Understanding patient-provider communication entered via a patient portal system

ABSTRACT Our study examines patient-provider communication via a patient portal in a large medical center. Our study is based on 1172 interactions made among stakeholders concerning 100 patients who are randomly selected from the 2009 MyHealthAtVanderbilt.com (a patient portal at the Vanderbilt Medical Center) patient pool; among which, 35 use the patient portal for messages. The findings show a wide range of topics discussed and ways in which patients provide and seek information as well as express psychosocial and emotional needs. In addition, while the patient portal has advantages over traditional communication technologies, it was not the primary communication media for our study sample. More research is needed to better elucidate barriers to the use of patient portals and the optimal methods of communication in differing contexts

Engaging Pregnant Women in Kenya with a Hybrid Computer-Human SMS Communication System

A growing body of HCI4D research studies the use of SMS communication to deliver health and information services to underserved populations. This paper contributes a novel dimension to this field of study by examining if a hybrid computer-human SMS system can engage pregnant women in Kenya in health-related communication. Our approach lever- ages the different strengths of both the computer and the human. The computer automates the bulk-sending of personalized messages to patients, allowing the human to read patients’ replies and respond to those in need of attention. Findings from a 12-month deployment with 100 women show that our approach is capable of engaging the majority of participants in health-related conversations. We show that receiving messages from the system triggers participant communication and the amount of communication increases as participants approach their expected due date. In addition, analysis of participants’ messages shows that they often contain sensitive health information conveyed through a complex mixture of languages and ‘txting’ abbreviations, all of which highlight the benefits of including a human in the workflow. Our findings are relevant for HCI researchers and practitioners interested in understanding or engaging underserved populations

A Systems Engineering Approach to a Just-In-Time intervention system

Systems Engineering, a diverse engineering field provides tools and processes to develop efficient systems across different domains. Design thinking, and Agile methodologies are some of the commonly used tools in system design. A mobile health solution using Systems Engineering principle is proposed in managing one of the costliest and common chronic diseases, Asthma. Out of many chronic diseases, Asthma is chosen to be studied, since it has shown a multi-fold increase in the last thirty years. Also, one in nine children in the United States is affected by Asthma. There is no cure for this chronic disease, but it can be controlled by proper medication and symptom tracking. The Just-in-Time Asthma Self-Management and Intervention (JASMIN) is a hybrid mobile application that provides efficient ways for patients to track the asthma symptoms, to learn and get educated about Asthma and their allergens, to communicate and get the necessary support from the care team in the long-term asthma control. JASMIN system is built on a Bio-Behavioral model which encourages and enables the use of system including parents, peers, school personnel and health care providers. JASMIN sends text message interventions to the entire care team when the child fails to track the symptom, ensuring the regularity in symptom adherence. The action plan which is rarely used when written in a physical journal has been given a digital form in JASMIN enabling the provider or parent to update it whenever the need arises. JASMIN is proposed to be used in a pilot study at East Tennessee Children Hospital recruiting 60 children who are between 7-17 years old and their parents and the providers treating their asthma

Email is Alive: How to Communicate with Graduate College Students

The purpose of this research is to ascertain how graduate college students prefer to be communicated with regarding academic deadlines, professional development events and social events. Living in a Web 3.0 world, where people are never alone, but rather always connected, there are several methods to share information. I focus on email, websites, text messaging, instant messaging, and Facebook. For the richest data, I used both quantitative and qualitative methods. First, I conducted focus groups and then designed and distributed a survey. If more engaged students are the more successful, they first need to be aware of ways to get engaged. What is the best form of communication to convey the information that will engage them? Results showed that graduate students prefer email over text messaging and instant messaging when receiving information regarding academic deadlines, professional development events, and social events

Harnessing Collaborative Technologies: Helping Funders Work Together Better

This report was produced through a joint research project of the Monitor Institute and the Foundation Center. The research included an extensive literature review on collaboration in philanthropy, detailed analysis of trends from a recent Foundation Center survey of the largest U.S. foundations, interviews with 37 leading philanthropy professionals and technology experts, and a review of over 170 online tools.The report is a story about how new tools are changing the way funders collaborate. It includes three primary sections: an introduction to emerging technologies and the changing context for philanthropic collaboration; an overview of collaborative needs and tools; and recommendations for improving the collaborative technology landscapeA "Key Findings" executive summary serves as a companion piece to this full report

