Growing Disparities in Patient-Provider Messaging: Trend Analysis Before and After Supportive Policy

Internet use for health information, health service utilization, and quality of care in the U.S

BACKGROUND

Increased internet use for health information in the United States enhances interactions with healthcare professionals, but its effects on healthcare utilization and care quality are still being investigated. We explored the association between internet use for health information, patient-centered communication (PCC), and sociodemographic factors on the likelihood of visiting a health care provider and quality of care. We also examined if PCC mediates this association.

METHODS

We conducted a secondary data analysis using the National Cancer Center Institutes (NCI) Health Information National Trends Survey (HINTS) 2018-2020. Multinomial logistic regression and path analyses assessed variable interrelationships and mediating effects.

RESULTS

Individuals using the internet for health information for themselves were 2.40 times more likely (P <.001) to have frequent provider visits and 1.18 times more likely (P <.022) to rate their care as very good/good compared to excellent, compared to those who did not use the internet for health information for themselves. In contrast, individuals using the internet for discussion with their providers were 2.05 times more likely (P <.001) to have increased visits, and they were 40% less likely (P <.001) to rate their care as fair/poor compared to excellent, relative to those who did not use the internet for discussions. Path analysis indicated that individuals using the internet for health information for themselves may negatively impact PCC, resulting in lower quality ratings, while those who use the internet for discussions with healthcare providers had a positive effect on PCC, leading to higher care ratings.

CONCLUSION

This study enhances our understanding of how PCC and internet use for health information impact US healthcare. Using the internet for provider discussions positively impacts perceived care quality, highlighting PCC's vital role.

Ethics in Patient Preferences for Artificial Intelligence-Drafted Responses to Electronic Messages

Importance

The rise of patient messages sent to clinicians via a patient portal has directly led to physician burnout and dissatisfaction, prompting uptake of artificial intelligence (AI) to alleviate this burden. It is important to understand patient preferences around AI in patient-clinician communication as ethical guidelines on appropriate use and disclosure (patient notification of AI use) are developed.

Objective

To analyze patient preferences regarding use of AI in electronic messages.

Design, Setting, and Participants

A survey study was conducted within the Duke University Health System's patient advisory committee, consisting of individuals 18 years or older who participate in periodic surveys to inform health system patient care practices. Multiple surveys were administered to test the impact of different factors, including response author, disclosure (AI, human, or none), and seriousness of the topic. A follow-up survey assessed preferred disclosure verbiage. Surveys were administered from October 31 to December 11, 2023.

Exposure

Multiple surveys.

Main Outcomes and Measures

Participants rated their overall satisfaction, usefulness of the information, and perceived level of care on a 5-point Likert scale.

Results

Of the 2511 members surveyed, 1455 (57.9%) responded, with respondents being older (median age, 57 [IQR, 49-70] vs 53 [IQR, 41-62] years), more educated (872 of 1083 [80.5%] vs 319 of 440 [72.5%] with a college or graduate degree), and predominantly female (921 [63.3%]). Participants preferred AI- compared with human-drafted responses, with a mean difference for satisfaction of -0.30 (95% CI, -0.37 to -0.23) points, usefulness of -0.28 (95% CI, -0.34 to -0.22) points, and perception they were cared for of -0.43 (95% CI, -0.50 to -0.37) points. Participants tended to have higher satisfaction with a human disclosure over AI disclosure, with a mean difference of 0.13 (95% CI, 0.05-0.22) points, and with no disclosure over AI authorship disclosure, with a mean difference of 0.09 (95% CI, 0.01-0.17) points. Regardless of author or disclosure type, more than 75% of respondents were satisfied (agree or strongly agree) with the response.

Conclusions and Relevance

In this survey study, participants expressed a mild preference for messages written by AI but had a slightly decreased satisfaction when told AI was involved. Patient experience must be considered along with ethical implementation of AI. Although AI disclosure may slightly reduce satisfaction, disclosure should be maintained to uphold patient autonomy and empowerment.

The Evolution of Health Information Technology for Enhanced Patient-Centric Care in the United States: Data-Driven Descriptive Study

BACKGROUND

Health information technology (health IT) has revolutionized health care in the United States through interoperable clinical care data exchange, e-prescribing, electronic public health reporting, and electronic patient access to health information.

