Training to Optimize Collaborative Use of an Inpatient Portal

Improving Provisioning of an Inpatient Portal: Perspectives from Nursing Staff

BACKGROUND

 Inpatient portals are recognized to provide benefits for both patients and providers, yet the process of provisioning tablets to patients by staff has been difficult for many hospitals.

OBJECTIVE

 Our study aimed to identify and describe practices important for provisioning an inpatient portal from the perspectives of nursing staff and provide insight to enable hospitals to address challenges related to provisioning workflow for the inpatient portal accessible on a tablet.

METHODS

 Qualitative interviews were conducted with 210 nursing staff members across 26 inpatient units in six hospitals within The Ohio State University Wexner Medical Center (OSUWMC) following the introduction of tablets providing access to an inpatient portal, MyChart Bedside (MCB). Interviews asked questions focused on nursing staffs' experiences relative to MCB tablet provisioning. Verbatim interview transcripts were coded using thematic analysis to identify factors associated with tablet provisioning. Unit provisioning performance was established using data stored in the OSUWMC electronic health record about provisioning status. Provisioning rates were divided into tertiles to create three levels of provisioning performance: (1) higher; (2) average; and (3) lower.

RESULTS

 Three themes emerged as critical strategies contributing to MCB tablet provisioning success on higher-performing units: (1) establishing a feasible process for MCB provisioning; (2) having persistent unit-level MCB tablet champions; and (3) having unit managers actively promote MCB tablets. These strategies were described differently by staff from the higher-performing units when compared with characterizations of the provisioning process by staff from lower-performing units.

CONCLUSION

 As inpatient portals are recognized as a powerful tool that can increase patients' access to information and enhance their care experience, implementing the strategies we identified may help hospitals' efforts to improve provisioning and increase their patients' engagement in their health care.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Care Team Perspectives About an Inpatient Portal: Benefits and Challenges of Patients' Portal Use During Hospitalization

While current research about inpatient portals has focused largely on the patient perspective, it is also critical to consider the care team point of view, as support from these individuals is essential to successful portal implementation and use. We held brief in-person interviews with 433 care team members across a six-hospital health system to explore opinions about patients' use of an inpatient portal as perceived by care team members. Using the Inpatient Portal Evaluation Framework, we characterized benefits and challenges of portal use that care team members reported affected patients, themselves, and the collaborative work of these care teams with their patients. Interviewees noted inpatient portals can improve patient care and experience and also indicated room for improvement in portal use for hospitalized patients. Further understanding of the care team perspective is critical to inform approaches to inpatient portal implementation that best benefit both patients and providers.

Facilitating Organizational Change to Accommodate an Inpatient Portal

BACKGROUND

Patient portals are becoming more commonly used in the hospital inpatient setting. While the potential benefits of inpatient portals are acknowledged, there is a need for research that examines the challenges of portal implementation and the development of best practice approaches for successful implementation.

OBJECTIVE

We conducted this study to improve our understanding of the impact of the implementation of an inpatient portal on care team members in the context of a large academic medical center. Our study focused on the perspectives of nursing care team members about the inpatient portal.

METHODS

We interviewed care team members (n = 437) in four phases throughout the 2 years following implementation of an inpatient portal to learn about their ongoing perspectives regarding the inpatient portal and its impact on the organization.

RESULTS

The perspectives of care team members demonstrated a change in acceptance of the inpatient portal over time in terms of buy-in, positive workflow changes, and acknowledged benefits of the portal for both care team members and patients. There were also changes over time in perspectives of the care team in regards to (1) challenges with new technology, (2) impact of the portal on workflow, and (3) buy-in. Six strategies were identified as important for implementation success: (1) convene a stakeholder group, (2) offer continual portal training, (3) encourage shared responsibility, (4) identify champions, (5) provide provisioning feedback, and (6) support patient use.

CONCLUSION

Inpatient portals are recognized as an important tool for both patients and care team members, but the implementation of such a technology can create challenges. Given the perspectives care team members had about the impact of the inpatient portal, our findings suggest implementation requires attention to organizational changes that are needed to accommodate the tool and the development of strategies that can address challenges associated with the portal.

