Interpreting Laboratory Results with Complementary Health Information: A Human Factors Perspective.

The desire to access personal and high-quality health information electronically is increasing, not only in Canada, but globally. With the advent of the COVID - 19 pandemic the desire and demand for telemedicine and timely access to personal health data such as online laboratory (lab) results has increased substantially. This study examines citizens' perspectives of being provided with high-quality information about a specific lab test (i.e., potassium) in the same display as a trend graph. Therefore, the objective of this study is to test how participants managed this additional information about the context of the test, understood, and applied it. The researchers analyzed the responses of semi-structured interviews with Canadian participants (N=24) using conventional content analysis. This paper examined four themes related to providing complementary information concurrently with lab results in the same display: 1) Benefits of Collocated Information, 2) Information Overload, 3) Misinterpretation, 4) Confusion. This study provided examples of some of the difficulties that the participants faced accessing their lab values online, while navigating and discerning complimentary high-quality health information available in their patient portal.

Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes.

BACKGROUND: The 21st Century Cures Act mandates patients' access to their electronic health record (EHR) notes. To our knowledge, no previous work has systematically invited patients to proactively report diagnostic concerns while documenting and tracking their diagnostic experiences through EHR-based clinician note review. OBJECTIVE: To test if patients can identify concerns about their diagnosis through structured evaluation of their online visit notes. METHODS: In a large integrated health system, patients aged 18-85 years actively using the patient portal and seen between October 2019 and February 2020 were invited to respond to an online questionnaire if an EHR algorithm detected any recent unexpected return visit following an initial primary care consultation ("at-risk" visit). We developed and tested an instrument (Safer Dx Patient Instrument) to help patients identify concerns related to several dimensions of the diagnostic process based on notes review and recall of recent "at-risk" visits. Additional questions assessed patients' trust in their providers and their general feelings about the visit. The primary outcome was a self-reported diagnostic concern. Multivariate logistic regression tested whether the primary outcome was predicted by instrument variables. RESULTS: Of 293 566 visits, the algorithm identified 1282 eligible patients, of whom 486 responded. After applying exclusion criteria, 418 patients were included in the analysis. Fifty-one patients (12.2%) identified a diagnostic concern. Patients were more likely to report a concern if they disagreed with statements "the care plan the provider developed for me addressed all my medical concerns" [odds ratio (OR), 2.65; 95% confidence interval [CI], 1.45-4.87) and "I trust the provider that I saw during my visit" (OR, 2.10; 95% CI, 1.19-3.71) and agreed with the statement "I did not have a good feeling about my visit" (OR, 1.48; 95% CI, 1.09-2.01). CONCLUSION: Patients can identify diagnostic concerns based on a proactive online structured evaluation of visit notes. This surveillance strategy could potentially improve transparency in the diagnostic process.

The formation of patient trust and its transference to online health services: the case of a Dutch online patient portal for rehabilitation care.

BACKGROUND: Trust is widely recognized as a crucial factor in successful physician-patient communication and patient engagement in treatment. However, with the rise of eHealth technologies, such as online patient portals, the role of trust and the factors that influence it need to be reconsidered. In this study, we aim to identify the factors that contribute to trust in an eHealth service and we aim to identify the consequences of trust in an eHealth service in terms of use. METHODS: The Patient Trust Assessment Tool was provided to new outpatients of a rehabilitation center in the Netherlands, that were expected to use the center's online patient portal. Via this tool, we assessed five trust-related factors. This data was supplemented by questions about demographics (age, gender, rehabilitation treatment) and data about use (number of sessions, total time spent in sessions), derived from data logs. Data was analyzed via Partial Least Squares Structural Equation Modelling. RESULTS: In total, 93 patients participated in the study. Out of these participants, 61 used the portal at least once. The measurement model was considered good. Trust in the organization was found to affect trust in the care team (ß = .63), trust in the care team affected trust in the treatment (ß = .60). Both, trust in the care team and trust in the treatment influenced trust in the technology (ß = .42 and .30, respectively). Trust in the technology affected the holistic concept trust in the service (ß = .78). This holistic trust in the service finally, did not affect use. CONCLUSIONS: This study shows that the formation of this trust is not unidimensional, but consists of different, separate factors (trust in the care organization, trust in the care team and trust in the treatment). Trust transfer does take place from offline to online health services. However, trust in the service does not directly affect the use of the eHealth technology.

