Introduction of a Medical Patient Portal to the Uninsured Patient

abstract: Purpose: The purpose of this evidence-based practice project was to improve participation by increasing registration on to a medical patient portal to an uninsured population. Medical patient portals have the potential to provide patients with timely, transparent access to health care information and engage them in their health care process and management. This may result in improved disease management outcomes. Methods: This project was guided by a The Rosswurm and Larrabee Model for Change to Evidence- Based Practice and Pender’s health promotion framework. IRB Approved by ASU. The instruction was implemented at an urban clinic in downtown phoenix that serves uninsured and underserved individuals. Uninsured participants were recruited (n=50). A survey pre and post registration was conducted to assess knowledge and medical portal participation in addition a random pre and post chart review was performed. Results: Descriptive statistics was used to describe sample and outcome variables. A chi-square test of independence was calculated comparing pre and post intervention significant change was found (χ2 (1) = .002, P<0.05.), a paired sample t test was calculated to compare knowledge pre and post registration instruction the mean pre-10.187(SD = 4.422), post mean was 16.958(SD=.856). A significant increase of knowledge was found (t (47) =-9.573, p (<.001). Outcomes: In this population both patients and providers have seen significant benefits such as increased communication and patient participation, from the implementation of evidence based educational tools such as instruction with teach back, and the usage of brochures. Potential Implication for sustainability includes the lack of a designated individual that is bilingual to register patients, making patients aware of the existence of a medical patient portal, patient’s fear of sharing immigration status

Factors that affect the use of electronic personal health records among patients: A systematic review

Background: Electronic personal health records (ePHRs) are web-based tools that enable patients to access parts of their medical records and other services. In spite of the potential benefits of using ePHRs, their adoption rates remain very low. The lack of use of ePHRs among patients leads to implementation failures of these systems. Many studies have been conducted to examine the factors that influence patients’ use of ePHRs, and they need to be synthesised in a meaningful way.ObjectiveThe current study aimed to systematically review the evidence regarding factors that influence patients’ use of ePHRs. Methods: The search included: 42 bibliographic databases (e.g. Medline, Embase, CINHAL, and PsycINFO), hand searching, checking reference lists of the included studies and relevant reviews, contacting experts, and searching two general web engines. Study selection, data extraction, and study quality assessment were carried out by two reviewers independently. The quality of studies was appraised using the Mixed Methods Appraisal Tool. The extracted data were synthesised narratively according to the outcome: intention to use, subjective measures of use, and objective measures of use. The identified factors were categorised into groups based on Or and Karsh’s conceptual framework. Results: Of 5225 citations retrieved, 97 studies were relevant to this review. These studies examined more than 150 different factors: 59 related to intention to use, 52 regarding subjectively-measured use, and 105 related to objectively-measured use. The current review was able to draw definitive conclusions regarding the effect of only 18 factors. Of these, only three factors have been investigated in connection with every outcome, which are: perceived usefulness, privacy and security concerns, and internet access. Conclusion: Of the numerous factors examined by the included studies, this review concluded the effect of 18 factors: 13 personal factors (e.g. gender, ethnicity, and income), four human-technology factors (e.g. perceived usefulness and ease of use), and one organisational factor (facilitating conditions). These factors should be taken into account by stakeholders for the successful implementation of these systems. For example, patients should be assured that the system is secure and no one can access their records without their permission in order to decrease their concerns about the privacy and security. Further, advertising campaigns should be carried out to increase patients’ awareness of the system. More studies are needed to conclude the effect of other factors. In addition, researchers should conduct more theory-based longitudinal studies for assessing factors affecting initial use and continuing use of ePHRs among patients