OBJECTIVE

This study aims to examine progress in health IT adoption and its alignment with the Office of the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health IT (ASTP's) mission to enhance health care through data access and exchange.

METHODS

This study leverages data on end users of health IT to capture trends in engagement in interoperable clinical care data exchange (ability to find, send, receive, and integrate information from outside organizations), e-prescribing, electronic public health reporting, and capabilities to enable patient access to electronic health information. Data were primarily sourced from the American Hospital Association Annual Survey IT Supplement (2008 to 2023), Surescripts e-prescribing use data (2008 to 2023), the National Cancer Institute's Health Information National Trends Survey (2014 to 2022), and the National Center for Health Statistics' National Electronic Health Records Survey (2009 to 2023).

RESULTS

Since 2009, there has been a 10-fold increase in electronic health record (EHR) use among hospitals and a 5-fold increase among physicians. This enabled the interoperable exchange of electronic health information, e- prescribing, electronic public health data exchange, and the means for patients and their caregivers to access crucial personal health information digitally. As of 2023, 70% of hospitals are interoperable, with many providers integrated within EHR systems. Nearly all pharmacies and 92% of prescribers possess e-prescribing capabilities, an 85%-point increase since 2008. In 2013, 40% of hospitals and one-third of physicians allowed patients to view their online medical records. Patient access has improved, with 97% of hospitals and 65% of physicians possessing EHRs that enable patients to access their online medical records. As of 2022, three-fourths of individuals report being offered access to patient portals, and over half (57%) report engaging with their health information through their patient portal. Electronic public health reporting has also seen an increase, with most hospitals and physicians actively engaged in key reporting types.

CONCLUSIONS

Federal incentives have contributed to the widespread adoption of EHRs and broad digitization in health care, while efforts to promote interoperability have encouraged collaboration across health care entities. As a result, interoperable clinical care data exchange, e-prescribing, electronic public health reporting, and patient access to health information have grown substantially over the past quarter century and have been shown to improve health care outcomes. However, interoperability hurdles, usability issues, data security concerns, and inequitable patient access persist. Addressing these issues will require collaborative efforts among stakeholders to promote data standardization, implement governance structures, and establish robust health information exchange networks.

The Role of Health Information Technology on Colorectal Cancer Screening Participation Among Smokers In The United States

Background: Despite advances in its prevention and early detection, colorectal cancer (CRC) remains a leading cause of morbidity and mortality in the United States and smokers are at an increased risk. Health information technology (HIT) has shown promise in the uptake of preventive health services, including CRC, and may prove useful among smokers. Methods: We obtained data from 7,419 adults who completed the 2018-2020 Health Information National Trends Survey. Using multivariable logistic regression models, we examined the relationship between HIT use and CRC screening participation. Results: Over 20% of current smokers had no access to HIT tools, and those with access were less likely than never smokers to use HIT in checking test results (odds ratio [OR] 0.58; 95% confidence interval [CI] [0.42-0.80]). Among former smokers, using HIT to check test results (OR 3.41; 95% CI [1.86-6.25]), look up health information online (OR 2.20; 95% CI [1.15-4.22]), and make health appointments (OR 2.86; 95% CI [1.39-5.89]) was associated with increased participation in CRC screening. Among current smokers, the use of HIT was not associated with a change in CRC screening participation. Conclusion: HIT use is associated with higher levels of CRC screening among former smokers, which is reassuring given their increased risk of CRC. The low ownership and use of HIT among current smokers of CRC screening age presents a challenge that may limit the integration of HIT into routine CRC screening services.

Collecting patient-reported outcome measures in the electronic health record: Lessons from the NIH pragmatic trials Collaboratory

The NIH Pragmatic Trials Collaboratory supports the design and conduct of 27 embedded pragmatic clinical trials, and many of the studies collect patient reported outcome measures as primary or secondary outcomes. Study teams have encountered challenges in the collection of these measures, including challenges related to competing health care system priorities, clinician's buy-in for adoption of patient-reported outcome measures, low adoption and reach of technology in low resource settings, and lack of consensus and standardization of patient-reported outcome measure selection and administration in the electronic health record. In this article, we share case examples and lessons learned, and suggest that, when using patient-reported outcome measures for embedded pragmatic clinical trials, investigators must make important decisions about whether to use data collected from the participating health system's electronic health record, integrate externally collected patient-reported outcome data into the electronic health record, or collect these data in separate systems for their studies.

