Oncology Clinicians' Perspectives on Online Patient Portal Use in Pediatric and Adolescent Cancer

Acceptability of Adolescent Portal Access Policies to Parents and Adolescents: A Delphi Study

PURPOSE

United States healthcare systems have enacted varied adolescent online patient portal policies. No prior work has established whether these policies are acceptable to adolescents and parents.

METHODS

Mixed-method Delphi approach with 18 parents and 18 adolescents with and without chronic illness. We presented 19 policies related to (1) who can access different types of information through the portal; (2) timing of results release; and (3) portal messaging policies, such as whether individuals are charged for portal messages. Panelists voted on whether they "supported," "could live with," or "opposed" each policy.

RESULTS

Thirty-six panelists completed surveys with no attrition. For access-related policies, panelists opposed prohibiting parent or adolescent access, and they accepted policies that provided transparent access to sensitive and nonsensitive information for parents and adolescents. Panelists failed to reach consensus about whether adolescents should have the granular ability to determine which parts of the medical record their parents can see. For policies related to timing of release, panelists found either immediate or delayed access to results to be acceptable, although more panelists supported immediate access. For portal messaging policies, panelists supported the ability of parents and adolescents to send messages and opposed being charged for portal messages. Panelists found it acceptable for adolescents to see messages written by their parents, but failed to reach consensus on whether parents should see messages written by adolescents.

DISCUSSION

Some healthcare systems have implemented adolescent portal policies that panelists opposed or found concerning. Hospital leaders should consider these data as they re-evaluate institutional policies.

Adolescent and parental proxy online record access: analysis of the empirical evidence based on four bioethical principles

BACKGROUND

During recent decades, providing patients with access to their electronic health records (EHRs) has advanced in healthcare. In the European Union (EU), the General Data Protection Regulation provides individuals with the right to check their data in registries such as EHRs. A proposal for a European Health Data Space has been launched, which will further strengthen patients' right to have online access to their EHRs throughout Europe. Against these policy changes, scant attention has been paid to the ethical question about whether adolescents and parents should access the adolescent's EHR, and if so, under what conditions.

METHODS

In this paper, we apply biomedical ethical principles to explore key questions about adolescents' and parents' access to adolescents' EHRs, with the aim of informing future discussions about the development of ethical and policy practice guidelines.

RESULTS

Drawing on current empirical research, we find preliminary evidence that in some contexts, patient online record access (ORA) could help to facilitate autonomy for adolescents and parents as well as offering support in managing appointments and medications. Notably, however, we find contrasting perspectives between adolescents' and parents' experienced benefits and healthcare professionals' (HCPs) perceived potential harm, with the latter worried about decreased documentation quality after access. Concerns about capacity to understand their health information, and increased anxiety among adolescents obstruct the support of adolescent autonomy among parents and HCPs. Still, research is limited, particularly with respect to adolescents' experiences of reading their EHRs, and differences across settings have not been closely examined.

CONCLUSIONS

To advance more comprehensive understanding of the effects of ORA, and to inspire greater attention to, and development of, evidence-informed ethical guidance in this domain of clinical practice, we outline a range of empirical questions regarding adolescents' and parents' experiences that now warrant further study.

Perspectives on Swedish Regulations for Online Record Access Among Adolescents With Serious Health Issues and Their Parents: Mixed Methods Study

BACKGROUND

With the increasing implementation of patient online record access (ORA), various approaches to access to minors' electronic health records have been adopted globally. In Sweden, the current regulatory framework restricts ORA for minors and their guardians when the minor is aged between 13 and 15 years. Families of adolescents with complex health care needs often desire health information to manage their child's care and involve them in their care. However, the perspectives of adolescents with serious health issues and their parents have not been studied.

OBJECTIVE

This study aims to qualitatively and quantitatively investigate the perceived benefits and risks of ORA and the awareness of and views on ORA regulations among adolescents with serious health issues and their parents in Sweden.

METHODS

We used a convergent mixed methods (qualitative and quantitative) design, consisting of a survey and semistructured individual interviews with adolescents with serious health issues (aged 13-18 y) and their parents. Participants were recruited via social media and in clinics. Quantitative data were presented descriptively. Interviews were audio recorded, transcribed, and analyzed using inductive thematic content analysis.

