Laboratory Results Release to Patients under the 21st Century Cures Act: The Eight Stakeholders Who Should Care.

A major aim of the 21st Century Cures Act is to support patients' access to their electronic health data and to prevent information blocking practices by health care organizations and health information technology developers. Prior to the Cures Act, significant variation existed in patient access to laboratory test results, key pieces of health data which enable timely self-management and engagement in care. Although many health care systems began releasing test results immediately through patient portals because of the Cures Act, implementation remains challenging due to variations in state regulations around electronic results release, local interpretations of allowable exceptions to Cures information blocking, concerns about privacy of sensitive laboratory results, and technological limitations. This paper outlines the eight stakeholder groups involved in implementation of electronic laboratory result release to patients and describes recommendations for these groups to consider in achieving the Cures Act goals to support a patient's access to their health information and control of their health care.

Informatics response to address the COVID-19 pandemic in a safety net healthcare system.

In service of particularly vulnerable populations, safety net healthcare systems must nimbly leverage health information technology (IT), including electronic health records (EHRs), to coordinate the medical and public health response to the novel coronavirus (COVID-19). Six months after the San Francisco Department of Public Health implemented a new EHR across its hospitals and citywide clinics, California declared a state of emergency in response to COVID-19. This paper describes how the IT and informatics teams supported San Francisco Department of Public Health's goals of expanding the safety net healthcare system capacity, meeting the needs of specific vulnerable populations, increasing equity in COVID-19 testing access, and expanding public health analytics and research capacity. Key enabling factors included critical partnerships with operational leaders, early identification of priorities, a clear governance structure, agility in the face of rapidly changing circumstances, and a commitment to vulnerable populations.

An Untapped Potential in Primary Care: Semi-Structured Interviews with Clinicians on How Patient Portals Will Work for Caregivers in the Safety Net.

BACKGROUND: Patients within safety-net settings are less likely to access health information on patient portals, despite expressed interest. Family and friends are important resources to assist these patients (ie, Medicaid recipients, older patients, patients with limited English proficiency) in navigating health systems, and provider support of the use of patient portals among these groups may also facilitate caregivers' use of their patients' portal. OBJECTIVE: Because safety net providers work closely with caregivers to care for their patients, we used qualitative methods to explore safety net providers' perspectives on portal use among caregivers for their patients, especially as there is limited literature about caregivers' use of portals in the safety net. METHODS: We conducted 45- to 60-min semistructured telephone interviews with providers from three large California safety-net health systems. The interviews focused on providers' experiences with caregivers, caregiver roles, and how the portal could be leveraged as a tool to support caregivers in their responsibilities. A total of three coders analyzed the interview transcripts using both deductive and inductive approaches and established a consensus regarding major themes. RESULTS: Of the 16 participants interviewed, 4 specialized in geriatrics, and all held a leadership or administrative role. We described themes highlighting providers' recognition of potential benefits associated with caregiver portal use and specific challenges to caregiver engagement. CONCLUSIONS: Providers recognized the potential for portals to improve information delivery and communication by helping caregivers assist socially and medically complex patients in the safety net. Providers in safety net sites also discussed a clear need for better ways to keep in touch with patients and connect with caregivers, yet security and privacy are perhaps of higher importance in these settings and may pose challenges to portal adoption. They noted that caregivers of patients in the safety net likely face similar communication barriers as patients, especially with respect to digital literacy, health literacy, and English proficiency. Further research is needed to assess and support caregivers' interest and ability to access portals across barriers in health and digital literacy, and English proficiency. Portal platforms and health systems must also address specific strategies to uphold patient preferences while maintaining privacy and security.

Evaluation of a Health Information Technology-Enabled Collective Intelligence Platform to Improve Diagnosis in Primary Care and Urgent Care Settings: Protocol for a Pragmatic Randomized Controlled Trial.