Testing a Model of Patient Portal Use in Adult Patients.

PURPOSE: The aim of this study was to test a modified version of the Technology Acceptance Model, which describes users' technology adoption, to examine the relations between patient portal use and potential influencing factors in adult patients who have used patient portals. The modified model posits that patient portal use can be explained by attitude and self-efficacy for using patient portals, perceived usefulness and ease of use, data privacy and security concerns, eHealth literacy, education level, and age. DESIGN: A cross-sectional anonymous online survey was conducted for adult patients who had used their patient portals in the past 12 months. METHODS: Participants were recruited from 20 settings selected in a large integrated health care system. Data from 743 patients were subject to structural equation modeling for model testing. FINDINGS: Sixty-eight percent were White and female, with a mean age of 53.1 years (SD = 15.34). Forty-seven percent used patient portals about monthly or more frequently. Scores for perceived usefulness and ease of use of patient portals were relatively high (as measured using the modified Perceived Health Web Site Usability Questionnaire; each item mean, 6.0-6.2; range, 1-7). The final model adequately fit the data (comparative fit index = .983, standardized root mean square residual = .064, root mean square error of approximation = .059). Patient portal self-efficacy and data privacy and security concerns had a direct impact on patient portal use. Perceived usefulness and ease of use, eHealth literacy, education level, and age indirectly influenced patient portal use. CONCLUSIONS: This study contributes to expanding a theoretical understanding of adult patients' patient portal use in a real health care environment. Future studies need to include more diverse populations in various settings. CLINICAL RELEVANCE: Knowledge gained from this study can be used by technology experts to make patient portals more user friendly and by administrators to implement patient portals more effectively.

Words Matter: What Do Patients Find Judgmental or Offensive in Outpatient Notes?

BACKGROUND: Sharing outpatient notes with patients may bring clinically important benefits, but notes may sometimes cause patients to feel judged or offended, and thereby reduce trust. OBJECTIVE: As part of a larger survey examining the effects of open notes, we sought to understand how many patients feel judged or offended due to something they read in outpatient notes, and why. DESIGN: We analyzed responses from a large Internet survey of adult patients who used secure patient portals and had at least 1 visit note available in a 12-month period at 2 large academic medical systems in Boston and Seattle, and in a rural integrated health system in Pennsylvania. PARTICIPANTS: Adult ambulatory patients with portal accounts in health systems that offered open notes for up to 7 years. APPROACH: (1) Quantitative analysis of 2 dichotomous questions, and (2) qualitative thematic analysis of free-text responses on what patients found judgmental or offensive. KEY RESULTS: Among 22,959 patient respondents who had read at least one note and answered the 2 questions, 2,411 (10.5%) reported feeling judged and/or offended by something they read in their note(s). Patients who reported poor health, unemployment, or inability to work were more likely to feel judged or offended. Among the 2,411 patients who felt judged and/or offended, 2,137 (84.5%) wrote about what prompted their feelings. Three thematic domains emerged: (1) errors and surprises, (2) labeling, and (3) disrespect. CONCLUSIONS: One in 10 respondents reported feeling judged/offended by something they read in an outpatient note due to the perception that it contained errors, surprises, labeling, or evidence of disrespect. The content and tone may be particularly important to patients in poor health. Enhanced clinician awareness of the patient perspective may promote an improved medical lexicon, reduce the transmission of bias to other clinicians, and reinforce healing relationships.

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.

Electronic Patient Portal Use in Orthopaedic Surgery Is Associated with Disparities, Improved Satisfaction, and Lower No-Show Rates.