RESULTS

The survey population included 88 individuals (adolescents: n=31, 35%; parents: n=57, 65%). Interviews were completed by 8 (26%) of the 31 adolescents and 17 (30%) of the 57 parents. The mean age of the surveyed adolescents was 16 (SD 1.458) years, and most of the parents (29/57, 51%) were aged 45 to 54 years. The surveys indicated that most of the parents (51/56, 91%) were critical of the access gap, and most of the adolescents (20/31, 65%) were unaware of the age at which they could gain access. In the interviews, adolescents and parents identified benefits related to ORA that were categorized into 6 themes (empowering adolescents, improved emotional state, enhanced documentation accuracy, improved partnership and communication, supported parental care management, and better prepared for appointments) and risks related to ORA that were categorized into 4 themes (emotional distress and confusion, threatened confidentiality, increased burden, and low usability). Adolescents' and parents' views on ORA regulations were categorized into 3 themes (challenges of the access gap, balancing respect for autonomy and support, and suggested regulatory change).

CONCLUSIONS

In Sweden, ORA regulations and a lack of available information cause significant inconvenience for adolescents with serious health issues and their parents. Views on access age limits differed, with adolescents expressing their perceived need for independent access, while parents exhibited concerns about adolescents having ORA. The findings indicated the importance of increased education, dialogue, and flexibility to uphold confidential and consistent delivery of adolescent health care. Further exploration is needed to understand the experiences of adolescents and parents in diverse clinical and geographic contexts, as well as the perspectives of pediatric health care professionals on restrictive ORA regulations.

Advancing cancer care through digital access in the USA: a state-of-the-art review of patient portals in oncology

Patient portal use among patients with cancer has increased significantly in recent years. This state-of-the-art review seeks to address and analyse literature involving patient portal use by patients with cancer and their care partners. In this review, we queried articles from PubMed published between January 2018 and April 2024 that describe recent trends and the current presence of portals in cancer care for patients, proxy users and/or care partners. We searched for articles addressing three overarching themes: (1) trends and disparities in portal adoption and use among patients with cancer, (2) use of specific portal components and functions in cancer care and (3) associations between portal use and cancer-related outcomes. Our search identified 278 unique studies, of which 82 were relevant empiric studies that met inclusion criteria and were included in this review. These papers aligned with 12 subthemes, including disparities in patient portal access, growing use of telemedicine via patient portal and patient access to immediately available to electronic health information. Our findings indicate that patient portals play an increasingly important role in helping patients manage their cancer care, despite few disparities that contribute to inequitable use. However, despite consistent growth in use over recent years, there are many areas for improvement in how portals support patients with cancer and a demand for functionality to continually evolve with patient needs.

Electronic Communication Between Children's Caregivers and Health Care Teams: Scoping Review on Parental Caregiver's Perceptions and Experience

Background

Asynchronous communication via electronic modes (e-communication), including patient portals, secure messaging services, SMS text messaging, and email, is increasingly used to supplement synchronous face-to-face medical visits; however, little is known about its quality in pediatric settings.

Objective

This review aimed to summarize contemporary literature on pediatric caregivers' experiences with and perspectives of e-communication with their child's health care team to identify how e-communication has been optimized to improve patient care.

Methods

A scoping review following the Arksey and O'Malley methodological framework searched PubMed, CINAHL, Embase, and Web of Science using terms such as "Electronic Health Records" and "Communication" from 2013 to 2023 that discussed caregiver experiences and perspectives of e-communication with their child's health care provider. Studies were excluded if they were abstracts, non-English papers, nonscientific papers, systematic reviews, or quality improvement initiatives, or pertained to synchronous telemedicine. We conducted a two-step screening process by scanning the title and abstract and reviewing the full text by two independent screeners to confirm eligibility. From an initial 903 articles identified via the database search, 23 articles fulfilled all the inclusion criteria and are included in this review.

Results

Of the 23 articles meeting the inclusion criteria, 11 used quantitative methods, 7 used qualitative methods, and 5 used mixed methods. The caregiver sample sizes ranged from 51 to 3339 in the quantitative studies and 8 to 36 in the qualitative and mixed methods studies. A majority (n=17) used the patient portal that was self-categorized by the study. Secure messaging through a portal or other mobile health app was used in 26% (n=6) of the studies, while nonsecure messaging outside of the portal was used 17% (n=4) of the time and email was used 33.3% (n=8) of the time. In 19 of the studies, parents reported positive experiences with and a desire for e-communication methods.