BACKGROUND: Diagnostic error in ambulatory care, a frequent cause of preventable harm, may be mitigated using the collective intelligence of multiple clinicians. The National Academy of Medicine has identified enhanced clinician collaboration and digital tools as a means to improve the diagnostic process. OBJECTIVE: This study aims to assess the efficacy of a collective intelligence output to improve diagnostic confidence and accuracy in ambulatory care cases (from primary care and urgent care clinic visits) with diagnostic uncertainty. METHODS: This is a pragmatic randomized controlled trial of using collective intelligence in cases with diagnostic uncertainty from clinicians at primary care and urgent care clinics in 2 health care systems in San Francisco. Real-life cases, identified for having an element of diagnostic uncertainty, will be entered into a collective intelligence digital platform to acquire collective intelligence from at least 5 clinician contributors on the platform. Cases will be randomized to an intervention group (where clinicians will view the collective intelligence output) or control (where clinicians will not view the collective intelligence output). Clinicians will complete a postvisit questionnaire that assesses their diagnostic confidence for each case; in the intervention cases, clinicians will complete the questionnaire after reviewing the collective intelligence output for the case. Using logistic regression accounting for clinician clustering, we will compare the primary outcome of diagnostic confidence and the secondary outcome of time with diagnosis (the time it takes for a clinician to reach a diagnosis), for intervention versus control cases. We will also assess the usability and satisfaction with the digital tool using measures adapted from the Technology Acceptance Model and Net Promoter Score. RESULTS: We have recruited 32 out of our recruitment goal of 33 participants. This study is funded until May 2020 and is approved by the University of California San Francisco Institutional Review Board until January 2020. We have completed data collection as of June 2019 and will complete our proposed analysis by December 2019. CONCLUSIONS: This study will determine if the use of a digital platform for collective intelligence is acceptable, useful, and efficacious in improving diagnostic confidence and accuracy in outpatient cases with diagnostic uncertainty. If shown to be valuable in improving clinicians' diagnostic process, this type of digital tool may be one of the first innovations used for reducing diagnostic errors in outpatient care. The findings of this study may provide a path forward for improving the diagnostic process. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/13151.

Perspectives of English, Chinese, and Spanish-Speaking Safety-Net Patients on Clinician Computer Use: Qualitative Analysis.

BACKGROUND: Safety-net systems serve patients with limited health literacy and limited English proficiency (LEP) who face communication barriers. However, little is known about how diverse safety-net patients feel about increasing clinician electronic health record (EHR) use. OBJECTIVE: The aim of this study was to better understand how safety-net patients, including those with LEP, view clinician EHR use. METHODS: We conducted focus groups in English, Spanish, and Cantonese (N=37) to elicit patient perspectives on how clinicians use EHRs during clinic visits. Using a grounded theory approach, we coded transcripts to identify key themes. RESULTS: Across multiple language groups, participants accepted multitasking and silent clinician EHR use if focused on their care. However, participants desired more screen share and eye contact, especially when demonstrating physical concerns. All participants, including LEP participants, wanted clinicians to include them in EHR use. CONCLUSIONS: Linguistically diverse patients accept the value of EHR use during outpatient visits but desire more eye contact, verbal warnings before EHR use, and screen-sharing. Safety-net health systems should support clinicians in completing EHR-related tasks during the visit using patient-centered strategies for all patients.

Disparities in Patient-Reported Interest in Web-Based Patient Portals: Survey at an Urban Academic Safety-Net Hospital.

BACKGROUND: Offering hospitalized patients' enrollment into a health system's patient portal may improve patient experience and engagement throughout the care continuum, especially across care transitions, but this process is less studied than portal engagement in the ambulatory setting. Patient portal disparities exist and may lead to differences in access or outcomes. As such, it is important to study upstream factors in a typical hospital workflow that could lead to those disparities in safety-net settings. OBJECTIVE: The objective of this study was to evaluate sociodemographic characteristics associated with interest in a health care system's portal among hospitalized patients and reasons for no interest. METHODS: Nurses assessed interest in a Web-based patient portal, expressed by the patient as "yes" or "no," as part of the admission nursing assessment among patients at an academic urban safety-net hospital and recorded responses in the electronic health record (EHR), including reasons for no interest. We extracted patient responses from the EHR. RESULTS: Among 23,994 hospitalizations over a 2-year period, 35.90% (8614/ 23,994) reported an interest in a Web-based portal. Reasons for no interest included the following: not interested/other reason 41.68% (6410/15,380), no ability to use/access computers/internet 29.59% (4551/15,380), doesn't speak English 11.15% (1715/15,380), physically or mentally unable 8.70% (1338/15,380), does not want to say 8.70% (1338/15,380), security concerns 0.03% (4/15,380), and not useful 0.16% (24/15,380). Among the 16,507 unique patients included in this sample, portal interest was lower in older, African American, non-English speaking, and homeless patient populations. CONCLUSIONS: In a safety-net system, patient interest at the time of hospitalization in a Web-based enterprise portal-a required step before enrollment-is low with significant disparities by sociodemographic characteristics. To avoid worsening the digital divide, new strategies are needed and should be embedded within routine workflows to engage vulnerable safety-net patients in the use of Web-based health technologies.