BACKGROUND: Electronic patient portal (EPP) use has been associated with a number of benefits in the internal medicine setting. Few studies have examined the disparities in and the benefits of EPP utilization among surgical patients. The purposes of this study were to examine factors associated with EPP use among patients undergoing an orthopaedic surgical procedure and to determine if EPP use is associated with improved outcomes or satisfaction after orthopaedic surgical procedures. METHODS: We queried all patients undergoing an orthopaedic surgical procedure from May 2015 to December 2018 at 2 academic medical centers in an integrated hospital system. Patient demographic characteristics, operative characteristics, satisfaction scores, and patient-reported outcome measures (PROMs) were collected. Multivariable logistic regression was used to identify disparities in EPP use. Adjusted logistic and linear regressions were then used to assess the association between EPP use and the various outcome metrics while controlling for confounders identified in the previous analysis. RESULTS: Numerous demographic factors were independently associated with EPP use among patients undergoing an orthopaedic surgical procedure, including English speakers compared with non-English speakers (odds ratio [OR], 2.37 [95% confidence interval (CI), 2.01 to 2.79]); African-American or black race (OR, 0.42 [95% CI, 0.36 to 0.48]) and Hispanic race (OR, 0.52 [95% CI, 0.44 to 0.61]) compared with white race; college education compared with high school education (OR, 2.30 [95% CI, 2.12 to 2.49]); and a surgical procedure for orthopaedic trauma compared with that for the hand or upper extremity (OR, 0.51 [95% CI, 0.45 to 0.58]) (p < 0.001 for all), among others. EPP use was independently associated with the increased likelihood of completing a PROM (OR, 1.57 [95% CI, 1.45 to 1.7]) and a satisfaction survey (OR, 2.38 [95% CI, 2.17 to 2.61]) and improved overall patient satisfaction (mean difference, 2.61 points [95% CI, 1.79 to 3.43 points]) (p < 0.001 for all). Finally, EPP use was independently associated with lower mean no-show rates (6.8% [95% CI, 6.4% to 7.2%] compared with 9.3% [95% CI, 8.9% to 9.7%]). The lower no-show rate for EPP users corresponded to an estimated $218,225 in savings for our institution within the first postoperative year. CONCLUSIONS: This study identified significant disparities in EPP use among patients undergoing an orthopaedic surgical procedure. Given that EPP use was independently associated with lower no-show rates and improved patient satisfaction among patients undergoing an orthopaedic procedure, efforts to reduce these disparities are warranted. CLINICAL RELEVANCE: EPPs are increasingly being used by health-care systems to improve communication between providers and patients; however, providers should be aware of and strive to eliminate disparities in EPP utilization among orthopaedic patients. Within orthopaedic surgery, EPPs are associated with a number of benefits, including lower no-show rates and increased patient satisfaction.

Association of Mobile Patient Portal Access With Diabetes Medication Adherence and Glycemic Levels Among Adults With Diabetes.

Importance: Online patient portals support self-management, and mobile devices expand portal access, but whether this translates to improvements in diabetes outcomes is unclear. Objective: To examine the association of adding mobile patient portal access with diabetes medication adherence and glycemic levels among adults with diabetes. Design, Setting, and Participants: This retrospective cohort study included patients with diabetes treated at Kaiser Permanente Northern California, a large, integrated health care delivery system, from April 1, 2015, to December 31, 2017. Inclusion criteria were adults with diabetes with an oral diabetes prescription at baseline and no insulin use. Data were analyzed from March 2018 to March 2019. Exposures: Patient portal access status for each calendar month from April 2015 to December 2017, categorized as never used, used from a computer only, used from a mobile device only, or used from both computer and mobile device. Main Outcomes and Measures: Medication adherence, measured by monthly percentage of days covered (PDC), and glycemic levels, measured by changes in glycated hemoglobin A1c (HbA1c) levels. The association of portal access with study outcomes was assessed using linear regression with patient-level fixed effects and adjusting for time-changing variables, stratified by baseline HbA1c level. Results: Among 111 463 included patients (mean [SD] age, 63.79 [12.93] years; 59 918 [53.76%] men), the number of patients using the portal from both a computer and mobile device increased over time from 38 371 patients (34.42%) in April 2015 to 57 920 patients (61.71%) in December 2017. Among patients with no prior portal access, adding computer-only portal access was associated with an increase in PDC of 1.16 (95% CI, 0.63 to 1.70) percentage points and a change of -0.06 (95% CI, -0.08 to -0.03) percentage points in HbA1c level, and adding both mobile and computer portal access was associated with an increase in PDC of 1.67 (95% CI, 1.10 to 2.23) percentage points and a change of -0.13 (95% CI, -0.16 to -0.10) percentage points in HbA1c level. Among patients with higher baseline HbA1c level (>8.0%), changing from no portal access to both computer and mobile access was associated with an increase in PDC of 5.09 (95% CI, 3.78 to 6.40) percentage points and a change of -0.19 (95% CI, -0.27 to -0.15) percentage points in HbA1c level. Conclusions and Relevance: These findings suggest that providing patients with computer patient portal access and combining it with mobile patient portal access are associated with significantly improved diabetes medication adherence and glycemic control, with greater benefits among patients with more clinical need. Convenient access to portal self-management tools through a mobile device could significantly improve diabetes management.