Good practice guide in learning and teaching

Once again this publication is produced to celebrate and promote good teaching and learning support and to offer encouragement to those imaginative and innovative staff who continue to wish to challenge students to learn to maximum effect. It is hoped that others will pick up some good ideas from the articles contained in this volume. We have again changed our approach for this 2007/08 edition (our fifth) of the Aston Business School Good Practice Guide. As before, some contributions were selected from those identifying interesting best practice on their Annual Module Reflection Forms in 2006/2007. Brookes? contribution this year is directly from her annual reflection. Other contributors received HELM (Research Centre in Higher Education Learning and Management) small research grants in 2006/2007. Part of the conditions were for them to write an article for this publication. We have also been less tight on the length of the articles this year. Some contributions are, therefore, on the way to being journal articles. HELM will be working with these authors to help develop these for publication. Looking back over the last five years it is brilliant to see how many different people have contributed over the years and, therefore, how much innovative learning and teaching work has been taking place in ABS over this time. In the first edition we were just pleased for people to write a few pages on their teaching. Now things have changed dramatically. The majority of the articles are grounded in empirical research (some funded by HELM small research grants) and Palmer?s article was produced as part of the University?s Postgraduate Certificate in Learning and Teaching. Most encouraging of all, four of this year?s articles have since been developed further and submitted to refereed journals. We await news of publication as we go to press. It is not surprising that how to manage large groups still remains a central theme of the articles, ABS has a large and still growing student body. Essex and Simpson have looked at trying to encourage students to attend taught sessions, on the basis that there is a strong correlation between attendance and higher performance. Their findings are forming the platform of a further study currently being carried out in the Undergraduate Programme. A number of the other articles concentrate on trying to encourage students to engage with study in an innovative way. This is particularly obvious in Shaw?s work. Everyone who has been around campus lately has had evidence that the students on Duncan?s modules have clearly been inspired. I found myself, for example, playing golf in the student dining room as part of this initiative! The articles by Jarzabkowski & Guilietti and Ho involved much larger surveys. This is another first for the Good Practice Guide and marks the first step on what will clearly be larger research efforts for these authors in this area. We look forward to the journal publications which will result from this work. The last articles are the result of HELM?s hosting of the national conference of the Higher Education Academy?s Business, Management, Accounting and Finance (BMAF) Subject Centre Conference in May 2007. Belal and Foster have written about their impressions of the Conference and Andrews has included the paper she gave. The papers on employability and widening participation are the centre of HELM?s current work. In the second volume we mentioned the launch of the School?s Research Centre in Higher Education Learning and Management (HELM). Since then HELM has stimulated a lot of activity across the School (and University) particularly linking research and teaching. A list of the HELM seminars for 2007/2008 is listed as Appendix 1 of this publication. Further details can be obtained from Catherine Foster ([email protected]), who coordinates the HELM seminars. We have also been working on a list of target journals to guide ABS staff who wish to publish in this area. These are included as Appendix 2 of this publication. May I thank the contributors for taking time out of their busy schedules to write the articles and to Julie Green, the Quality Manager, for putting the varying diverse approaches into a coherent and publishable form and for agreeing to fund the printing of this volume

What\u27s in a Message? The Impact of Patient-Clinician Email Message Content on Patient Health Outcomes and Healthcare Utilization