A Randomized Trial to Train Vulnerable Primary Care Patients to Use a Patient Portal.

BACKGROUND: Patient portals are becoming ubiquitous. Previous research has documented substantial barriers, especially among vulnerable patient subgroups such as those with lower socioeconomic status or limited health literacy (LHL). We tested the effectiveness of delivering online, video-based portal training to patients in a safety net setting. METHODS: We created an online video curriculum about accessing the San Francisco Health Network portal, and then randomized 93 English-speaking patients with 1+ chronic diseases to receive 1) an in-person tutorial with a research assistant, or 2) a link to view the videos on their own. We also examined a third, nonrandomized usual care comparison group. The primary outcome was portal log-in (yes/no) 3 to 6 months post-training, assessed via the electronic health record. Secondary outcomes were self-reported attitudes and skills collected via baseline and follow-up surveys. RESULTS: Mean age was 54 years, 51% had LHL, 60% were nonwhite, 52% were female, 45% reported fair/poor health, and 76% reported daily Internet use. At followup, 21% logged into the portal, with no differences by arm (P = .41), but this was higher than the overall clinic rate of 9% (P < .01) during the same time period. We found significant prepost improvements in self-rated portal skills (P = .03) and eHealth literacy (P < .01). Those with LHL were less likely to log in post-training (P < .01). CONCLUSIONS: Both modalities of online training were comparable, and neither mode enabled a majority of vulnerable patients to use portals, especially those with LHL. This suggests that portal training will need to be more intensive or portals need improved usability to meaningfully increase use among diverse patients.

Testing and improving the acceptability of a web-based platform for collective intelligence to improve diagnostic accuracy in primary care clinics.

OBJECTIVES: Usable tools to support individual primary care clinicians in their diagnostic processes could help to reduce preventable harm from diagnostic errors. We conducted a formative study with primary care providers to identify key requisites to optimize the acceptability of 1 online collective intelligence platform (Human Diagnosis Project; Human Dx). MATERIALS AND METHODS: We conducted semistructured interviews with practicing primary care clinicians in a sample of the US community-based clinics to examine the acceptability and early usability of the collective intelligence online platform using standardized clinical cases and real-world clinical cases from the participants' own practice. We used an integrated inductive-deductive qualitative analysis approach to analyze the interview transcripts. RESULTS AND DISCUSSION: Perceived usefulness, perceived accuracy, quality assurance, trust, and ease of use emerged as essential domains of acceptability required for providers to use a collective intelligence tool in clinical practice. Participants conveyed that the collective opinion should: (1) contribute to their clinical reasoning, (2) boost their confidence, (3) be generated in a timely manner, and (4) be relevant to their clinical settings and use cases. Trust in the technology platform and the clinical accuracy of its collective intelligence output emerged as an incontrovertible requirement for user acceptance and engagement. CONCLUSION: We documented key requisites to building a collective intelligence technology platform that is trustworthy, useful, and acceptable to target end users for assistance in the diagnostic process. These key lessons may be applicable to other provider-facing decision support platforms.

Finding Meaning in Medication Reconciliation Using Electronic Health Records: Qualitative Analysis in Safety Net Primary and Specialty Care.

