Portals of Change: How Patient Portals Will Ultimately Work for Safety Net Populations

"Black Women Don't Always Put Our Healthcare First": Facilitators and Barriers to Cervical Cancer Screening and Perceptions of Human Papillomavirus Self-Testing Among Church-Affiliated African American Women

Background: African American women are at greater risk for cervical cancer incidence and mortality than White women. Up to 90% of cervical cancers are caused by human papillomavirus (HPVs) infections. The National Institutes of Health (NIH) co-developed HPV self-test kits to increase access to screening, which may be critical for underserved populations. Purpose/Research Design: This mixed methods study used the Theory of Planned Behavior to examine attitudes, barriers, facilitators, and intentions related to receipt of cervical cancer screening and perceptions of HPV self-testing among church-affiliated African American women. Study Sample/Data Collection: Participants (N = 35) aged 25-53 participated in focus groups and completed a survey. Results: Seventy-four percent of participants reported receipt of cervical cancer screening in the past 3 years. Healthcare providers and the church were supportive referents of screening. Past trauma and prioritizing children's healthcare needs were screening barriers. Concerns about HPV self-testing included proper test administration and result accuracy. Conclusions: Strategies to mitigate these concerns (e.g., delivering HPV self-test kits to the health department) are discussed.

The State-of-the-Art of Patient Portals: Adapting to External Factors, Addressing Barriers, and Innovating

BACKGROUND AND OBJECTIVE

Recent external factors-the 21st Century Cures Act and the coronavirus disease 2019 (COVID-19) pandemic-have stimulated major changes in the patient portal landscape. The objective of this state-of-the-art review is to describe recent developments in the patient portal literature and to identify recommendations and future directions for the design, implementation, and evaluation of portals.

METHODS

To focus this review on salient contemporary issues, we elected to center it on four topics: (1) 21st Century Cures Act's impact on patient portals (e.g., Open Notes); (2) COVID-19's pandemic impact on portals; (3) proxy access to portals; and (4) disparities in portal adoption and use. We conducted targeted PubMed searches to identify recent empirical studies addressing these topics, used a two-part screening process to determine relevance, and conducted thematic analyses.

RESULTS

Our search identified 174 unique papers, 74 were relevant empirical studies and included in this review. Among these papers, we identified 10 themes within our four a priori topics, including preparing for and understanding the consequences of increased patient access to their electronic health information (Cures Act); developing, deploying, and evaluating new virtual care processes (COVID-19); understanding current barriers to formal proxy use (proxy access); and addressing disparities in portal adoption and use (disparities).

CONCLUSION

Our results suggest that the recent trends toward understanding the implications of immediate access to most test results, exploring ways to close gaps in portal adoption and use among different sub-populations, and finding ways to leverage portals to improve health and health care are the next steps in the maturation of patient portals and are key areas that require more research. It is important that health care organizations share their innovative portal efforts, so that successful measures can be tested in other contexts, and progress can continue.

The Future of Community Outreach: Using Patient Portals to Provide Voter Resources during the Coronavirus Disease 2019 Pandemic

BACKGROUND

During the coronavirus disease 2019 (COVID-19) pandemic, there was a concern for the 2020 general election becoming a superspreader event due to in-person voting.

OBJECTIVES

Our project addressed this concern by disseminating nonpartisan websites detailing safe voter options in the state of North Carolina to prevent community spread of the virus as much as possible.

METHODS

In this study, patient portals were used to disseminate a Research Electronic Data Capture survey containing embedded links to voter resources including nonpartisan websites discussing voting options. The survey also asked for demographic data and sentiments regarding the resources provided. Quick response (QR) codes with the survey link were also placed in the clinics during the study period.

RESULTS

The survey was sent to 14,842 patients who had at least one patient encounter in the past 12 months at one of three General Internal Medicine clinics at Atrium Health Wake Forest Baptist. Survey participation through both the patient portals and QR codes was assessed. Patient sentiments toward the voter resources in regard to (1) interest and (2) perceived helpfulness were collected in the survey. In total, 738 (4.99%) patients filled out the survey. Eighty-seven percent of survey respondents reported that the voter resources were helpful. Significantly more black patients than white (29.3 vs. 18.2, p < 0.05) voiced interest in voter resources. There was no statistical significance across gender or reported comorbidities.