Exploring the Digital Divide: Age and Race Disparities in Use of an Inpatient Portal

Background: Age and race disparities in the use of new technologies-the digital divide-may be limiting the potential of patient-facing health information technology to improve health and health care. Objective: To investigate whether disparities exist in the use of patient portals designed specifically for the inpatient environment. Methods: Patients admitted to the six hospitals affiliated with a large, Midwestern academic medical center from July 2017 to July 2018 were provided with access to a tablet equipped with an inpatient portal and recruited to participate in the study (n = 842). Demographic characteristics of study enrollees were obtained from patients' electronic health records and surveys given to patients during their hospital stay. Log files from the inpatient portal were used to create a global measure of use and calculate use rates for specific portal features. Results: We found both age and race disparities in use of the inpatient portal. Patients aged 60-69 (45.3% difference, p < 0.001) and those over age 70 (36.7% difference, p = 0.04) used the inpatient portal less than patients aged 18-29. In addition, African American patients used the portal less than White patients (40.4% difference, p = 0.004). Discussion: These findings suggest that the availability of the technology alone may be insufficient to overcome barriers to use and that additional intervention may be needed to close the digital divide. Conclusions: We identified lower use of the inpatient portal among African American and older patients, relative to White and younger patients, respectively.

Patient Portals Facilitating Engagement With Inpatient Electronic Medical Records: A Systematic Review

Background

Engaging patients in the delivery of health care has the potential to improve health outcomes and patient satisfaction. Patient portals may enhance patient engagement by enabling patients to access their electronic medical records (EMRs) and facilitating secure patient-provider communication.

Objective

The aim of this study was to review literature describing patient portals tethered to an EMR in inpatient settings, their role in patient engagement, and their impact on health care delivery in order to identify factors and best practices for successful implementation of this technology and areas that require further research.

Methods

A systematic search for articles in the PubMed, CINAHL, and Embase databases was conducted using keywords associated with patient engagement, electronic health records, and patient portals and their respective subject headings in each database. Articles for inclusion were evaluated for quality using A Measurement Tool to Assess Systematic Reviews (AMSTAR) for systematic review articles and the Quality Assessment Tool for Studies with Diverse Designs for empirical studies. Included studies were categorized by their focus on input factors (eg, portal design), process factors (eg, portal use), and output factors (eg, benefits) and by the valence of their findings regarding patient portals (ie, positive, negative, or mixed).

Results

The systematic search identified 58 articles for inclusion. The inputs category was addressed by 40 articles, while the processes and outputs categories were addressed by 36 and 46 articles, respectively: 47 articles addressed multiple themes across the three categories, and 11 addressed only a single theme. Nineteen articles had high- to very high-quality, 21 had medium quality, and 18 had low- to very low-quality. Findings in the inputs category showed wide-ranging portal designs; patients’ privacy concerns and lack of encouragement from providers were among portal adoption barriers while information access and patient-provider communication were among facilitators. Several methods were used to train portal users with varying success. In the processes category, sociodemographic characteristics and medical conditions of patients were predictors of portal use; some patients wanted unlimited access to their EMRs, personalized health education, and nonclinical information; and patients were keen to use portals for communicating with their health care teams. In the outputs category, some but not all studies found patient portals improved patient engagement; patients perceived some portal functions as inadequate but others as useful; patients and staff thought portals may improve patient care but could cause anxiety in some patients; and portals improved patient safety, adherence to medications, and patient-provider communication but had no impact on objective health outcomes.

Conclusions

While the evidence is currently immature, patient portals have demonstrated benefit by enabling the discovery of medical errors, improving adherence to medications, and providing patient-provider communication, etc. High-quality studies are needed to fully understand, improve, and evaluate their impact.

Empowering Patients during Hospitalization: Perspectives on Inpatient Portal Use

BACKGROUND

Patients have demonstrated an eagerness to use portals to access their health information and connect with care providers. While outpatient portals have been extensively studied, there is a recognized need for research that examines inpatient portals.

OBJECTIVE

We conducted this study to improve our understanding about the role of a portal in the context of inpatient care. Our study focused on a large sample of the general adult inpatient population and obtained perspectives from both patients and care team members about inpatient portal use.

METHODS

We interviewed patients (n = 120) who used an inpatient portal during their hospitalization at 15 days or 6 months after discharge to learn about their portal use. We also interviewed care team members (n = 331) 4 weeks, 6 months, and 12 months after inpatient portal implementation to collect information about their ongoing perspectives about patients' use of the portal.

RESULTS

The perspectives of patients and care team members generally converged on their views of the inpatient portal. Three features-(1) ordering meals, (2) looking up health information, and (3) viewing the care team-were most commonly used; the secure messaging feature was less commonly used and of some concern to care team members. The inpatient portal benefited patients in four main ways: (1) promoted independence, (2) reduced anxiety, (3) informed families, and (4) increased empowerment.

CONCLUSION

Inpatient portals are recognized as a tool that can enhance the delivery of patient-centered care. In addition to empowering patients by increasing their sense of control, inpatient portals can support family members and caregivers throughout the hospital stay. Given the consistency of perspectives about portal use across patients and care team members, our findings suggest that inpatient portals may facilitate shifts in organizational culture that increase the patient centeredness of care and improve patient experience in the hospital context.

