Descriptive examination of secure messaging in a longitudinal cohort of diabetes patients in the ECLIPPSE study

A Multisite Demonstration of Shared Access to Older Adults' Patient Portals

Importance

The patient portal has a growing role in health care. Many health systems have implemented shared access functionality in which patients may register a care partner with unique identity credentials to access their portal. Uptake of shared access has been limited.

Objective

To examine the outcomes of a multisite demonstration involving organizational strategies associated with registration and use of patient portal shared access.

Design, Setting, and Participants

This quality improvement study was conducted in diverse sites within 3 health systems in the US: (1) geriatric oncology, (2) geriatric medicine, and (3) primary care. Patients aged 65 years or older with 1 or more visits during the 12-month demonstration period (July 1, 2022, through July 1, 2023, for sites 1 and 2; site 3 was delayed 3 months) and care partners who used the portal accounts of patients meeting these criteria were included. The 6-month postdemonstration period (August 1, 2023, through January 1, 2024) was compared with the 6-month predemonstration period (January 1 through June 1, 2022).

Exposures

Organizational strategies (brochures, webpages, tip sheets, and implementation toolkits created using a human-centered design) to encourage shared access registration and use.

Main Outcomes and Measures

Portal registration and use (logins, laboratory results viewed, clinical notes viewed, visits scheduled) by type of access (patient and care partner) from electronic health record data were examined. Patient- and care partner-reported awareness and use of shared access were measured using a postdemonstration survey.

Results

A total of 16 005 patients from the 3 sites met the inclusion criteria (84.8% younger than 85 years and 61.5% women). Most patients had an activated portal account (91.0%) and logged in at least once (84.8%) during the 24 months spanning the demonstration and pre- and postdemonstration periods. New portal registrations were stable, but nonsignificant for shared access (110 of 14 758 [0.7%] vs 91 of 14 016 [0.6%]) and significantly decreased for patient access (677 of 3158 [21.5%] vs 225 of 1520 [13.2%]). Use of shared access before vs after the demonstration increased for number of logins (mean [SD], 5.9 [11.4] vs 6.8 [14.1]), laboratory results viewed (mean [SD], 0.7 [2.7] vs 1.1 [3.7]), clinical notes viewed (mean [SD], 0.2 [1.1] vs 0.6 [3.2]), and visits scheduled (mean [SD], 0.8 [10.8] vs 1.0 [5.4]). Of the 91 care partners reporting portal use in the postdemonstration survey, 48 (52.7%) indicated primarily using patient credentials and 31 (34.1%) indicated primarily using their own credentials. Less than one-half of patients (721 of 1664 [43.3%]) stated being aware of shared access.

Conclusions and Relevance

These findings show no association of the multisite demonstration with increased new registrations for shared access and only modest increases in portal use among care partners of older adults. As portal use expands to encompass legal documentation, medical decision-making, and patient education, policies to support proper use of identity credentials are needed.

Pediatric Clinical Staff Perspectives on Secure Messaging

BACKGROUND

Secure messaging (SM) is a communication feature within a patient portal that allows patients and clinical staff to exchange health-related information securely and confidentially.

PURPOSE

This study aimed to explore how pediatric clinical staff use SM, identify challenges in its implementation, and suggest quality improvements.

METHODS

A descriptive quantitative study was administered using an online survey in a large health care system. The Task, User, Representation, and Function framework guided the research.

RESULTS

The survey participants were moderately satisfied with the SM. Opportunities to design this system to be more efficient and maximize patient safety were identified.

CONCLUSION

Improving training and workflow can aid in incorporating SM into clinician's daily routines, focusing on enhancing user satisfaction. Future developments aimed at increasing usage and standardizing message content are crucial for encouraging adoption and ensuring patient safety.

The CREATE TRUST Communication Framework for Patient Messaging Services

This Viewpoint proposes a messaging framework called CREATE TRUST to improve written communication with patients.

Precision communication: Physicians' linguistic adaptation to patients' health literacy

Little quantitative research has explored which clinician skills and behaviors facilitate communication. Mutual understanding is especially challenging when patients have limited health literacy (HL). Two strategies hypothesized to improve communication include matching the complexity of language to patients’ HL (“universal tailoring”); or always using simple language (“universal precautions”). Through computational linguistic analysis of 237,126 email exchanges between dyads of 1094 physicians and 4331 English-speaking patients, we assessed matching (concordance/discordance) between physicians’ linguistic complexity and patients’ HL, and classified physicians’ communication strategies. Among low HL patients, discordance was associated with poor understanding (P = 0.046). Physicians’ “universal tailoring” strategy was associated with better understanding for all patients (P = 0.01), while “universal precautions” was not. There was an interaction between concordance and communication strategy (P = 0.021): The combination of dyadic concordance and “universal tailoring” eliminated HL-related disparities. Physicians’ ability to adapt communication to match their patients’ HL promotes shared understanding and equity. The ‘Precision Medicine’ construct should be expanded to include the domain of ‘Precision Communication.’

Challenges and solutions to employing natural language processing and machine learning to measure patients' health literacy and physician writing complexity: The ECLIPPSE study

OBJECTIVE

In the National Library of Medicine funded ECLIPPSE Project (Employing Computational Linguistics to Improve Patient-Provider Secure Emails exchange), we attempted to create novel, valid, and scalable measures of both patients' health literacy (HL) and physicians' linguistic complexity by employing natural language processing (NLP) techniques and machine learning (ML). We applied these techniques to > 400,000 patients' and physicians' secure messages (SMs) exchanged via an electronic patient portal, developing and validating an automated patient literacy profile (LP) and physician complexity profile (CP). Herein, we describe the challenges faced and the solutions implemented during this innovative endeavor.

MATERIALS AND METHODS

To describe challenges and solutions, we used two data sources: study documents and interviews with study investigators. Over the five years of the project, the team tracked their research process using a combination of Google Docs tools and an online team organization, tracking, and management tool (Asana). In year 5, the team convened a number of times to discuss, categorize, and code primary challenges and solutions.

RESULTS

We identified 23 challenges and associated approaches that emerged from three overarching process domains: (1) Data Mining related to the SM corpus; (2) Analyses using NLP indices on the SM corpus; and (3) Interdisciplinary Collaboration. With respect to Data Mining, problems included cleaning SMs to enable analyses, removing hidden caregiver proxies (e.g., other family members) and Spanish language SMs, and culling SMs to ensure that only patients' primary care physicians were included. With respect to Analyses, critical decisions needed to be made as to which computational linguistic indices and ML approaches should be selected; how to enable the NLP-based linguistic indices tools to run smoothly and to extract meaningful data from a large corpus of medical text; and how to best assess content and predictive validities of both the LP and the CP. With respect to the Interdisciplinary Collaboration, because the research required engagement between clinicians, health services researchers, biomedical informaticians, linguists, and cognitive scientists, continual effort was needed to identify and reconcile differences in scientific terminologies and resolve confusion; arrive at common understanding of tasks that needed to be completed and priorities therein; reach compromises regarding what represents "meaningful findings" in health services vs. cognitive science research; and address constraints regarding potential transportability of the final LP and CP to different health care settings.

DISCUSSION

Our study represents a process evaluation of an innovative research initiative to harness "big linguistic data" to estimate patient HL and physician linguistic complexity. Any of the challenges we identified, if left unaddressed, would have either rendered impossible the effort to generate LPs and CPs, or invalidated analytic results related to the LPs and CPs. Investigators undertaking similar research in HL or using computational linguistic methods to assess patient-clinician exchange will face similar challenges and may find our solutions helpful when designing and executing their health communications research.