CONCLUSION

Multicultural, underserved, and underinsured patients perceived the most benefit. During public health crises, patient portal messages can be used to bridge information gaps and promote better health outcomes in a timely and effective manner.

Patient Recommendations for the Content and Design of Electronic Returns of Genetic Test Results: Interview Study Among Patients Who Accessed Their Genetic Test Results via the Internet

BACKGROUND

Genetic test results will be increasingly made available electronically as more patient-facing tools are developed; however, little research has been done that collects data on patient preferences for content and design before creating results templates.

OBJECTIVE

This study identifies patient preferences for the electronic return of genetic test results, including what considerations should be prioritized for content and design.

METHODS

Following user-centered design methods, 59 interviews were conducted by using semistructured protocols. The interviews explored the content and design issues of patient portals that facilitated the return of test results to patients. We interviewed patients who received electronic results for specific types of genetics tests (pharmacogenetic tests, hereditary blood disorder tests, and tests for the risk of heritable cancers) or electronically received any type of genetic or nongenetic test results.

RESULTS

In general, many of participants felt that there always needed to be some clinician involvement in electronic result returns and that electronic coversheets with simple summaries would be helpful for facilitating this. Coversheet summaries could accompany, but not replace, the more detailed report. Participants had specific suggestions for such results summaries, such as only reporting the information that was the most important for patients to understand, including next steps, and doing so by using clear language that is free of medical jargon. Electronic result returns should also include explicit encouragement for patients to contact health care providers about questions. Finally, many participants preferred to manage their care by using their smartphones, particularly in instances when they needed to access health information on the go.

CONCLUSIONS

Participants recommended that a patient-friendly front section should accompany the more detailed report and made suggestions for organization, content, and wording. Many used their smartphones regularly to access test results; therefore, health systems and patient portal software vendors should accommodate smartphone app design and web portal design concomitantly when developing platforms for returning results.

An Evidence-Based Roadmap for the Provision of More Equitable Telemedicine

OBJECTIVE

During the coronavirus disease 2019 pandemic, as a safety-net organization with a substantial percentage of patients of color and with limited English proficiency (LEP), we were wary of furthering health disparities in our community. We analyzed gaps in telemedicine (telephone and video) delivery in our communities, quantified the effects of our tests of change, and began the process of accumulating evidence to create a road map for other organizations.

METHODS

We leveraged Lean problem-solving strategies to identify modifiable gaps across multiple domains that could inhibit equity in telemedicine. We implemented tests of change across domains of community engagement, technology, education, and access. We observed the proportion of telemedicine encounters across races and languages between April and November, 2020. Regression analyses tested the impact of race and language on telemedicine controlling for age, gender, insurance, and time.

RESULTS

Several rounds of changes and enhancements were associated with changes in telemedicine use of +5.5% (p < 0.0001) for Hispanic, +4.0% (p < 0.0001) for Spanish-speaking, -2.1% for Black (p < 0.05), and -4.4% for White patients (p < 0.001). African-American, Hispanic, and non-English-speaking patients had between 2.3 and 4.6 times the odds of preferring telephone to video encounters (p < 0.0001), with increases in preferences for video use over time (p < 0.05).

CONCLUSION

Our roadmap to improve equitable delivery of telemedicine was associated with a significant improvement in telemedicine use among certain minority populations. Most populations of color used telephone more often than video. This preference changed over time and with equity-focused changes in telemedicine delivery.

Electronic Health Literacy among Linguistically Diverse Patients in the Los Angeles County Safety Net Health System

BACKGROUND

Electronic health (eHealth) literacy may affect telehealth uptake, yet few studies have evaluated eHealth literacy in underserved populations.

OBJECTIVE

The objective of this study was to describe technology access and use patterns as well as eHealth literacy levels among English-speaking and LEP patients in a Los Angeles safety net health system.