How Patients Use a Patient Portal: An Institutional Case Study of Demographics and Usage Patterns

BACKGROUND

Given the widespread electronic health record adoption, there is increasing interest to leverage patient portals to improve care.

OBJECTIVE

To determine characteristics of patient portal users and the activities they accessed in the patient portal.

METHODS

We performed a retrospective analysis of patient portal usage at University of California, Los Angeles, Health from July 2014 to May 2015. A total dataset of 505,503 patients was compiled with 396,303 patients who did not register for the patient portal and 109,200 patients who registered for a patient portal account. We compared patients who did not register for the online portal to the top 75th percentile of users based on number of logins, which was done to exclude those who only logged in to register. Finally, to avoid doing statistical analysis on too large of a sample and overpower the analysis, we performed statistical tests on a random sample of 300 patients in each of the two groups.

RESULTS

Patient portal users tended to be older (49.45 vs. 46.22 years in the entire sample, p = 0.008 in the random sample) and more likely female (62.59 vs. 54.91% in the entire sample, p = 0.035 in the random sample). Nonusers had more monthly emergency room (ER) visits on average (0.047 vs. 0.014, p < 0.001). The most frequently accessed activity on the portal was viewing laboratory results (79.7% of users looked at laboratory results).

CONCLUSION

There are differences between patient portal users and nonusers, and further understanding of these differences can serve as foundation for further investigation and possible interventions to drive patient engagement and health outcomes.

Understanding Secure Messaging in the Inpatient Environment: A New Avenue for Communication and Patient Engagement

BACKGROUND

Patient portals, and the secure messaging feature in particular, have been studied in the outpatient setting, but research in the inpatient setting is relatively less mature.

OBJECTIVE

To understand the topics discussed in secure messaging in the inpatient environment, we analyzed and categorized messages sent within an inpatient portal.

MATERIALS AND METHODS

This observational study examined the content of all secure messages sent from December 2013 to June 2017 within an inpatient portal at a large Midwestern academic medical center (AMC). We analyzed a total of 2,598 messages, categorizing them by sender (patient, family, or care team member), type, and topic, and conducted a descriptive analysis of categories and an examination of code co-occurrence.

RESULTS

Patients were the most frequent message senders (63%); family members sent the fewest messages (10%). We identified five types of messages: Alert/Request; Thanks; Response; Question; and Other (typo/test message). Patient messages included Alerts/Requests (38%), Questions (31%), Statements of Thanks (24%), Response (1.2%), and Other (5%). We also identified 14 nonmutually exclusive message topics: Medication; Procedure/Treatment Plan; Schedule; Pain; Results; Diet; Discharge; Non-Medication Questions; Provider Requests; Symptoms; Custodial; Technical Issues; Potential Error; and Contact Information. Patient message topics most commonly discussed Symptoms (18%), Procedure/Treatment Plan (14%), or Pain (12%).

CONCLUSION

Our analysis of secure message content suggests certain message types and topics such as Alerts/Requests and Questions about symptoms and treatment plans are particularly important to patients. These findings demonstrate that both patients and family members utilize the secure messaging function to engage in the care process by posing questions, making requests, and alerting staff to problems. As this technology is implemented in additional facilities, future work should examine how use of secure messaging may be influenced by factors including patients' demographics, reasons for hospitalization, and length of stay.

Communicating with Vulnerable Patient Populations: A Randomized Intervention to Teach Inpatients to Use the Electronic Patient Portal

BACKGROUND

Patient portals are expanding as a means to engage patients and have evidence for benefit in the outpatient setting. However, few studies have evaluated their use in the inpatient setting, or with vulnerable patient populations.

OBJECTIVE

This article assesses an intervention to teach hospitalized vulnerable patients to access their discharge summaries using electronic patient portals.

METHODS

Patients at a safety net hospital were randomly assigned to portal use education or usual care. Surveys assessed perceptions of discharge paperwork and the electronic portal.

RESULTS

Of the 202 prescreened eligible patients (e.g., deemed mentally competent, spoke English, and had a telephone), only 43% had working emails. Forty-four percent of participants did not remember receiving or reading discharge paperwork. Patients trained in portal use (n = 47) or receiving usual care (n = 23) preferred hospitals with online record access (85 and 83%, respectively), and felt that online access would increase their trust in doctors (85 and 87%) and satisfaction with care (91% each). Those who received training in portal use were more likely to register for the portal (48% vs. 11%; p < 0.01).

CONCLUSION

Patients had positive perceptions of portals, and education increased portal use. Lack of email access is a notable barrier to electronic communication with vulnerable patients.