Introduction In the upcoming chapters, we present our study findings as three papers ready for submission to peer-reviewed journals. The first paper describes the associations between taxa and the characteristics of the patients and clinic staff who exchange those messages. The second paper explores the associations between those taxa and patients’ healthcare utilization. The third paper presents associations between taxa and patient health outcomes for diabetes and hypertension. We conclude with how the three papers are related and highlight the importance of this research. Across the three papers, we reference a theory-based taxonomy we developed specifically for secure messaging. A number of researchers have created taxonomies to classify secure message content. Although these contained common themes, many were used only once or twice in published research and few classified content generated by clinic staff. We built our taxonomy upon commonly used themes from these existing classification systems. In contrast with other researchers, however, we leveraged theoretical constructs to group taxa and identify the concepts within messages that must be present for logical linkages between message content and patient outcomes. To identify why patients might outreach to clinicians during times of uncertainty, we referenced Mishel’s Uncertainty in Illness Theory (Mishel, 1988, 1999). We leveraged the framework developed by Street, Makoul, Arora, and Epstein (2009) to highlight patient task-oriented requests that might manifest in secure messages (e.g., to support self-care, satisfaction), and clinician-generated content that might support improved patient health outcomes. Our three papers present the first reports using this taxonomy and are the first to explore associations between taxa, patient outcomes, and the senders’ and receivers’ characteristics. We sampled patients with diabetes and/or hypertension to demonstrate that our taxonomy could be applied to different health conditions, and to highlight any differences in taxa use based on health condition. We included threads initiated and completed between January 1 and December 31, 2017. Our study included 2111 patients, of whom 49 percent initiated 7346 threads that included 10163 patient-generated messages and 8146 messages generated by 674 unique clinic staff (hereafter referred to as clinician-generated messages). Patient and Clinic Staff Characteristics Associated with Message Content In the first paper, we described the coding process and interrater and intrarater reliability derived from that process, and then presented our findings on the characteristics of the senders and receivers associated with selected taxa. We estimated both unadjusted and adjusted differences in characteristics associated with the use of each taxon. We assessed taxon use as a dichotomous variable that was positive if the patient or clinician sent or received at least one message coded with the selected taxon. For patient-generated taxa, we explored associations with the characteristics of the sender (which types of patients sent these taxa) and receiver (which types of clinic staff received these types of content). Similarly, we explored the associations between clinician-generated taxa and the characteristics of the sender (what types of clinic staff sent these taxa) and receiver (what types of patients were the recipients of this content). We created separate regression models for patient characteristics (demographic, geographic, health condition and status, and thread volume) and staff characteristics (staff type, specialty, and message volume). Our patient-level analyses included only the 1031 patients who initiated message threads using the patient portal. Our analyses found differences in taxa use by patients’ age, sex, race, health condition and status, and distance from clinic. Younger patients and females were less likely to share certain types of information with clinic staff (clinic updates among younger patients OR=0.77; 95% CI: 0.65-0.91; self-reporting biometrics by women OR=0.78; 95% CI: 0.62-0.98). Use of certain types of task-oriented requests varied by age (younger patients’ prescription refills OR=0.77; 95% CI: 0.65-0.90 and scheduling requests OR=1.41; 95% CI: 1.19-1.68) and race (black vs white requests for preventive care appointments OR=2.68; 95% CI: 1.30-5.51, requests for a new or changed prescription OR=0.72; 95% CI: 0.53-0.98, and laboratory or other diagnostic procedures OR=0.66; 95% CI: 0.46-0.95). Younger and uninsured patients were less likely to receive medical guidance from clinic staff (OR=0.84; 95% CI: 0.71-0.99 and OR=0.21; 95% CI: 0.06-0.72, respectively), but patients with public payers were two times more likely to receive medical guidance compared to patients with private payers (95% CI: 1.27-3.24). Females were less likely to receive confirmation that requests were fulfilled (OR=0.81; 95% CI: 0.68-0.97). These findings highlight differences in how patients used secure messaging to communicate with their clinic staff, which could result in differential access to care. Further, the differences in taxa use by clinic staff by patients’ characteristics might further exacerbate existing disparities in care and highlight opportunities for training and education to reduce these discrepancies. Healthcare Services Utilization Associated with Message Content The Street, Makoul, et al. (2009) framework highlights access to care as an intermediate outcome in the pathway between health outcomes and communication functions such as information exchange, enabling self-care, and making decisions. Patients reported that effective communication delivered through secure messaging prevented unnecessary appointments (Alpert, Markham, Bjarnadottir, & Bylund, 2019); however, prior studies that explored links between secure messaging and healthcare utilization only considered message volume, not what was said in those messages. Our second paper is the first to explore whether content is associated with healthcare utilization. We measured utilization in four ways: number of outpatient visits, number of emergency department visits, number of inpatient visits, and medication adherence. We created separate medication adherence dichotomous variables for diabetes and hypertension, based on having an average condition-specific medication possession ratio greater than 0.8 (Clifford, Perez-Nieves, Skalicky, Reaney, & Coyne, 2014; Khunti, Seidu, Kunutsor, & Davies, 2017; Krass, Schieback, & Dhippayom, 2015; Schulz et al., 2016). We measured our independent variables as the taxon prevalence among patient- or clinician-generated taxa, as appropriate. Our covariates included the patient characteristics described in the first paper. To estimate incidence rate ratios for the three visit dependent variables, we conducted