PATIENT PORTAL USE AND ITS ASSOCIATION WITH CLINICAL OUTCOMES IN PATIENTS WITH TYPE 2 DIABETES

Background: The rapid growth of type 2 diabetes mellitus (T2DM) in the United States presents significant challenges. Patient portals are promising tools that address the increasing number of individuals with T2DM and engage these people in the process of managing their chronic condition. Objectives: The purposes of this study were: 1) to describe the portal usage pattern by individuals with T2DM over the two-year study period; 2) to identify whether sociodemographic, socioeconomic, and clinical characteristics differ between portal users and non-users; and 3) to longitudinally examine the effect of portal use on glycemic control in patients with T2DM. Methods: This two-year retrospective, observational cohort study utilized data from the ambulatory electronic health records (EHR) of the University of Pittsburgh Medical Center (UPMC) Physician Services and its ancillary patient portal. The study included adults seen in an outpatient setting of UPMC between January 2015 and December 2016. We applied descriptive statistics to describe sample characteristics and portal usage patterns. Logistic regression was used to examine factors associated with portal use. A propensity score matching (PSM) technique was conducted to equate the portal user and non-user groups, and mixed modeling was performed to examine the effect of portal use on hemoglobin A1c (HbA1c) over time. Results: Nearly one-third of the individuals (n=12,615, 32.9%, 95% CI: [32.3%,33.3%]) with T2DM used the portals. An increased portal usage was observed before and after a physician visit, and on weekdays compared to weekends (p<0.001). In general, we found associations of age, race, income, and the number of chronic conditions with portal usage, and several other predictors modified these effects (ps<0.05). After PSM, both groups showed a non-linear decline of HbA1c over time (p<.001), and the portal users (n=4,924) demonstrated a greater decrease and better maintenance than the non-users (n=4,924, p<.001). Conclusions: Our findings highlight the promising effect of a patient portal on clinical glycemic control in persons with T2DM. Disparities in patient portals need to be addressed to bridge the existing gaps in diabetes outcomes. Future study should explore mechanisms through which the portal contributes to better clinical outcomes to guide evidence-based portal design and implementation

Effectiveness of Telemedicine in Diabetes Management: A Retrospective Study in an Urban Medically Underserved Population Area (UMUPA).

The purpose of this research is to assess the efficacy of employing telemedicine (TM) technology compared to traditional face-to-face (F2F) visits as an alternative healthcare delivery service for managing diabetes in populations residing in urban medically underserved areas (UMUPA). Researchers investigating public health and healthcare systems fully grasp the enormous challenges encountered by vulnerable populations as a result of healthcare access barriers.1 Prior to the COVID-19 pandemic, F2F visits were most often utilized for healthcare delivery service, which frequently posed barriers for vulnerable populations. When marginalized people, encounter healthcare access barriers, a cascade of events generally occur leading to forestalling or avoiding healthcare services entirely, complicating disease management, resulting in negative health outcomes. This was a novel study examining the hemoglobin A1c (HbA1c) values of 111 patients with uncontrolled type 2 diabetes mellitus (T2DM) and 81 patients with prediabetes. Retrospective electronic patient health records (PHR) from a medical clinic were examined from January 1st, 2019, to June 30th, 2021. The results indicate that lowering HbA1c values for T2DM patients through utilizing TM is similar to outcomes from traditional visits, suggesting that TM may be an alternative mode of healthcare delivery for vulnerable populations. Results for patients with prediabetes were not statistically significant. Patients with uncontrolled diabetes and prediabetes shared a number of similar characteristics; they were predominantly Black, non-Hispanic, females, with a median age of 57 years; and resided in locations with inadequate access to healthcare services in an UMUPA. The majority of patients with uncontrolled diabetes who reside in an UMUPA completed appointments utilized TM technology, lending credence to its potential as an alternative healthcare delivery service for underserved populations. TM technology supports PH and the healthcare system with a viable, alternative strategy for expanding healthcare access where chronic illness and disease pose a significant threat to the health and wellbeing of vulnerable groups. Optimal treatment for patients with diabetes necessitates a proactive, coordinated, systems-thinking team approach. This research supports PH’s endeavors in tackling the long-standing healthcare access barrier challenges in underserved populations

Using the Electronic Patient Portal to Engage Patients with Multiple Chronic Conditions

