic health record; PHR = personal
health record AFFILIATIONS: From the Robert A. Foisie School of Business (Drs Tulu, Strong, and Johnson), Worcester Polytechnic Institute; and Reliant Medical Group (Drs Trudel and Garber and Ms Sundaresan), Worcester, MA.
272 Topics in Practice Management
from both patients and providers are arguably important factors in accelerating adoption rates. We wanted to understand how specialists and their patients use patient portals. Many studies have evaluated the use of patient portals in general; by primary care physicians; or for specific chronic diseases, such as diabetes,2,5,6 but it is unclear how much work has been done to evaluate the use of patient portals by specialists. We chose pulmonologists as representative specialists because they commonly treat both acute and chronic illnesses with a diversity of interventions and order a wide variety of tests, the results of which need to be communicated to the patient. These characteristics are common to varying degrees with other medical and surgical specialists who would be expected to promote the value of patient portals.
CORRESPONDENCE TO:
Lawrence Garber, MD, Reliant Medical Group, 630 Plantation St, Worcester, MA 01605; e-mail: Lawrence. [email protected] Copyright Ó 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. DOI: http://dx.doi.org/10.1378/chest.14-2559
[
149#1 CHEST JANUARY 2016
]
We first reviewed the literature for studies on the use of patient portals or PHRs for pulmonary conditions or by pulmonologists to support patient engagement. We focused on patient portals used specifically for patient engagement because we believe that engaged patients participate more actively in their health-care management and related decisions and gain the
most value from portals. Next, we analyzed patient portal data in a multispecialty group practice to determine how pulmonologists and their teams use portal technology. This article thus summarizes the current knowledge regarding the use of patient portals by pulmonologists and determines gaps that future research should address.
Materials and Methods
for patients with chronic conditions or (2) the abstract mentioned the use of PHRs for pulmonary conditions. The abstract reviews identified 23 potentially relevant articles. We conducted full-text reviews of the 23 articles to better assess level of relevance and to categorize findings. To ensure that we did not miss any relevant publication, we implemented the same literature review strategy in PubMed. PubMed queries returned only four results, with two being unique hits. One of these was included as one of the aforementioned 23 articles from Google Scholar, whereas the other was identified as irrelevant based on review of the abstract.
Figure 1 illustrates the literature review strategy. We determined two sets of search key words—one focused on capturing relevant articles about patient portals and the other focused on capturing articles about pulmonology—and combined the resulting search phrases with the term “patient engagement.” The literature review was conducted between July and December 2014, and the results consider articles published before July 2014. We started the literature review by searching for a given set of key words (Fig 1) anywhere in the text using Google Scholar. The combinations of the three key word sets identified in Figure 1 generated 317 unique results. Next, we conducted a relevance review of abstracts for all 317 articles. An article was considered potentially relevant if it satisfied either of the following conditions: (1) the abstract mentioned a study about the use of PHRs or patient portals
Results of the Literature Review Among the 23 articles reviewed, only one fully satisfied the relevance criteria.7 The authors argued that to realize
To illustrate the use of patient portals by pulmonologists and how their use compares with that by physicians in general, we conducted a review of messages in a patient portal used by a large multispecialty group practice in the northeastern United States. The analysis focused on the messages handled by the pulmonologists and their teams in this practice.
the benefits of PHRs for self-management of a complex chronic disease like COPD, either the patients need to have high levels of health literacy or the PHR system Step 3: Clean duplicates and identify unique papers
Step 1: Identify search key words
(n = 317) 1st Key word
2nd Key word
1.1 Personal Health Record 1.2 Personal Health Records 1.3 PHR 1.4 Patient Portal 1.5 Patient Portals
2.1 Pulmonology 2.2 Pulmonary 2.3 Pulmonologist 2.4 Respiratory 2.5 Asthma 2.6 Emphysema 2.7 COPD
3rd Key word Step 4: Determine relevant papers through abstract review
3. Patient Engagement
Relevance Criteria: a) the abstract mentions a study about the use of PHR for patients with chronic conditions; or b) the abstract mentions use of PHRs for pulmonary conditions (n = 23)
Step 2: Conduct literature search (eg, 1.1 (1.2, 1.3, 1.4, 1.5) + 2.1+ 3. = Pulmonology) Pulmonology n = 23 Pulmonary n = 232 Pulmonologist n = 23 Respiratory n = 167 Asthma n = 432 Emphysema n = 26 COPD n = 146
Step 5: Review full papers to determine study approach and findings of PHR use studies and their relevance to pulmonology domain
Figure 1 – Literature review strategy. PHR ¼ personal health record.