BACKGROUND: Safety net health systems face barriers to effective ambulatory medication reconciliation for vulnerable populations. Although some electronic health record (EHR) systems offer safety advantages, EHR use may affect the quality of patient-provider communication. OBJECTIVE: This mixed-methods observational study aimed to develop a conceptual framework of how clinicians balance the demands and risks of EHR and communication tasks during medication reconciliation discussions in a safety net system. METHODS: This study occurred 3 to 16 (median 9) months after new EHR implementation in five academic public hospital clinics. We video recorded visits between English-/Spanish-speaking patients and their primary/specialty care clinicians. We analyzed the proportion of medications addressed and coded time spent on nonverbal tasks during medication reconciliation as "multitasking EHR use," "silent EHR use," "non-EHR multitasking," and "focused patient-clinician talk." Finally, we analyzed communication patterns to develop a conceptual framework. RESULTS: We examined 35 visits (17%, 6/35 Spanish) between 25 patients (mean age 57, SD 11 years; 44%, 11/25 women; 48%, 12/25 Hispanic; and 20%, 5/25 with limited health literacy) and 25 clinicians (48%, 12/25 primary care). Patients had listed a median of 7 (IQR 5-12) relevant medications, and clinicians addressed a median of 3 (interquartile range [IQR] 1-5) medications. The median duration of medication reconciliation was 2.1 (IQR 1.0-4.2) minutes, comprising a median of 10% (IQR 3%-17%) of visit time. Multitasking EHR use occurred in 47% (IQR 26%-70%) of the medication reconciliation time. Silent EHR use and non-EHR multitasking occurred a smaller proportion of medication reconciliation time, with a median of 0% for both. Focused clinician-patient talk occurred a median of 24% (IQR 0-39%) of medication reconciliation time. Five communication patterns with EHR medication reconciliation were observed: (1) typical EHR multitasking for medication reconciliation, (2) dynamic EHR use to negotiate medication discrepancies, (3) focused patient-clinician talk for medication counseling and addressing patient concerns, (4) responding to patient concerns while maintaining EHR use, and (5) using EHRs to engage patients during medication reconciliation. We developed a conceptual diagram representing the dilemma of the multitasking clinician during medication reconciliation. CONCLUSIONS: Safety net visits involve multitasking EHR use during almost half of medication reconciliation time. The multitasking clinician balances the cognitive and emotional demands posed by incoming information from multiple sources, attempts to synthesize and act on this information through EHR and communication tasks, and adopts strategies of silent EHR use and focused patient-clinician talk that may help mitigate the risks of multitasking. Future studies should explore diverse patient perspectives about clinician EHR multitasking, clinical outcomes related to EHR multitasking, and human factors and systems engineering interventions to improve the safety of EHR use during the complex process of medication reconciliation.

Language-concordant automated telephone queries to assess medication adherence in a diverse population: a cross-sectional analysis of convergent validity with pharmacy claims.

BACKGROUND: Clinicians have difficulty accurately assessing medication non-adherence within chronic disease care settings. Health information technology (HIT) could offer novel tools to assess medication adherence in diverse populations outside of usual health care settings. In a multilingual urban safety net population, we examined the validity of assessing adherence using automated telephone self-management (ATSM) queries, when compared with non-adherence using continuous medication gap (CMG) on pharmacy claims. We hypothesized that patients reporting greater days of missed pills to ATSM queries would have higher rates of non-adherence as measured by CMG, and that ATSM adherence assessments would perform as well as structured interview assessments. METHODS: As part of an ATSM-facilitated diabetes self-management program, low-income health plan members typed numeric responses to rotating weekly ATSM queries: "In the last 7 days, how many days did you MISS taking your …" diabetes, blood pressure, or cholesterol pill. Research assistants asked similar questions in computer-assisted structured telephone interviews. We measured continuous medication gap (CMG) by claims over 12 preceding months. To evaluate convergent validity, we compared rates of optimal adherence (CMG ≤ 20%) across respondents reporting 0, 1, and ≥ 2 missed pill days on ATSM and on structured interview. RESULTS: Among 210 participants, 46% had limited health literacy, 57% spoke Cantonese, and 19% Spanish. ATSM respondents reported ≥1 missed day for diabetes (33%), blood pressure (19%), and cholesterol (36%) pills. Interview respondents reported ≥1 missed day for diabetes (28%), blood pressure (21%), and cholesterol (26%) pills. Optimal adherence rates by CMG were lower among ATSM respondents reporting more missed days for blood pressure (p = 0.02) and cholesterol (p < 0.01); by interview, differences were significant for cholesterol (p = 0.01). CONCLUSIONS: Language-concordant ATSM demonstrated modest potential for assessing adherence. Studies should evaluate HIT assessments of medication beliefs and concerns in diverse populations. TRIAL REGISTRATION: NCT00683020 , registered May 21, 2008.