METHODS

Patients, aged ≥18 years with a diagnosis of diabetes mellitus and/or hypertension, and their caregivers were recruited from three primary care safety-net clinics in Los Angeles County (California) between June - July 2017. Participants' electronic health literacy was assessed by the eHealth Literacy Scale (eHEALS); participants were also asked about technology access and use. We examined these measures in English-speaking and limited English proficient (LEP) Spanish-speaking patients.

RESULTS

A total of 71 participants (62 patients and 9 caregivers) completed the questionnaire. The mean age of the respondents was 56 years old. More than half of participants used a phone that could connect to the Internet (67%). The mean score for 10 eHEALS items was in the moderate range (26/50 points). There was no difference in mean eHEALS between language groups. However, 47% of Spanish-speaking participants "agreed/strongly agreed" that they knew how to use the Internet to answer their health questions, compared to 68% of English-speaking participants (P<.05).

CONCLUSIONS

In this sample of patients from a diverse safety net population, perceived skills and confidence in engaging with electronic health systems were low, particularly among LEP Spanish-speakers, despite moderate levels of electronic health literacy. More studies are needed among diverse patient populations to better assess eHealth literacy and patients' digital readiness, and to examine how these patient metrics directly impact telehealth utilization.

Moving Towards Equity With Digital Health Innovations for Stroke Care

Digital health has long been championed as a means to expanding access to health care. Now that the COVID-19 pandemic accelerated many health systems' integration of digital tools for care, digital health may provide a path towards more accessible stroke prevention and treatment, particularly for historically disadvantaged patient populations. Stroke management is composed of multiple time points where digital health innovations have the potential to augment health access and treatment: from primary prevention, to the time-sensitive detection of ischemic stroke, administration of thrombolytic agents and consideration for endovascular interventions, to appropriate post-acute care, rehabilitation, and lifelong secondary stroke prevention-stroke care relies on a multidisciplinary and standardized approach. However, as we discuss pointedly in this Focused Update, underrepresented individuals face multilevel digital health disparities that potentially diminish the benefits of these digital advances. As such, these multilevel needs must be discussed and accounted for as health systems seek to integrate innovative and equitable digital health solutions towards stroke care.

Health Equity and Actionable Disparities in Stroke: 2021 Update

There are stark inequities in stroke incidence, prevalence, acute care, rehabilitation, risk factor control, and outcomes. To address these inequities, it is critical to engage communities in identifying priorities and designing, implementing, and disseminating interventions. This issue of Stroke features health equity themed lectures delivered during the International Stroke Conference and Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving meetings in 2021 as well as articles covering issues of disparities and diversity in stroke. Bruce Ovbiagele, MD, MSc, MAS, MBA, MLS, received the 2021 William Feinberg Award Lecture for his lifetime achievements in seeking global and local solutions to cerebrovascular health inequities. The second annual Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving symposium, which took place the day before the International Stroke Conference in February 2021, focused on community-engaged research for reducing inequities in stroke. Phil Gorelick, MD was awarded the Edgar J. Kenton III Award for his lifetime achievements in using community engagement strategies to recruit and retain Black participants in observational studies and clinical trials. Walter Koroshetz, MD, Director of the National Institute of Neurological Disorders and Stroke delivered the keynote lecture on stroke inequities and Richard Benson, MD, PhD, Director of the Office of Global Health and Health Disparities at National Institute of Neurological Disorders and Stroke, gave a lecture focused on National Institute of Neurological Disorders and Stroke efforts to address inequities. Nichols et al highlighted approaches of community-based participatory research to address stroke inequities. Verma et al showcased digital health innovations to reduce inequities in stroke. Das et al showed that the proportion of underrepresented in medicine vascular neurology fellows has lowered over the past decade and authors provided a road map for enhancing the diversity in vascular neurology. Clearly, to overcome inequities, multipronged strategies are required, from broadening representation among vascular neurology faculty to partnering with communities to conduct research with meaningful impact.

Patient Preferences for Patient Portal-Based Telepsychiatry in a Safety Net Hospital Setting During COVID-19: Cross-sectional Study

BACKGROUND

Patient portals are a safe and secure way for patients to connect with providers for video-based telepsychiatry and help to overcome the financial and logistical barriers associated with face-to-face mental health care. Due to the COVID-19 pandemic, telepsychiatry has become increasingly important to obtaining mental health care. However, financial and technological barriers, termed the "digital divide," prevent some patients from accessing the technology needed to use telepsychiatry services.