journal.publications.chestnet.org
273
needs to match the health literacy levels of its users. By going through the four levels of health literacy described in Nutbeam’s health literacy model8 and the selfmanagement needs of patients with COPD associated with each level of literacy in this model, the authors provided design suggestions for PHR systems. At functional, interactive, and critical health literacy levels, the authors suggested (1) the use of large icons, pictorial depictions, and talking touch screens; (2) the use of embedded Internet links; and (3) the conduct of usability testing for validation of an effective design.7 Although the article focused solely on patients with COPD as users of a PHR, it was a conceptual piece and did not present a research study. A second study that focused on patients with COPD mentioned only incidentally that most patients did not use the patient portal provided by the health system.9 The present review reveals a wide spectrum of factors affecting perceived value and adoption of PHRs. During early use of PHR systems, researchers concluded that patients with chronic diseases such as asthma and COPD are more likely to adopt and use PHRs.6,10 A more recent study of PHRs from the perspective of diffusion of innovation theory reported that when the outcome measure is not simply adoption but rather the value PHR systems offer in terms of improved communication between patients and providers, having chronic conditions was not a predictor of perceived value from these systems.5 Lack of motivation and lack of awareness by patients were reported as the main barriers to enrollment in patient portals, even among patients with chronic diseases.11 A study that tested the effects of a patient-centered care plan using an EHR and paper-based reporting on improving self-management among patients with chronic diseases concluded that the addition of patient portals would not only allow efficient implementation TABLE 1
of the plan but also increase patient engagement.12 However, perceived importance of self-management features provided by patient portals are reported to vary among race groups, with whites more likely to perceive this to be important than blacks.11 Several articles focused on the use of patient portals for chronic disease management. A qualitative study focusing on the effects of online chronic disease management portals on outcomes in patients with diabetes reported that such portals increase access to information and engagement in health care.13 Another article presented a model for using personally controlled health records based on the assumption that use of these systems will improve patterns of care and patient engagement among adolescents with diabetes.14 The remaining 16 articles were not related to the use of PHR or patient portal systems in pulmonology departments or for chronic pulmonary diseases, even though they mentioned PHRs and patients with chronic conditions in their abstracts and, hence, were considered for full review. However, they provided important insights into the acceptance and adoption of patient portals and health information technologies among all patients, including those with chronic diseases. One article presented several projects initiated through Project Health Design,15 which focused on bringing observations of daily living into the clinical workflow through mobile health technology. Articles that focused on the factors affecting acceptance and adoption of patient portals showed that a satisfactory patientprovider relationship,16 higher levels of selfdetermination in managing health,17 and better usability13 are positively associated with PHR acceptance. Studying how PHRs are implemented and deployed led to other interesting findings on PHR use. For example,
] Distributions of Messages Sent From Pulmonary Department to Patients (June 1, 2013, to May 31, 2014)
Patient Portal Message Type Response to patient medical advice request
Pulmonary Message Count
Pulmonary Message %
Group Practice Message %
517
50
40
57
6
9
Messages originated by pulmonary department
313
31
40
Response to patient appointment schedule request
120
12
8
3
<1
1
Response to patient medication renewal request
Response to patient customer service request about an appointment Response to an appointment request for health maintenance Total of all message types
274 Topics in Practice Management
14
1
2
1,024
100
100
[
149#1 CHEST JANUARY 2016
]
TABLE 2 ]
Distribution of Messages Sent From Patients to Pulmonary Department (June 1, 2013, to May 31, 2014)
Patient Portal Message Type
Pulmonary Message Count
Pulmonary Message %
Group Practice Message %
Patient medical advice request
556
60
51
Patient medication renewal request
180
19
27
Response to a message started by a pulmonologist
110
12
9
Patient appointment schedule request Total of all message types
the communication tactics used during PHR rollout were reported to significantly affect acceptance of the system.16 Other researchers determined that a mismatch exists between provider perceptions about the characteristics of patients who are early adopters and the characteristics reported by the actual users.18 Providers expected to see a difference in computer skills; demographics, such as young age; and personality characteristics, such as being organized and proactive, between early adopters and nonusers of the system, but the results of patient surveys from both groups revealed no such difference. On the other hand, in relation to the most commonly used features in a patient portal, other studies reported differences in terms of demographics.19 These findings indicate the importance of more granular
84
9
13
930
100
100
studies when it comes to understanding patient portal use and its effect on health outcomes. Finally, some articles did not provide directly relevant information for pulmonologists, pulmonary diseases, or chronic diseases but, rather, focused on the value of PHRs from a financial perspective,20 the role nurses play in supporting coordination of care through the use of patient portals,21 the potential benefits of patients facing technologies within the context of meaningful use requirements,22 the potential of mobile health-care technology,23,24 how patients can use the new health information technology to receive better health care,25 and the effects of making provider visit notes available to patients online.26 Other articles focused on patient
Figure 2 – Medical advice request screen from patient portal. PCP ¼ primary care physician.
journal.publications.chestnet.org
275
portals as an advanced health information exchange application,27 how portals can provide decision support to improve patient engagement,28 the impact of tablet computer use on patient engagement for inpatient settings,29 and the role of patient engagement in prevention within the context of primary care.30 From the present review, it is clear that although PHRs could offer great value to providers and patients, research shows very rare use of PHR systems or patient portals among patients with pulmonary conditions, an important gap for future research. This gap may be due to low patient and provider use of PHRs. To better understand whether lack of research in this area might be due to lack of use, we conducted a case study.