Reducing Misses and Near Misses Related to Multitasking on the Electronic Health Record: Observational Study and Qualitative Analysis.

BACKGROUND: Clinicians' use of electronic health record (EHR) systems while multitasking may increase the risk of making errors, but silent EHR system use may lower patient satisfaction. Delaying EHR system use until after patient visits may increase clinicians' EHR workload, stress, and burnout. OBJECTIVE: We aimed to describe the perspectives of clinicians, educators, administrators, and researchers about misses and near misses that they felt were related to clinician multitasking while using EHR systems. METHODS: This observational study was a thematic analysis of perspectives elicited from 63 continuing medical education (CME) participants during 2 workshops and 1 interactive lecture about challenges and strategies for relationship-centered communication during clinician EHR system use. The workshop elicited reflection about memorable times when multitasking EHR use was associated with "misses" (errors that were not caught at the time) or "near misses" (mistakes that were caught before leading to errors). We conducted qualitative analysis using an editing analysis style to identify codes and then select representative themes and quotes. RESULTS: All workshop participants shared stories of misses or near misses in EHR system ordering and documentation or patient-clinician communication, wondering about "misses we don't even know about." Risk factors included the computer's position, EHR system usability, note content and style, information overload, problematic workflows, systems issues, and provider and patient communication behaviors and expectations. Strategies to reduce multitasking EHR system misses included clinician transparency when needing silent EHR system use (eg, for prescribing), narrating EHR system use, patient activation during EHR system use, adapting visit organization and workflow, improving EHR system design, and improving team support and systems. CONCLUSIONS: CME participants shared numerous stories of errors and near misses in EHR tasks and communication that they felt related to EHR multitasking. However, they brainstormed diverse strategies for using EHR systems safely while preserving patient relationships.

Certified Medical Interpreters' Perspectives on Relationship-Centered Communication in Safety-Net Care.

This article was migrated. The article was marked as recommended. Background: Interpreters may offer valuable perspectives on ways clinicians could improve communication skills. Relationship-centered communication (RCC) curricula aim to promote effective communication between patients and clinicians and among members of health care teams. Methods: We conducted a 90-minute workshop with certified interpreters at an academically affiliated safety-net system to solicit feedback on content offered during RCC skills trainings. We applied an editing analysis style to transcribed quotes to reveal opportunities to optimize RCC skills trainings for application in interpreted interactions to improve safety-net care for diverse populations. Results: Twenty-two Spanish-, Cantonese-, Mandarin-, Vietnamese-, and Russian-speaking interpreters participated. Overall, interpreters emphasized the importance of creating a supportive environment for safety-net patients. One Spanish-speaking interpreter added: "When they get up in the morning and go to work, they may get deported. So, that's important to create an atmosphere to help them open up. And they may tell you stuff that's directly pertinent to patient care." Thematic analysis revealed opportunities to tailor and reinforce each RCC stage. On agenda-setting and rapport-building: "We need a little background on the phone, and we don't know how many people are in the room ... Sometimes you're talking to the mom, but the doctor didn't even bother to say it.. [If] we're lost, we're bound to make mistakes." On eliciting the patient's perspective: "Start with this information so they know you're still going to give them your advice: "I'm going to let you know what I think is going on, but what do you think is going on?" On negotiating a shared plan: "[Teachback] is really important. Otherwise it puts an incredible burden on the interpreter ... I'm not sure that the patient really understood." Conclusions: Teaching RCC in partnership with medical interpreters could provide opportunities to deepen clinician RCC skills for more effective patient-interpreter-clinician interactions.