Recruitment of trial participants through electronic medical record patient portal messaging: A pilot study.

BACKGROUND/AIM: Cost-efficient methods are essential for successful participant recruitment in clinical trials. Patient portal messages are an emerging means of recruiting potentially eligible patients into trials. We assessed the response rate and complaint rate from direct-to-patient, targeted recruitment through patient portals of an electronic medical record for a clinical trial, and compared response rates by differences in message content. METHODS: The Study to Understand Fall Reduction and Vitamin D in You (STURDY) trial is a National Institutes of Health-sponsored, community-based study of vitamin D supplementation for fall prevention in older adults conducted at Johns Hopkins. Potential participants were identified using the Epic electronic medical record at the Johns Hopkins Health System based on age (≥70 years), ZIP code (30-mile radius of study site), and prior activation of a patient portal account. We prepared a shorter message and a longer message. Both had basic information about study participation, but the longer message also contained information about the significance of the study and a personal invitation from the STURDY principal investigator. The Hopkins Institutional Review Board did not require prior consent from the patient or their providers. We calculated the response rate and tracked the number of complaints and requests for removal from future messages. We also determined response rate according to message content. RESULTS: Of the 5.5 million individuals receiving care at the Johns Hopkins Health System, a sample of 6896 met our inclusion criteria and were sent one patient portal recruitment message between 6 April 2017 and 3 August 2017. Assessment of enrollment by this method ended on 1 December 2017. There were 116 patients who expressed interest in the study (response rate: 1.7%). Twelve (0.2%) recipients were randomized. There were two complaints (0.03%) and one request to unsubscribe from future recruitment messages (0.01%). Response rate was higher with the longer message than the shorter message (2.1% vs 1.2%; p = 0.005). CONCLUSION: Patient portal messages inviting seniors to participate in a randomized controlled trial resulted in a response rate similar to commercial email marketing and resulted in very few complaints or opt-out requests. Furthermore, a longer message with more content enhanced response rate. Recruitment through patient portals might be an effective strategy to enroll trial participants.

Assessment of Accuracy and Usability of a Fee Estimator for Ambulatory Care in an Integrated Health Care Delivery Network.

Importance: Given increased enrollment in high-deductible health insurance plans and mandates from the Patient Protection and Affordable Care Act, individualized price transparency tools are needed. Objective: To assess accuracy and initial user experience of a cost estimation tool for ambulatory procedures delivered via an online patient portal and informed by real-time data feeds from third-party payers. Design, Setting, and Participants: This quality improvement study included patients aged 18 years and older at an integrated health care system in Northern California. Data from patients who used the cost estimator tool from August 21, 2018, to April 9, 2019, and who had matching explanation of benefits statements were used to assess accuracy of the tool. User experience was assessed with a brief survey completed online or via postal mail. Data were analyzed from April 15, 2019, to October 11, 2019. Main Outcomes and Measures: Tool accuracy and user experience and satisfaction. Results: As of April 30, 2019, 4610 estimates (3569 [77.4%] via internet; 1041 [22.6%] via telephone) were produced using the cost estimator tool. Among 342 individuals who had an estimate and a matching explanation of benefits statement, 287 estimates (83.9%) were accurate. All 342 individuals with an estimate and an explanation of benefits statement were invited to participate in a user survey, and 125 individuals completed the survey (36.5% response rate). Survey respondents included 92 (73.6%) women, 72 (57.6%) non-Hispanic white participants , 91 participants (72.8%) with a college degree or higher, and 55 participants (44.0%) with an income of $100 000 per year or higher. Mean (SD) age was 46.8 (13.1) years. Ninety-nine participants (79.2%) found the tool easy to use, 109 participants (87.2%) would use it again, and 100 participants (80.0%) would recommend it to others. Seven participants (5.6%) reported contacting a clinician about the estimate, and 12 participants (9.6%) changed their decision based on the estimate. Conclusions and Relevance: This quality improvement study is the first report of an online cost estimator in an integrated health care delivery network. The findings suggest that the tool, informed by real-time data feeds from third-party payers, was easy to use and provided accurate results. Increasing the number of searchable services and sharing best practices with other health care systems who share the same portal platform are the next steps for the tool.