Use of a Patient Portal by Pulmonologists in a Group Practice We looked at the use of a patient portal implemented in early 2009 in a multispecialty group practice in the northeastern United States. As of May 31, 2014, 51,770 active patients in this practice had activated their access to the patient portal. The pulmonary department comprised six pulmonologists who served 2,099 patients with access to the patient portal, corresponding to 35.2% of the patient panel for the department. This participation rate is similar to that of the group practice as a whole, which was 37.8%, but contrasted cardiology and obstetrics and gynecology participation, which was significantly different at 33.2% and 46.9%, respectively (two-tailed, one-sample t test P < .001). Since 2009, > 500,000 messages were received and a little > 400,000 messages were sent by the group practice through the patient portal. Messages sent and received by the pulmonologists and their teams corresponded to 1.5% and 0.7%, respectively, of all the messages handled by the portal across the practice. Among the 2,099 portal users in pulmonology, 19.5% (411 unique patients) received a message from and 12.6% (264 unique patients) sent a message to the pulmonologists and their teams between June 1, 2013, and May 31, 2014, compared with 50% and 41%, respectively, through any provider in the group practice. Tables 1 and 2 present the distribution of the message types sent and received by the pulmonologists and their teams, compared with the group practice experience as a whole. This comparison illuminates some interesting characteristics that are more prevalent in the pulmonary specialty. For example, pulmonologists originated fewer messages than the group practice average (31% vs 40%, respectively). Chart review revealed that the majority of physician-originated messages were regarding
276 Topics in Practice Management
test results. It is likely that pulmonologists order fewer tests and thus reported fewer test results compared with, for example, internal medicine physicians and neurologists who originated 44% and 60%, respectively, of the patient portal messages in their practices. In contrast, hematologists and cardiologists originated only 14% and 21% of their patient portal messages, respectively. Some of these variations may also be explained by variability in patient needs and desire to ask questions through the portal. In contrast, pulmonologists addressed more patient problems through the patient portal than the group practice average. This is seen both for medical advice requests (Fig 2 shows the patient portal screen for this feature) from patients (60% vs 51%) and responses from the pulmonologists and their teams (50% vs 40%). Overall, this case study demonstrates that pulmonologists and a significant number of their patients are using the patient portal, with more messages characterized as being related to health issues than to administrative tasks.
Conclusions PHRs have value to providers and patients in numerous health-care settings and scenarios; however, this review of the literature reveals that in the PHR and patient portal knowledge base accumulated to date, very few studies have addressed the use of PHRs for pulmonary conditions or by pulmonologists. As shown in the example presented herein, use of a patient portal is a significant form of communication between providers and patients, and pulmonologists use the portal differently than other physicians. The example studied provides important insights into how adoption of patient portals can be energized. Further studies are needed to explore opportunities and to elucidate changes in quality, safety, satisfaction, and financial outcomes related to the use of PHRs.
Acknowledgments Financial/nonfinancial disclosures: None declared. Other contributions: The authors thank graduate students Xinrui Che, MS-IT, and Yun Lin, MS-ODL, for help in conducting the literature search.
References 1. Furukawa MF, King J, Patel V, Hsiao C-J, Adler-Milstein J, Jha AK. Despite substantial progress in EHR adoption, health information exchange and patient engagement remain low in office settings. Health Aff (Millwood). 2014;33(9):1672-1679.