OBJECTIVE

As an extension to a clinic's outreach project during COVID-19 to improve patient engagement with video-based visits through the hospital's patient portal among adult behavioral health patients at an urban safety net hospital, we aim to assess patient preference for patient portal-based video visits or telephone-only visits and to identify the demographic variables associated with their preference.

METHODS

Patients in an outpatient psychiatry clinic were contacted by phone, and preference for telepsychiatry by phone or video through a patient portal, as well as device preference for video-based visits, were documented. Patient demographic characteristics were collected from the electronic medical record.

RESULTS

A total of 128 patients were reached by phone. A total of 79 (61.7%) patients chose video-based visits, and 69.6% (n=55) of these patients preferred to access the patient portal through a smartphone. Older patients were significantly less likely to agree to video-based visits.

CONCLUSIONS

Among behavioral health patients at a safety net hospital, there was relatively low engagement with video-based visits through the hospital's patient portal, particularly among older adults.

Perspectives from leadership and frontline staff on telehealth transitions in the Los Angeles safety net during the COVID-19 pandemic and beyond

Objectives

The start of the COVID-19 pandemic led the Los Angeles safety net health system to dramatically reduce in-person visits and transition abruptly to telehealth/telemedicine services to deliver clinical care (remote telephone and video visits). However, safety net patients and the settings that serve them face a "digital divide" that could impact effective implementation of such digital care. The study objective was to examine attitudes and perspectives of leadership and frontline staff regarding telehealth integration in the Los Angeles safety net, with a focus on telemedicine video visits.

Methods

This qualitative study took place in the Los Angeles County Department of Health Services (LAC DHS), the second-largest safety net health system in the US. This system disproportionately serves the uninsured, Medicaid, racial/ethnic minority, low-income, and Limited English Proficient (LEP) patient populations of Los Angeles County. Staff and leadership personnel from each of the five major LAC DHS hospital center clinics, and community-based clinics from the LAC DHS Ambulatory Care Network (ACN) were individually interviewed (video or phone calls), and discussions were recorded. Interview guides were based on the Consolidated Framework for Implementation Research (CFIR), and included questions about the video visit technology platform and its usability, staff resources, clinic needs, and facilitators and barriers to general telehealth implementation and use. Interviews were analyzed for summary of major themes.

Results

Twenty semi-structured interviews were conducted in August to October 2020. Participants included LAC DHS physicians, nurses, medical assistants, and physical therapists with clinical and/or administrative roles. Narrative themes surrounding telehealth implementation, with video visits as the case study, were identified and then categorized at the patient, clinic (including provider), and health system levels.

Conclusions

Patient, clinic, and health system level factors must be considered when disseminating telehealth services across the safety net. Participant discussions illustrated how multilevel facilitators and barriers influenced the feasibility of video visits and other telehealth encounters. Future research should explore proposed solutions from frontline stakeholders as testable interventions towards advancing equity in telehealth implementation: from patient training and support, to standardized workflows that leverage the expertise of multidisciplinary teams.

Patients Contributing to Visit Notes: Mixed Methods Evaluation of OurNotes

Background

Secure patient portals are widely available, and patients use them to view their electronic health records, including their clinical notes. We conducted experiments asking them to cogenerate notes with their clinicians, an intervention called OurNotes.

Objective

This study aims to assess patient and provider experiences and attitudes after 12 months of a pilot intervention.

Methods

Before scheduled primary care visits, patients were asked to submit a word-constrained, unstructured interval history and an agenda for what they would like to discuss at the visit. Using site-specific methods, their providers were invited to incorporate the submissions into notes documenting the visits. Sites served urban, suburban, and rural patients in primary care practices in 4 academic health centers in Boston (Massachusetts), Lebanon (New Hampshire), Denver (Colorado), and Seattle (Washington). Each practice offered electronic access to visit notes (open notes) to its patients for several years. A mixed methods evaluation used tracking data and electronic survey responses from patients and clinicians. Participants were 174 providers and 1962 patients who submitted at least 1 previsit form. We asked providers about the usefulness of the submissions, effects on workflow, and ideas for the future. We asked patients about difficulties and benefits of providing the requested information and ideas for future improvements.