Exploring life with a long-term condition using asynchronous online communication.

OBJECTIVE: We describe the development and evaluation of a novel programme that uses an online patient portal system to provide medical students with early and authentic experience of patient interaction. METHODS: Focus group discussions were held with students, tutors and patients who had taken part in the first year of the programme. RESULTS: The programme provided an opportunity for early patient interaction in a safe environment. Students were able to practice communication skills learnt elsewhere in the course as well as identifying some of the different skills required for asynchronous online interactions. The approach gave opportunities to develop understanding of aspects of life with a long-term condition. CONCLUSION: Using an online patient portal system to interact with a patient enabled students to develop and apply their communication skills in a safe environment and gain a holistic view of a patient's experience. PRACTICE IMPLICATIONS: Medical students need to be equipped with the skills needed to communicate electronically with patients. Current medical curricula currently focus on more traditional models of the consultation. Further research is needed to establish best practice in this rapidly growing area.

Benefit of Tetrahydrocannabinol versus Cannabidiol for Common Palliative Care Symptoms.

Objectives: To determine the relative contributions of tetrahydrocannabinol (THC) and cannabidiol (CBD) to patients' self-ratings of efficacy for common palliative care symptoms. Design: This is an electronic record-based retrospective cohort study. Model development used logistic regression with bootstrapped confidence intervals (CIs), with standard errors clustered to account for multiple observations by each patient. Setting: This is a national Canadian patient portal. Participants: A total of 2,431 patients participated. Main Outcome Measures: Self-ratings of efficacy of cannabis, defined as a three-point reduction in neuropathic pain, anorexia, anxiety symptoms, depressive symptoms, insomnia, and post-traumatic flashbacks. Results: We included 26,150 observations between October 1, 2017 and November 28, 2018. Of the six symptoms, response was associated with increased THC:CBD ratio for neuropathic pain (odds ratio [OR]: 3.58; 95% CI: 1.32-9.68; p = 0.012), insomnia (OR: 2.93; 95% CI: 1.75-4.91; p < 0.001), and depressive symptoms (OR: 1.63; 95% CI: 1.07-2.49; p = 0.022). Increased THC:CBD ratio was not associated with a greater response of post-traumatic stress disorder (PTSD)-related flashbacks (OR: 1.43; 95% CI: 0.60-3.41; p = 0.415) or anorexia (OR: 1.61; 95% CI: 0.70-3.73; p = 0.265). The response for anxiety symptoms was not significant (OR: 1.13; 95% CI: 0.77-1.64; p = 0.53), but showed an inverted U-shaped curve, with maximal benefit at a 1:1 ratio (50% THC). Conclusions: These preliminary results offer a unique view of real-world medical cannabis use and identify several areas for future research.

Portal Use Among Patients With Chronic Conditions: Patient-reported Care Experiences.

BACKGROUND: Personal health records offer patients access to view their own health information and to manage their care online through secure patient portal tools. Little is known about the patient-reported experience in using health portals to manage chronic conditions. OBJECTIVE: In a patient-centered research study, we examined how using portal tools affects patient health care experiences among patients with chronic conditions. We also examined barriers among nonportal users. RESEARCH DESIGN: A cross-sectional patient survey. SUBJECTS: Patients with a chronic condition in an integrated delivery system offering a patient portal. MEASURES: Respondents reported barriers, preferences, and experiences in using the patient portal, and whether using the portal changed their overall health. RESULTS: Among all the 1824 respondents (70% response rate), portal nonusers reported preferring in-person health care (54%) or experiencing internet access barriers (41%). Portal users reported that using the portal was convenient (90%), the information available was useful (92%), and that it integrated well with other health care (92%). Among users, 31% reported that using the portal had improved their overall health. After adjustment, patients were significantly more likely to report that portal use improved their health if they had also reported convenience, information usefulness, or integration with other care (P<0.05). Reassuringly, patient-reported impacts on overall health did not vary by patient characteristics (including age, race, sex, education, income, complex conditions). CONCLUSION: Patients with chronic conditions using the portal reported convenience, information usefulness, and integration of the patient portal with their health care; these may act as potential pathways improving health.