[
149#1 CHEST JANUARY 2016
]
2. Emont S. Measuring the Impact of Patient Portals: What the Literature Tells Us. Oakland, CA: California Healthcare Foundation; 2011. 3. Market disruption imminent as hospitals and physicians aggressively adopt patient portal technology. Frost & Sullivan website. http:// www.frost.com/prod/servlet/press-release.pag?docid¼285477570. Accessed June 11, 2015. 4. Patient portal preferences: IndustryView 2014. Software Advice website. http://www.softwareadvice.com/medical/industryview/ patient-portals-2014. Accessed June 11, 2015. 5. Emani S, Yamin CK, Peters E, et al. Patient perceptions of a personal health record: a test of the diffusion of innovation model. J Med Internet Res. 2012;14(6):e150. 6. Miller H, Vandenbosch B, Ivanov D, Black P. Determinants of personal health record use: a large population study at Cleveland Clinic. J Healthc Inf Manag. 2007;21(3):44-48. 7. Mitchell B, Begoray DL. Electronic personal health records that promote self-management in chronic illness. OJIN. 2010;15(3). http://www.nursingworld.org/MainMenuCategories/ ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152 010/No3-Sept-2010/Articles-Previously-Topic/Electronic-PersonalHealth-Records-and-Chronic-Illness.aspx. Accessed June 11, 2015. 8. Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promot Int. 2000;15(3):259-267. 9. Panos RJ, Krywkowski-Mohn SM, Sherman SN, Lach LA. Patient reported determinants of health: a qualitative analysis of veterans with chronic obstructive pulmonary disease. COPD. 2013;10(3): 333-347. 10. Hsu J, Huang J, Kinsman J, et al. Use of e-Health services between 1999 and 2002: a growing digital divide. J Am Med Inform Assoc. 2005;12(2):164-171. 11. Goel MS, Brown TL, Williams A, Cooper AJ, Hasnain-Wynia R, Baker DW. Patient reported barriers to enrolling in a patient portal. J Am Med Inform Assoc. 2011;18(suppl 1):i8-i12.
16. Agarwal R, Anderson C, Zarate J, Ward C. If we offer it, will they accept? Factors affecting patient use intentions of personal health records and secure messaging. J Med Internet Res. 2013;15(2):e43. 17. Assadi V. Adoption of Integrated Personal Health Record Systems: A Self-Determination Theory Perspective [dissertation]. Hamilton, ON: McMaster University; 2013. 18. Butler JM, Carter M, Hayden C, et al. Understanding adoption of a personal health record in rural health care clinics: revealing barriers and facilitators of adoption including attributions about potential patient portal users and self-reported characteristics of early adopting users. AMIA Annu Symp Proc. 2013;2013:152-161. 19. Sue VM, Griffin MT, Allen JY. Beyond adoption: individual differences in the use of personal health record features in an integrated healthcare organisation. Int J Biomed Eng Technol. 2013;11(3):252-269. 20. Kaelber DC, Shah S, Vincent A, et al. The Value of Personal Health Records. Charlestown, MA: Center for Information Technology Leadership; 2008. 21. Wilson ML, Murphy LS, Newhouse RP. Patients’ access to their health information: a meaningful-use mandate. J Nurs Adm. 2012;42(11):493-496. 22. Ahern DK, Woods SS, Lightowler MC, Finley SW, Houston TK. Promise of and potential for patient-facing technologies to enable meaningful use. Am J Prev Med. 2011;40(5 suppl 2):S162-S172. 23. Stylianou A, McCormack H, Kokmotou R. Editorial: applying mHealth solutions. Eur J ePractice. 2013;20:2-4. 24. Chiarini G, Ray P, Akter S, Masella C, Ganz A. mHealth technologies for chronic diseases and elders: a systematic review. IEEE J Selected Areas Commun. 2013;31(9):6-18. 25. Finn NB. e-Patients Live Longer: The Complete Guide to Managing Health Care Using Technology. Bloomington, IN: iUniverse; 2011. 26. Kind EA, Fowles JB, Craft CE, Kind AC, Richter SA. No change in physician dictation patterns when visit notes are made available online for patients. Mayo Clin Proc. 2011;86(5):397-405.
12. Chunchu K, Mauksch L, Charles C, Ross V, Pauwels J. A patient centered care plan in the EHR: improving collaboration and engagement. Fam Syst Health. 2012;30(3):199-209.
27. McCarthy DB, Propp K, Cohen A, Sabharwal R, Schachter AA, Rein AL. Learning from Health Information Exchange Technical Architecture and Implementation in Seven Beacon Communities. EGEMS (Wash DC). 2014;2(1):1060.
13. Urowitz S, Wiljer D, Dupak K, et al. Improving diabetes management with a patient portal: a qualitative study of diabetes self-management portal. J Med Internet Res. 2012;14(6):e158.
28. Haddad M, Chetty G. Development of a smart e-health portal for chronic disease management. Algorithms and Architectures for Parallel Processing. 2012;7440:284-291.
14. Weitzman ER, Kaci L, Quinn M, Mandl KD. Helping high-risk youth move through high-risk periods: personally controlled health records for improving social and health care transitions. J Diabetes Sci Tech. 2011;5(1):47-54.
29. Greysen SR, Khanna RR, Jacolbia R, Lee HM, Auerbach AD. Tablet computers for hospitalized patients: a pilot study to improve inpatient engagement. J Hosp Med. 2014;9(6):396-399.
15. Casper GR, Brennan PF. Project HealthDesign: a preliminary program-level report. AMIA Annu Symp Proc. 2013;2013:192-199.
journal.publications.chestnet.org
30. Gorin SNS, Senathirajah Y. The future of prevention in primary care. In: Gorin SS, ed. Prevention Practice in Primary Care. New York, NY: Oxford University Press; 2013:268-306.
277