Conclusions

The literature overwhelmingly supported caregiver satisfaction with and desire for e-communication in health care, but no literature intentionally studied how to improve the quality of e-communication, which is a critical gap to address.

Providing Adolescents with Access to Online Patient Portals: Interviews with Parent-Adolescent Dyads

OBJECTIVE

To identify perceived benefits, problems, facilitators, and barriers to adolescent online patient portal use.

STUDY DESIGN

Qualitative, semi-structured interviews with dyads of parents and adolescents with or without chronic illness. The study team purposively sampled for racial and ethnic minorities and fathers. Three team members then performed thematic analysis of the transcripts, with subsequent dyadic analysis of themes represented by related parents and adolescents.

RESULTS

We performed 102 interviews with 51 dyads of parents and adolescents (26 with chronic illness, 25 without chronic illness). Nearly all participants believed that adolescents should be permitted portal access. We identified 4 themes related to portal benefits: improves adolescent's knowledge of health; supports medical self-management and autonomy; strengthens communication and relationships; and supports parental influence. We identified 4 themes related to portal problems: misunderstanding or confusion; emotional distress; strain on relationships; and irresponsible use of portal. Facilitators of portal use included severity of illness, adolescent's curiosity, and ease of technology use. Barriers included lack of awareness or interest, complexity of information, and access difficulties. Twenty adolescents (39%) did not know they could access the portal, and 23 (45%) lacked interest in portals. Parents and adolescents seldom used the portal as a collaborative tool, and instead were engaging with the portal independently.

CONCLUSION

Parents and adolescents perceive several benefits and problems with portal use, but many adolescents lack interest in using portals. Adolescent portals represent an underutilized resource to engage adolescents in their care.

Real-Time Electronic Patient Portal Use Among Emergency Department Patients

Importance

Patients with inequitable access to patient portals frequently present to emergency departments (EDs) for care. Little is known about portal use patterns among ED patients.

Objectives

To describe real-time patient portal usage trends among ED patients and compare demographic and clinical characteristics between portal users and nonusers.

Design, Setting, and Participants

In this cross-sectional study of 12 teaching and 24 academic-affiliated EDs from 8 health systems in California, Connecticut, Massachusetts, Ohio, Tennessee, Texas, and Washington, patient portal access and usage data were evaluated for all ED patients 18 years or older between April 5, 2021, and April 4, 2022.

Exposure

Use of the patient portal during ED visit.

Main Outcomes and Measures

The primary outcomes were the weekly proportions of ED patients who logged into the portal, viewed test results, and viewed clinical notes in real time. Pooled random-effects models were used to evaluate temporal trends and demographic and clinical characteristics associated with real-time portal use.

Results

The study included 1 280 924 unique patient encounters (53.5% female; 0.6% American Indian or Alaska Native, 3.7% Asian, 18.0% Black, 10.7% Hispanic, 0.4% Native Hawaiian or Pacific Islander, 66.5% White, 10.0% other race, and 4.0% with missing race or ethnicity; 91.2% English-speaking patients; mean [SD] age, 51.9 [19.2] years). During the study, 17.4% of patients logged into the portal while in the ED, whereas 14.1% viewed test results and 2.5% viewed clinical notes. The odds of accessing the portal (odds ratio [OR], 1.36; 95% CI, 1.19-1.56), viewing test results (OR, 1.63; 95% CI, 1.30-2.04), and viewing clinical notes (OR, 1.60; 95% CI, 1.19-2.15) were higher at the end of the study vs the beginning. Patients with active portal accounts at ED arrival had a higher odds of logging into the portal (OR, 17.73; 95% CI, 9.37-33.56), viewing test results (OR, 18.50; 95% CI, 9.62-35.57), and viewing clinical notes (OR, 18.40; 95% CI, 10.31-32.86). Patients who were male, Black, or without commercial insurance had lower odds of logging into the portal, viewing results, and viewing clinical notes.

Conclusions and Relevance

These findings suggest that real-time patient portal use during ED encounters has increased over time, but disparities exist in portal access that mirror trends in portal usage more generally. Given emergency medicine's role in caring for medically underserved patients, there are opportunities for EDs to enroll and train patients in using patient portals to promote engagement during and after their visits.