Three in four Americans aged 65 and older is living with multiple chronic conditions. These patients have complex care needs and stand to benefit from tools facilitating engagement in their healthcare. Little is known regarding use of the electronic patient portal as a tool to support self-care in patients with multiple chronic conditions. The purpose of this multiple-methods study was to (1) explore characteristics and patterns of portal use by patients with multiple chronic conditions and (2) to understand the perceived usefulness of this tool to improve self-care. In phase 1, the quantitative phase, data from electronic health records and web server log files were analyzed. Patients (n=500) who were 45 years or older, registered portal users, and diagnosed with at least two chronic conditions were included in the analysis. No significant differences in portal use were found according to demographic characteristics, distance separating the patient from their primary care provider, and practice size and location. There was a significant difference between patients who accessed the portal to send a message to the provider and patient entered data in regards to logins (p\u3c .001 and p=.03). In phase 2, the qualitative phase, semi-structured interviews with patients (n=9) and providers (n=7) were conducted to understand how patients learn about the portal and their perceptions of usefulness for improving self-care in patients with multiple chronic conditions. Twelve categories related to four broad themes: 1) how patients are introduced to the EPP, 2) perceived benefits of the EPP, 3) perceived barriers to using the EPP, and 4) perceptions of using EPP for self-management of chronic illness were revealed. Implications for further research, policy, and practice are presented

Implementing system-wide risk stratification approaches: a review of critical success and failure factors

An Evidence Check rapid review brokered by the Sax Institute for the NSW Agency for Clinical Innovatio

Impact of implementing a computerised quality improvement intervention in primary healthcare

Health systems worldwide experience large evidence practice gaps with underuse of proven therapies, overuse of inappropriate treatments and misuse of treatments due to medical error. Quality improvement (QI) initiatives have been shown to overcome some of these gaps. Computerised interventions, in particular, are potential enablers to improving system performance. However, implementation of these interventions into routine practice has resulted in mixed outcomes and those that have been successfully integrated into routine practice are difficult to sustain. The objective of this thesis is to understand how a multifaceted, computerised QI intervention for cardiovascular disease (CVD) prevention and management was implemented in Australian general practices and Aboriginal Community Controlled Health Services and assess the implications for scale-up of the intervention. The intervention was implemented as part of a large cluster-randomised controlled trial, the TORPEDO (Treatment of Cardiovascular Risk using Electronic Decision Support) study. The intervention was associated with improved guideline recommended cardiovascular risk factor screening rates but had mixed impact on improving medication prescribing rates. In this thesis, I designed a multimethod process and economic evaluation of the TORPEDO trial. The aims were to: i. Develop a theory-informed logic model to assist in the design of the overall evaluation to address study aims (Chapter 3). ii. Conduct a post-trial audit to quantify changes in cardiovascular risk factor screening and prescribing to high risk patients over an 18-month post-trial period and understand the impact of the intervention outside of a research trial setting (Chapter 4). vi iii. Use normalisation process theory to identify the underlying mechanisms by which the intervention did and did not have an impact on trial outcomes (Chapter 5). iv. Use video ethnography to explore how the intervention was used and cardiovascular risk communicated between patients and healthcare providers (Chapter 6). v. Conduct an economic evaluation to inform policy makers for delivering the intervention at scale through Primary Health Networks in New South Wales (Chapter 7). vi. Use a new theory to explain the factors that drove adoption and non-adoption of the intervention and assess what modifications may be needed to promote spread and scale-up (Chapter 8). I found variable outcomes during the post-trial period with a plateauing of improvements in guideline recommended screening practices but an ongoing improvement in prescribing to high risk patients. The group that continued to have the most benefit was patients at high CVD risk who were not receiving recommended medications at baseline. The delay in prescribing recommended medication suggests healthcare providers adopt a cautious approach when introducing new treatments. Six intervention primary healthcare services participated as case studies for the process evaluation. Qualitative and quantitative data sources were combined at each primary healthcare service to enable a detailed examination of intervention implementation from multiple perspectives. The process evaluation identified the complex interaction between several underlying mechanisms that influenced the implementation processes and explained the mixed trial outcomes: (1) organisational mission; (2) leadership; (3) the role of teams; (4) technical competence and dependability of the software tools. Further, there were different ‘active ingredients’ vii necessary during the initial implementation compared to those needed to sustain use of the intervention. In the video ethnography and post-consultation patient interviews, important insights were gained into how the intervention was used, and its interpretation by the doctor and patient. Through ethnographic accounts, the doctor’s communication of cardiovascular risk was not sufficient in engaging patients and having them act upon their high-risk status; effective communication required interactions be assessed, discussed and negotiated. The economic evaluation identified the cost implications of implementing the intervention as part of a Primary Health Network program in the state of New South Wales, Australia; and modelled data looked at the impact of small but statistically significant reductions in clinical risk factors based on the trial data. When scaled to a larger population the intervention has potential to prevent major CVD events at under AU$50,000 per CVD event averted largely due to the low costs of implementing the intervention. However, the clinical risk factor reductions were small and a stronger case for investment would be made if the effects sizes could be enhanced and sustained over time. The findings from chapters 4-6 provide insight into the intricacy of the barriers influencing implementation processes and adoption of the intervention. Taken together, these studies provide a detailed explanation of the processes that may be required to implement such an intervention at scale and the factors that might influence its impact and sustainability. The findings are expected to assist policy makers, administrators and health professionals in developing multiple interdependent QI strategies at the organisational, provider and consumer levels to improve primary healthcare system performance for cardiovascular disease management and prevention