Electronic Medical Record-Based Electronic Messaging Among Patients with Breast Cancer: A Systematic Review

BACKGROUND

Electronic medical record (EMR) systems and electronic messages are an increasingly common conduit between physicians and patients. Clear benefits of this type of communication have been established, especially among cancer patients. Studies suggest that patient portals and electronic messaging platforms can help with care coordination between oncology providers and facilitate asynchronous patient-provider communication. Despite the many benefits, there is little research regarding EMR and secure messaging use, particularly among patients with breast cancer.

OBJECTIVES

The objective of this systematic review was to examine the evidence supporting the use of EMR-based messaging systems in patients with breast cancer.

METHODS

A systematic literature search of Ovid MEDLINE, PubMed, Scopus, Web of Science CINAHL, and Cochrane Library was conducted. Studies were required to be published between 2005 and 2022 and report data on demographic information and electronic messaging between patients and providers. Studies were excluded if they reported insufficient data, did not include breast cancer patients, or were not published in English.

RESULTS

This study identified 10 articles that met inclusion criteria. The resulting studies investigated topics such as: patterns of messaging and medication adherence, cancer screening, messaging as a predictor of behavior or outcomes, and symptom management. The literature indicates that electronic messaging with providers was associated with clinical benefits for breast cancer patients and improved screening behaviors.

CONCLUSION

This review uncovered multiple areas to focus future research on, including ideal volume of electronic messages sent and their relation to prescription adherence, studies focusing solely on the breast cancer population, racial disparities in electronic messaging, and provider perceptions of electronic messaging. It is vital that more work be done to understand barriers and gaps in EMR usage to ensure that all individuals can access this increasingly essential medical service while minimizing physician workload and burnout.

Associations between Florida counties' COVID-19 case and death rates and meaningful use among Medicaid providers: Cross-sectional ecologic study

Although the Health Information Technology for Economic and Clinical Health (HITECH) Act has accelerated adoption of Electronic Health Records (EHRs) among Medicaid providers, only half achieved Meaningful Use. Furthermore, Meaningful Use' impact on reporting and/or clinical outcomes remains unknown. To address this deficit, we assessed the difference between Medicaid providers who did and did not achieve Meaningful Use regarding Florida county-level cumulative COVID-19 death, case and case fatality rates (CFR), accounting for county-level demographics, socioeconomic and clinical markers, and healthcare environment. We found that cumulative incidence rates of COVID-19 deaths and CFRs were significantly different between the 5025 Medicaid providers not achieving Meaningful Use and the 3723 achieving Meaningful Use (mean 0.8334/1000 population; SD = 0.3489 vs. mean = 0.8216/1000; SD = 0.3227, respectively) (P = .01). CFRs were .01797 and .01781, respectively, P = .04. County-level characteristics independently associated with increased COVID-19 death rates and CFRs include greater concentrations of persons of African American or Black race, lower median household income, higher unemployment, and higher concentrations of those living in poverty and without health insurance (all P < .001). In accordance with other studies, social determinants of health were independently associated with clinical outcomes. Our findings also suggest that the association between Florida counties' public health outcomes and Meaningful Use achievement may have had less to do with using EHRs for reporting of clinical outcomes and more to do with using EHRs for coordination of care-a key measure of quality. The Florida Medicaid Promoting Interoperability Program which incentivized Medicaid providers towards achieving Meaningful Use, has demonstrated success regarding both rates of adoption and clinical outcomes. Because the Program ends in 2021, we support programs such as HealthyPeople 2030 Health IT which address the remaining half of Florida Medicaid providers who have not yet achieved Meaningful Use.

Differences in access to virtual and in-person primary care by race/ethnicity and community social vulnerability among adults diagnosed with COVID-19 in a large, multi-state health system

Background

Research exploring telehealth expansion during the COVID-19 pandemic has demonstrated that groups disproportionately impacted by COVID-19 also experience worse access to telehealth. However, this research has been cross-sectional or short in duration; geographically limited; has not accounted for pre-existing access disparities; and has not examined COVID-19 patients. We examined virtual primary care use by race/ethnicity and community social vulnerability among adults diagnosed with COVID-19 in a large, multi-state health system. We also assessed use of in-person primary care to understand whether disparities in virtual access may have been offset by improved in-person access.