Patients with complex chronic conditions: Health care use and clinical events associated with access to a patient portal.

BACKGROUND: For patients with diabetes, many with multiple complex chronic conditions, using a patient portal can support self-management and coordination of health care services, and may impact the frequency of in-person health care visits. OBJECTIVE: To examine the impact of portal access on the number of outpatient visits, emergency visits, and preventable hospitalizations. DESIGN: Observational study comparing patients' visit rates with and without portal access, using marginal structural modeling with inverse probability weighting estimates to account for potential bias due to confounding and attrition. SETTING: Large integrated delivery system which implemented a patient portal (2006-2007). PATIENTS: We examined 165,447 patients with diabetes defined using clinical registries. Our study included both patients with diabetes-only and patients with multiple complex chronic conditions (diabetes plus asthma, congestive artery disease, congestive heart failure, or hypertension). MEASUREMENTS: We examined rates of outpatient office visits, emergency room visits, and preventable hospitalizations (for ambulatory care sensitive conditions). RESULTS: Access to a patient portal was associated with significantly higher rates of outpatient office visits, in both patients with diabetes only and in patients with multiple complex conditions (p<0.05). In patients with multiple complex chronic conditions, portal use was also associated with significantly fewer emergency room visits (3.9 fewer per 1,000 patients per month, p<0.05) and preventable hospital stays (0.8 fewer per 1,000 patients per month, p<0.05). In patients with only diabetes, the results were directionally consistent but not statistically significantly associated with emergency room visits and preventable hospital stays. LIMITATIONS: Observational study in an integrated delivery system. CONCLUSION: Access to a patient portal can increase engagement in outpatient visits, potentially addressing unmet clinical needs, and reduce downstream health events that lead to emergency and hospital care, particularly among patients with multiple complex conditions.

Adherence to a novel home phototherapy system with integrated features.

OBJECTIVE: To measure adherence using a novel home UVB phototherapy system designed to promote adherence. STUDY DESIGN: A retrospective, observational study conducted to evaluate patients' adherence to a prescribed three-times-per-week treatment protocol using a novel home phototherapy system with integrated features designed to improve adherence. METHODS: Data was collected from 18 psoriasis patients, 27 vitiligo patients, and three atopic dermatitis patients using a novel home phototherapy system under normal use conditions. Adherence was also calculated using two alternative methods to allow for comparison between published phototherapy adherence studies. RESULTS: The median patient adherence (N= 48) to treatment with the home phototherapy system was 80%. There were no significant differences in adherence between different ages, genders, or diseases (P>0.05). Early adherence (N=48) to the home phototherapy system was 90% and dichotomous adherence (N=32) was 71%. CONCLUSIONS: By implementing a smartphone application and web-based portal with the home phototherapy system, patients have multiple mechanisms in place to ensure adherence.

Digital Patient Communication: Improving the Hospital-Patient Relationship.

Digitally engaging patients in their care processes was for many years limited to sharing care related documents (e.g. laboratory or radiology findings, discharge letters) with them through personal electronic health records. Newer concepts have led to the establishment of patient portals as patient frontends to a hospitals electronic health record. Rarely however have complete patient pathways with pre-hospitalization, inpatient stay and post-hospitalization been evaluated to identify chains of communication processes involving clinical care scenarios, as well as subsequent home monitoring scenarios. Neither have such approaches been integrated with digital communication processes related to a patients engagement in medical research projects. In order to enhance hospital-patient relationships in a holistic manner, we hypothesize that an integrated environment (e.g. patient portal) supporting shared decision making and communication in a patient´s care situation and in the same time providing communication processes for patient research engagement will optimize the patient-hospital relationship and be supportive in binding a patient to this care providing institution.

Mobile Device Applications for Electronic Patient Portals in Oncology.