Patient Web Portal Use Among Women with Gestational Diabetes

Background: The prevalence of gestational diabetes mellitus (GDM) continues to increase. Research suggests that adverse maternal and newborn outcomes increase in relation to the mother’s elevated blood glucose levels. Diabetes researchers discuss that utilizing information technology for self-management, particularly Internet-based modes of delivery, may result in individual improvements in diabetes outcomes. Scant research exists on the use of Internet-based tools such as patient web portals (PWPs) for GDM self-management and outcomes. Purpose: The purpose of this study was to examine PWP use in women with GDM. Specific aims of this study included: 1) compare the characteristics of nonusers and users of a patient web portal (PWP) for self-management including relationships between characteristics and PWP use, 2) in users of the PWP, describe the frequency and patterns of PWP use, and 3) compare glycemic control between PWP users and nonusers. Methods: A retrospective study was conducted using electronic health record (EHR) review of PWP users (n=91) and nonusers (n=67) who sought care in a diabetes and pregnancy clinic for GDM management. Results: PWP users were more likely to be employed fulltime than nonusers (p= .011). There were no statistically significant differences between users and nonusers for the other patient characteristics. Most users accessed the PWP each month in the third trimester but the number of days accessed varied greatly. The AVS [24.31 (SD 25.05)] and appointment reminders [15.44 (SD 17.00)] were accessed most frequently. Glycemic control did not differ significantly between users and nonusers (F (1.520, 191.474) = 184.428, p=.559). Discussion: This research provides insight into the patient characteristics of users and nonusers of a PWP for a non-chronic condition (GDM) and outlines the features of the PWP used. Patient web portals should be further stringently evaluated for their usability in this population of patients including facilitators and barriers to its use as well as dosage of utilization

The Impact of Pre-visit Contextual Data Collection on Patient Activation: Results from a Randomized Control Trial

Background The majority of health indicators are outside of the healthcare system, and current electronic health records (EHR) do not capture those indicators. There is a compelling opportunity to test consumer informatics tools that integrate patient\u27s life circumstances, goals, supports, risks, and care preferences into their EHR for point-of-care discussions. Purpose To determine whether the use of a patient-generated contextual data (PCD) tool designed to enhance the capture and sharing of PCD influenced patient activation. Design, Setting, and Participants A two-armed, non-blind, randomized control trial was conducted between May 2019, and October 2019 at two urban, academically affiliated primary care clinics. 301 patients were enrolled, randomized with stratification by race to study arms. Nearly equal percentages of control and intervention group participants (60.5% vs. 62.4%) and two-thirds of White vs one-third of Black participants completed both assessments (67% vs. 33%). Main outcomes and Measures The main outcome was the pre-/post-visit change in Patient Activation Measure (PAM) score, evaluated using intention-to-treat principles. Analysis was also conducted to determine if patient factors mediated racial differences in baseline PAM scores. Results Using intention-to-treat analysis, there were no significant differences in pre-/post-visit change in PAM scores by arm (p=.079). When allowing for an interaction between race and treatment arm, all interaction terms were not significant (p\u3e0.05). Mediation analysis results indicate income (p=0.025) and difficulty paying monthly bills (p=0.04) when treated as continuous variables, mediated the relationship between race and baseline PAM score. Conclusions and Relevance The findings indicate the PCD Tool did not affect patient activation. Socioeconomic status (SES) mediated baseline racial differences in the PAM score. These data indicate that further study of the relationships among SES and patient activation are needed. The findings also indicate that interventions targeting patient activation need to account for and be sensitive to patient\u27s SES