Methods

Using a cohort design, electronic health records, and Centers for Disease Control and Prevention Social Vulnerability Index, we compared changes in virtual and in-person primary care use by race/ethnicity and community social vulnerability in the year before and after COVID-19 diagnosis. Our study population included 11,326 adult patients diagnosed with COVID-19 between March and July 2020. We estimated logistic regression models to examine likelihood of primary care use. In all regression models we computed robust standard errors; in adjusted models we controlled for demographic and health characteristics of patients.

Results

In a patient population of primarily Hispanic/Latino and non-Hispanic White individuals, and in which over half lived in socially vulnerable areas, likelihood of virtual primary care use increased from the year before to the year after COVID-19 diagnosis (3.6 to 10.3%); while in-person use remained stable (21.0 to 20.7%). In unadjusted and adjusted regression models, compared with White patients, Hispanic/Latino and other race/ethnicity patients were significantly less likely to use virtual care before and after COVID-19 diagnosis; Hispanic/Latino, Native Hawaiian/Pacific Islander, and other race/ethnicity patients, and patients living in socially vulnerable areas were also significantly less likely to use in-person care during these time periods.

Conclusions

Newly expanded virtual primary care has not equitably benefited individuals from racialized groups diagnosed with COVID-19, and virtual access disparities have not been offset by improved in-person access. Health systems should employ evidence-based strategies to equitably provide care, including representative provider networks; targeted, empowering outreach; co-developed culturally and linguistically appropriate tools and technologies; and provision of enabling resources and services.

Email Patient-Provider Communication and Cancer Screenings Among US Adults: Cross-sectional Study

Background

The growth of electronic medical records and use of patient portals have allowed for patients and health care providers to communicate via email and direct messaging between health care visits. Email patient-provider communication (PPC) may enhance traditional face-to-face PPC by allowing patients to ask questions, receive clear explanations, engage in shared decision-making, and confirm their understanding between in-person visits. Despite increasing trends in the use of email PPC since the early 2000s, few studies have evaluated associations between email PPC and the uptake of preventive services.

Objective

The objective of this study was to determine associations between the use of email PPC and the likelihood of undergoing breast, cervical, and colon cancer screenings among adults who have received health care in the past 12 months.

Methods

Secondary, cross-sectional data from the 2011-2015 National Health Interview Survey were combined and analyzed. For each cancer screening, inclusion criteria were based on the age of screening recommendations and prior history of cancer diagnosis (n=35,912 for breast, n=48,512 for cervical, and n=45,884 for colon). The independent variable was whether adults used email PPC in the past 12 months (yes or no). The dependent variables were whether (1) women (aged ≥40 years) received a mammogram in the past 12 months; (2) women (aged 21-65 years) received a Pap test in the past 12 months; and (3) individuals (aged ≥50 years) received a colon cancer screening in the past 12 months. Bivariate and multivariable logistic regression analyses were conducted.

Results

Adults who reported receiving all three cancer screenings in the past 12 months were more likely to be non-Hispanic White; be married or living with a partner; have a bachelor’s degree or higher education level; have health insurance coverage; and perceive their health as excellent, very good, or good (all P<.001). Men were more likely to receive colon cancer screenings than women (P<.001). Multivariable logistic regression models showed women who used email to communicate with their health care providers had greater odds of receiving breast (odds ratio [OR] 1.32, 95% CI 1.20-1.44) and cervical (OR 1.11, 95% CI 1.02-1.20) cancer screenings than women who did not use email PPC. Adults who used email to communicate with their health care providers had 1.55 times greater odds (95% CI 1.42-1.69) of receiving a colon cancer screening than those who did not use email PPC.

Conclusions

Our results demonstrate that email PPC is a marker of increased likelihood of adults completing age-appropriate cancer screenings, particularly breast, cervical, and colon cancer screenings. More research is needed to examine other factors related to the reasons for and quality of email PPC between patients and health care providers and determine avenues for health education and intervention to further explore this association.

A Clinical Communication Tool (Loop) for Team-Based Care in Pediatric and Adult Care Settings: Hybrid Mixed Methods Implementation Study

BACKGROUND

Communication within the circle of care is central to coordinated, safe, and effective care; yet patients, caregivers, and health care providers often experience poor communication and fragmented care. Through a sequential program of research, the Loop Research Collaborative developed a web-based, asynchronous clinical communication system for team-based care. Loop assembles the circle of care centered on a patient, in private networking spaces called Patient Loops. The patient, their caregiver, or both are part of the Patient Loop. The communication is threaded, it can be filtered and sorted in multiple ways, it is securely stored, and can be exported for upload to a medical record.