PURPOSE: Mobile devices provide individuals with rapid and frequent access to electronic patient portals. We investigated how oncology patients use this technology to review test results and communicate with providers. PATIENTS AND METHODS: We performed a retrospective study of patients enrolled in the MyChart electronic health portal associated with the Epic electronic medical record at the Harold C. Simmons Comprehensive Cancer Center from 2012 to 2017. We recorded type of portal access according to year and patient characteristics. Associations among patient characteristics and types of portal access were tested using Mann-Whitney U test, χ2 test, and linear Gaussian regression models. RESULTS: Since the availability of a mobile device application in 2012, 2,524 patients with cancer accessed MyChart from a mobile device at least once, which accounted for 291,526 mobile log-ins. The number of patients with MyChart mobile application log-ins increased from 4% in 2012 to 13% in 2017 ( P = .004). Among these patients, the median proportion of log-ins that occurred through mobile device use increased from 22% to 72% during this time period ( P < .001). Mobile access occurred more frequently among younger ( P < .001), black ( P = .002), and Hispanic ( P = .004) patients. Since 2012, total portal log-in frequency increased approximately 110% among patients who used the mobile application compared with 25% among those who did not use the mobile application ( P < .001). CONCLUSION: Mobile access to electronic health portals has increased patient portal use, particularly among traditionally underserved populations. How this widely and immediately available technology affects patient expectations and experiences warrants additional study.

Patients' adoption of and feature access within electronic patient portals.

OBJECTIVES: We describe online portal account adoption and feature access among subgroups of patients who traditionally have been disadvantaged or represent those with high healthcare needs. STUDY DESIGN: Retrospective cohort study of insured primary care patients 18 years and older (N = 20,282) receiving care from an integrated health system. METHODS: Using data from an electronic health record repository, portal adoption was defined by 1 or more online sessions. Feature access (ie, messaging, appointment management, visit/admission summaries, and medical record access and management) was defined by user-initiated "clicks." Multivariable regression methods were used to identify patient factors associated with portal adoption and feature access among adopters. RESULTS: One-third of patients were portal adopters, with African Americans (odds ratio [OR], 0.50; 95% CI, 0.46-0.56), Hispanics (OR, 0.63; 95% CI, 0.47-0.84), those 70 years and older (OR, 0.48; 95% CI, 0.44-0.52), and those preferring a language other than English (OR, 0.43; 95% CI, 0.31-0.59) less likely to be adopters. On the other hand, the likelihood of portal adoption increased with a higher number of comorbidities (OR, 1.04; 95% CI, 1.02-1.07). Among adopters, record access and management features (95.9%) were accessed most commonly. The majority of adopters also accessed appointment management (76.6%) and messaging (59.1%) features. Similar race and age disparities were found in feature access among adopters. CONCLUSIONS: The diversity of portal features accessed may bode well for the ability of portals to engage some patients, but without purposeful intervention, reliance on portals alone for patient engagement may exacerbate known social disparities-even among those with an activated portal account.

Oncology Patient Portal Enrollment at a Comprehensive Cancer Center: A Quality Improvement Initiative.

PURPOSE: Patient portals (PPs) provide patients access to their electronic health record and may facilitate active engagement in their care. Because PP use has not been well studied among patients with cancer, we sought to: understand the willingness of patients with cancer to use the PP, identify barriers to PP use, and improve PP accessibility. MATERIALS AND METHODS: As part of an institutional quality improvement initiative, we used a stakeholder-driven approach to examine PP use at the Dana-Farber Cancer Institute (Boston, MA). We conducted a survey across all ambulatory oncology practices as well as staff and patient focus groups in one ambulatory practice. We deployed three interventions to address barriers: staff education, staff-assisted enrollment support, and independent enrollment support. RESULTS: In October 2015, 1,019 (87%) of 1,178 eligible patients completed the survey (PP enrolled, 57%; non-PP enrolled, 43%). PP-enrolled patients reported reviewing test results and appointment schedules. Non-PP-enrolled patients cited difficult PP enrollment, lack of computer access, and concern about sharing data electronically as barriers to PP enrollment. Focus groups (staff, n = 20; patient representatives, n = 5) also identified lack of awareness of PP benefits as a barrier. The interventions, deployed from November to December 2015, increased PP enrollment from 47% to 53% by January 2016. CONCLUSION: Patients with cancer want to communicate with their team through the PP, but barriers to enrollment impede use. Straightforward system-level interventions may increase enrollment. Further work is necessary to ascertain the degree to which increased PP enrollment leads to greater engagement and better outcomes.