Use of Complementary Health Approaches Among Diverse Primary Care Patients with Type 2 Diabetes and Association with Cardiometabolic Outcomes: From the SF Bay Collaborative Research Network (SF Bay CRN).

PURPOSE: To describe use of complementary health approaches (CHAs) among patients with type 2 diabetes, and independent associations between CHA use and Hemoglobin A1c (A1C) and lower-density lipoprotein (LDL) cholesterol. METHODS: Participants were enrolled onto the SMARTSteps Program, a diabetes self-management support program conducted between 2009 and 2013 in San Francisco. At the 6-month interview, CHA use in the prior 30 days was estimated using a 12-item validated instrument. Demographic and diabetes-related measures A1C were assessed at baseline and 6-month followup. AIC and LDL values were ascertained from chart review over the study period. Medication adherence was measured using pharmacy claims data at 6 and 12 months. RESULTS: Patients (n = 278) completed 6-month interviews: 74% were women and 71.9% were non-English speaking. Any CHA use was reported by 51.4% overall. CHA modalities included vitamins/nutritional supplements (25.9%), spirituality/prayer (21.2%), natural remedies/herbs (24.5%), massage/acupressure (11.5%), and meditation/yoga/tai chi (10.4%). CHA costs per month were $43.86 (SD = 118.08). Nearly one third reported CHA (30.0%) specifically for their type 2 diabetes. In regression models, elevated A1C (>8.0%) was not significantly associated with overall CHA use (odds ratio [OR] = 1.78; 95% confidence interval [CI], 0.7 to 4.52) whereas elevated LDL was (OR = 3.93; 95% CI, 1.57 to 9.81). With medication adherence added in exploratory analysis, these findings were not significant. CONCLUSIONS: CHA use is common among patients with type 2 diabetes and may be associated with poor cardiometabolic control and medication adherence.

The Next Frontier in Communication and the ECLIPPSE Study: Bridging the Linguistic Divide in Secure Messaging.

Health systems are heavily promoting patient portals. However, limited health literacy (HL) can restrict online communication via secure messaging (SM) because patients' literacy skills must be sufficient to convey and comprehend content while clinicians must encourage and elicit communication from patients and match patients' literacy level. This paper describes the Employing Computational Linguistics to Improve Patient-Provider Secure Email (ECLIPPSE) study, an interdisciplinary effort bringing together scientists in communication, computational linguistics, and health services to employ computational linguistic methods to (1) create a novel Linguistic Complexity Profile (LCP) to characterize communications of patients and clinicians and demonstrate its validity and (2) examine whether providers accommodate communication needs of patients with limited HL by tailoring their SM responses. We will study >5 million SMs generated by >150,000 ethnically diverse type 2 diabetes patients and >9000 clinicians from two settings: an integrated delivery system and a public (safety net) system. Finally, we will then create an LCP-based automated aid that delivers real-time feedback to clinicians to reduce the linguistic complexity of their SMs. This research will support health systems' journeys to become health literate healthcare organizations and reduce HL-related disparities in diabetes care.

The Challenges of Electronic Health Records and Diabetes Electronic Prescribing: Implications for Safety Net Care for Diverse Populations.

Widespread electronic health record (EHR) implementation creates new challenges in the diabetes care of complex and diverse populations, including safe medication prescribing for patients with limited health literacy and limited English proficiency. This review highlights how the EHR electronic prescribing transformation has affected diabetes care for vulnerable patients and offers recommendations for improving patient safety through EHR electronic prescribing design, implementation, policy, and research. Specifically, we present evidence for (1) the adoption of RxNorm; (2) standardized naming and picklist options for high alert medications such as insulin; (3) the widespread implementation of universal medication schedule and language-concordant labels, with the expansion of electronic prescription 140-character limit; (4) enhanced bidirectional communication with pharmacy partners; and (5) informatics and implementation research in safety net healthcare systems to examine how EHR tools and practices affect diverse vulnerable populations.

Improving best possible medication history with vulnerable patients at an urban safety net academic hospital using pharmacy technicians.