Poisson regressions with robust variance estimation (Hilbe, 2014). We estimated the odds of medication adherence associated with each taxon using logistic regression. In unadjusted analyses, we found that patients who initiated message threads had higher numbers of outpatient visits (p\u3c0.0001) and better hypertension medication adherence (p\u3c0.01), compared to patients who did not initiate threads. Among patients who initiated message threads, we identified a positive association between emergency department visits and prevalence of request denials from clinic staff (IRR=1.18; 95% CI: 1.03, 1.35) and patients’ requests for follow-up appointments (IRR=1.15; 95% CI: 1.07-1.23), as well as between clinic non-response and the number of outpatient visits (IRR=1.02; 95% CI: 1.00, 1.03). We identified an inverse association between hypertension medication adherence and patients’ appointment reschedule requests (OR=0.87; 95% CI: 0.79-0.96). These findings highlight opportunities for future research about the use of secure messaging to influence care delivery and access to care. Patient Health Outcomes Associated with Message Content Patients whose uncertainty in their illness is addressed experience less stress, leading to better health outcomes (Mishel, 1988). Through appropriate communication functions with clinicians, patients develop better understanding of their condition and how to manage it and may have improved access to care and self-care skills, which leads to better outcomes (Street, Makoul, et al., 2009). Our third paper describes the first study to assess the types of message content associated with improved health outcomes. We examined changes in patients’ glycemic index (A1C) for patients with diabetes and changes in diastolic (DBP) and systolic blood pressure (SBP) among patients with hypertension, comparing patients who sent or received messages with selected taxa to (1) those who sent other types of messages and (2) those who did not initiate threads in 2017. We measured outcome changes as the difference between baseline (the last measured value in 2016) and endpoint (the first measured value reported in 2018) measures. Similar to the analyses conducted for Paper 2, our independent variables were the prevalence of each taxon by patient, where the denominator was the number of patient- or clinician-generated taxa, as appropriate for the selected taxon. Analyses included only patients with the selected condition: 811 patients with diabetes only, 787 patients with hypertension only, and 513 patients with both conditions. We used linear regression to identify associations between the outcomes and each taxon. In unadjusted analyses, we found that patients who initiated threads had lower endpoint A1Cs (p=0.01) compared to patients who did not initiate threads. We observed improvements in A1C among patients who sent information seeking messages (b=-0.07; 95% CI: -0.13, -0.00). We also observed improved SBP associated with clinic non-response to patients’ threads (b=-0.30; 95% CI: -0.56, -0.04), staff acknowledgement and fulfillment of patients’ requests (b=-0.30; 95% CI: -0.58, -0.02), and patients’ complaints (b=-4.03; 95% CI: -7.94, -0.12). Poorer outcomes were associated with information sharing messages among patients with diabetes (b=0.08; 95% CI: 0.01, 0.15), and deferred information sharing by clinic staff among patients with hypertension (SBP b=1.29; 95% CI: 0.4-2.19). In addition, among patients with either condition, we observed positive associations between outcome and patient- and clinician-generated appreciation and praise messages with effect sizes ranging from 0.4 (A1C) to 5.69 (SBP). These findings demonstrate associations between outcomes and message content and further emphasize the need for training and education of clinic staff on appropriate use of secure messaging to prevent exacerbation of health disparities due to differential communication delivered through this modality. Conclusion We identified patient characteristics associated with patients’ use of taxa; not surprisingly, patients’ use of taxa varied by age, sex, and race. Taxa use varied by clinic staff characteristics consistent with the triage systems employed by most healthcare organizations (Heyworth et al., 2013; Ozkaynak et al., 2014; Wooldridge, Carayon, Hoonakker, Musa, & Bain, 2016). We also identified differences in staff’s taxa use based on the characteristics of the patient to whom they were sending the message. We further identified associations between taxa and healthcare utilization and health outcomes. If certain types of patients use taxa less frequently, and these taxa are associated with better outcomes or more appropriate utilization, then that presents opportunities to target those populations for education to shift their use of secure messaging. Further, if clinician-generated message content is associated with improved outcomes and clinic staff are not equitably sharing that content with all patients, there is an opportunity for education and training. Our research is a set of first-of-its-kind analyses that highlight differences in taxa use by both patients and clinicians and demonstrates the associations between those taxa and patient outcomes. Healthcare administrators and clinic staff should be aware of these associations and consider mitigation strategies to improve equitable secure messaging use by their staff and across their patient populations. The studies shared several limitations discussed in more detail in the papers themselves. These limitations included a need for more specificity in the taxa definitions and more rigorous coding processes, the lack of temporal indicators in the analysis, and limited patient and clinical characteristics. The analyses that incorporated A1C measurements suffered from significant missing data. Sample size for some taxa was limited so that the algorithms did not converge. The analyses were based on single taxa, which represented only one component of the overall thread discussion. Finally, our message sample included only those messages saved to patients’ charts, which likely led to an underrepresentation of taxa and clinic non-response. We highlighted a number of opportunities for future research across the three studies. Consideration should be given to refining taxa definitions and applying more rigorous coding practices, incorporating temporal elements into the analyses to provide context and support assessments of causality, adding relevant covariates such as message reading level or patients’ health literacy levels, and exploring other proximal and intermediate outcomes identified in the Street, Makoul, et al. (2009) framework. We also strongly recommend examining the impact of taxa pairings: analyses that consider the call-and-response nature of the full conversation occurring within the thread