Results

Forms were submitted before 9.15% (5365/58,652) eligible visits, and 43.7% (76/174) providers and 26.76% (525/1962) patients responded to the postintervention evaluation surveys; 74 providers and 321 patients remembered receiving and completing the forms and answered the survey questions. Most clinicians thought interim patient histories (69/74, 93%) and patient agendas (72/74, 97%) as good ideas, 70% (52/74) usually or always incorporated them into visit notes, 54% (40/74) reported no change in visit length, and 35% (26/74) thought they saved time. Their most common suggestions related to improving notifications when patient forms were received, making it easier to find the form and insert it into the note, and educating patients about how best to prepare their submissions. Patient respondents were generally well educated, most found the history (259/321, 80.7%) and agenda (286/321, 89.1%) questions not difficult to answer; more than 92.2% (296/321) thought sending answers before the visit a good idea; 68.8% (221/321) thought the questions helped them prepare for the visit. Common suggestions by patients included learning to write better answers and wanting to know that their submissions were read by their clinicians. At the end of the pilot, all participating providers chose to continue the OurNotes previsit form, and sites considered expanding the intervention to more clinicians and adapting it for telemedicine visits.

Conclusions

OurNotes interests patients, and providers experience it as a positive intervention. Participation by patients, care partners, clinicians, and electronic health record experts will facilitate further development.

COVID-19 and Open Notes: A New Method to Enhance Patient Safety and Trust

From April 5, 2021, as part of the 21st Century Cures Act, all providers in the United States must offer patients access to the medical information housed in their electronic records. Via secure health portals, patients can log in to access lab and test results, lists of prescribed medications, referral appointments, and the narrative reports written by clinicians (so-called open notes). As US providers implement this practice innovation, we describe six promising ways in which patients' access to their notes might help address problems that either emerged with or were exacerbated by the COVID-19 pandemic.

Clinician experience with telemedicine at a safety-net hospital network during COVID-19: a cross-sectional survey

Objective

The COVID-19 pandemic prompted unprecedented expansion of telemedicine services. We sought to describe clinician experiences providing telemedicine to publicly-insured, low-income patients during COVID-19.

Methods

Online survey of ambulatory clinicians in an urban safety-net hospital system, conducted May 28 2020-July 14 2020.

Results

Among 311 participants (response rate 48.3%), 34.7% (N=108/311) practiced in primary/urgent care, 37.0% (N=115/311) medical specialty and 7.7% (N=24/311) surgical clinics. 87.8% (273/311) had conducted telephone visits, 26% (81/311) video. Participants reported observing both technical and non-technical patient barriers. Clinicians reported concerns about the diagnostic safety of telephone (58.9%, 129/219) vs video (35.3%, 24/68). However, clinician comfort with telemedicine was high (89.3% (216/242) for telephone, 91.0% (61/67) for video), with many clinicians (220/239 or 92.1% telephone, 60/66 or 90.9% video) planning to continue telemedicine after COVID-19.

Conclusions

Clinicians in a safety-net healthcare system report high comfort with and intention to continue telemedicine after the pandemic, despite patient challenges and safety concerns.

Homeless Vulnerability During an Opioid Epidemic: Assessing the Mortality Risk Among People Experiencing Homelessness in Southern Californai

People experiencing homelessness suffer from a risk of mortality three to four times that of the general population, with drug-induced overdose replacing HIV as the emerging epidemic. This study assessed markers of mortality among people experiencing homelessness (N=157) in Orange County, CA during the Fall of 2016. We utilized the Vulnerability Index, an eight-question survey, to identify factors that may affect mortality risk among individuals experiencing homelessness and included two additional questions to identify potential risk of drug-induced overdose. Eighty-three percent of participants reported more than one heightened mortality risk marker and 64% may be at higher risk of drug-induced overdose. Given the state of the opioid epidemic, there is pressing need to couple public health interventions targeting people experiencing homelessness with harm reduction efforts including naloxone distribution (opioid-induced overdose reversal medication) and syringe exchange programs.