OBJECTIVE

The objective of this study was to implement and evaluate Loop. The study reporting adheres to the Standards for Reporting Implementation Research.

METHODS

The study was a hybrid type II mixed methods design to simultaneously evaluate Loop's clinical and implementation effectiveness, and implementation barriers and facilitators in 6 health care sites. Data included monthly user check-in interviews and bimonthly surveys to capture patient or caregiver experience of continuity of care, in-depth interviews to explore barriers and facilitators based on the Consolidated Framework for Implementation Research (CFIR), and Loop usage extracted directly from the Loop system.

RESULTS

We recruited 25 initiating health care providers across 6 sites who then identified patients or caregivers for recruitment. Of 147 patient or caregiver participants who were assessed and met screening criteria, 57 consented and 52 were enrolled on Loop, creating 52 Patient Loops. Across all Patient Loops, 96 additional health care providers consented to join the Loop teams. Loop usage was followed for up to 8 months. The median number of messages exchanged per team was 1 (range 0-28). The monthly check-in and CFIR interviews showed that although participants acknowledged that Loop could potentially fill a gap, existing modes of communication, workflows, incentives, and the lack of integration with the hospital electronic medical records and patient portals were barriers to its adoption. While participants acknowledged Loop's potential value for engaging the patient and caregiver, and for improving communication within the patient's circle of care, Loop's relative advantage was not realized during the study and there was insufficient tension for change. Missing data limited the analysis of continuity of care.

CONCLUSIONS

Fundamental structural and implementation challenges persist toward realizing Loop's potential as a shared system of asynchronous communication. Barriers include health information system integration; system, organizational, and individual tension for change; and a fee structure for health care provider compensation for asynchronous communication.

Racial and ethnic differences in self-reported telehealth use during the COVID-19 pandemic: a secondary analysis of a US survey of internet users from late March

Objective

Widespread technological changes, like the rapid uptake of telehealth in the US during the COVID-19 pandemic, risk creating or widening racial/ethnic disparities. We conducted a secondary analysis of a cross-sectional, nationally representative survey of internet users to evaluate whether there were racial/ethnic disparities in self-reported telehealth use early in the pandemic.

Materials and Methods

The Pew Research Center fielded the survey March 19–24, 2020. Telehealth use because of the pandemic was measured by asking whether respondents (N = 10 624) “used the internet or e-mail to connect with doctors or other medical professionals as a result of the coronavirus outbreak.” We conducted survey-weighted logistic regressions, adjusting for respondents’ socioeconomic characteristics and perceived threat of the pandemic to their own health (eg, no threat, minor, major).

Results

Approximately 17% of respondents reported using telehealth because of the pandemic, with significantly higher unadjusted odds among Blacks, Latinos, and those identified with other race compared to White respondents. The multivariable logistic regressions and sensitivity analyses show Black respondents were more likely than Whites to report using telehealth because of the pandemic, particularly when perceiving the pandemic as a minor threat to their own health.

Discussion

Black respondents are most likely to report using telehealth because of the COVID-19 pandemic, particularly when they perceive the pandemic as a minor health threat.

Conclusion

The systemic racism creating health and health care disparities has likely raised the need for telehealth among Black patients during the pandemic. Findings suggest opportunities to leverage a broadly defined set of telehealth tools to reduce health care disparities postpandemic.

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

The substantial expansion of secure messaging (SM) via the patient portal in the last decade suggests that it is becoming a standard of care, but few have examined SM use longitudinally. We examined SM patterns among a diverse cohort of patients with diabetes (N = 19 921) and the providers they exchanged messages with within a large, integrated health system over 10 years (2006-2015), linking patient demographics to SM use. We found a 10-fold increase in messaging volume. There were dramatic increases overall and for patient subgroups, with a majority of patients (including patients with lower income or with self-reported limited health literacy) messaging by 2015. Although more physicians than nurses and other providers messaged throughout the study, the distribution of health professions using SM changed over time. Given this rapid increase in SM, deeper understanding of optimizing the value of patient and provider engagement, while managing workflow and training challenges, is crucial.