BACKGROUND: Best possible medication history (BPMH) enhances the care of safety net patients, especially those with limited English proficiency and limited health literacy who are most vulnerable to medication error during the hospital admission process. Our large urban academic safety net centre faced numerous barriers to achieve BPMH among hospitalised patients including communication barriers that increase the time and complexity of eliciting BPMH, frequent provider turnover at our training institution and lack of an electronic health record (EHR) medication reconciliation tool to facilitate BPMH collection and monitoring. DESIGN: Leveraging opportunities afforded by the US federal incentive EHR programme, our multidisciplinary team designed an EHR-facilitated medication reconciliation programme by which pharmacy technicians engaged newly admitted patients and their caregivers at the bedside to develop and electronically document the BPMH. STRATEGY: Prior to this intervention, pharmacy technicians had no role in BPMH. Providers collected home medications documented on paper notes without a consistent methodology. With each plan-do-study-act (PDSA) cycle since the programme began, the goal was to increase the per cent of BPMH completed by a pharmacy technician. Individual PDSA cycles targeted either the pharmacy technicians by expanding their pool of eligible patients or provider engagement with the pharmacy technician workflow. RESULTS: By optimising not only the health information technology platform but also the operational processes, the programme achieved a nearly 80% generation of BPMH completed by a highly trained pharmacy technician, surpassing its intended goal of 50% BPMH completion by a pharmacy technician on admission. CONCLUSION: An EHR-facilitated tool improved BPMH at an urban academic safety net hospital using pharmacy technicians.

Computer use, language, and literacy in safety net clinic communication.

OBJECTIVE: Patients with limited health literacy (LHL) and limited English proficiency (LEP) experience suboptimal communication and health outcomes. Electronic health record implementation in safety net clinics may affect communication with LHL and LEP patients.We investigated the associations between safety net clinician computer use and patient-provider communication for patients with LEP and LHL. MATERIALS AND METHODS: We video-recorded encounters at 5 academically affiliated US public hospital clinics between English- and Spanish-speaking patients with chronic conditions and their primary and specialty care clinicians. We analyzed changes in communication behaviors (coded with the Roter Interaction Analysis System) with each additional point on a clinician computer use score, controlling for clinician type and visit length and stratified by English proficiency and health literacy status. RESULTS: Greater clinician computer use was associated with more biomedical statements (+12.4, P = .03) and less positive affect (-0.6, P < .01) from LEP/LHL patients. In visits with patients with adequate English proficiency/health literacy, greater clinician computer use was associated with less positive patient affect (-0.9, P < .01), fewer clinician psychosocial statements (-3.5, P < .05), greater clinician verbal dominance (+0.09, P < .01), and lower ratings on quality of care and communication. CONCLUSION: Higher clinician computer use was associated with more biomedical focus with LEP/LHL patients, and clinician verbal dominance and lower ratings with patients with adequate English proficiency and health literacy. DISCUSSION: Implementation research should explore interventions to enhance relationship-centered communication for diverse patient populations in the computer era.

Online patient websites for electronic health record access among vulnerable populations: portals to nowhere?

OBJECTIVE: With the rapid rise in the adoption of patient portals, many patients are gaining access to their personal health information online for the first time. The objective of this study was to examine specific usability barriers to patient portal engagement among a diverse group of patients and caregivers. MATERIALS AND METHODS: We conducted interviews using performance testing and think-aloud methods with 23 patients and 2 caregivers as they first attempted to use features of a newly launched patient portal. RESULTS: In navigating the portal, participants experienced basic computer barriers (eg, difficulty using a mouse), routine computer barriers (eg, mistyping, navigation issues), reading/writing barriers, and medical content barriers. Compared to participants with adequate health literacy, participants with limited health literacy required 2 additional minutes to complete each task and were more likely to experience each type of navigational barrier. They also experienced more inaccuracies in interpreting a test result and finding a treatment plan within an after-visit summary. DISCUSSION: When using a patient portal for the first time, participants with limited health literacy completed fewer tasks unassisted, had a higher prevalence of encountering barriers, took longer to complete tasks, and had more problems accurately interpreting medical information. CONCLUSION: Our findings suggest a strong need for tailored and accessible training and support to assist all vulnerable patients and/or caregivers with portal registration and use. Measuring the health literacy of a patient population might serve as a strong proxy for identifying patients who need the most support in using health technologies.