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Lory Tonioli
Carey Stevens
Andrea Vining
Rick Ramdon

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Discussion Questions
1. Discuss 4 implications of using EHR.

2. What are some of the advantages of an Electronic Health Record that impact your work day?

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Accountable Care Organizations and the EHR 

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Accountable Care Organizations and the EHR 

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A high level of functional care is required for an Accountable Care Organization to have access to patient information through the EHR system. This is typically seen in larger health-care facilities using team-based skills to offer patient care. Maintaining this high level standard ensures that organizations using the EHR have the resources necessary to not only maintain and update the EHR, but to also manage patient health record information safely and in accordance with applicable laws.

Huber, T. P., Shortell, S. M., & Rodriguez, H. P. (2017). Improving Care Transitions Management: Examining the Role of Accountable Care Organization Participation and Expanded Electronic Health Record Functionality. Health Services Research, 52(4), 1494–1510. https://doi-org.ju.idm.oclc.org/10.1111/1475-6773.12546.

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Sharing Your Electronic Health Record (EHR)

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The design and construction of the EHR required the inclusion of features that allow for easy patient access. Also included in this design are features that include a user-friendly interface that offers accessibility to a wide range of users and opportunities to update and expand as new features and patient information require new updates.

Klein, T.M., Augustin, M. & Otten, M. How should electronic health records be designed? A cross-sectional study in patients with psoriasis. BMC Med Inform Decis Mak 19, 218 (2019). https://doi.org/10.1186/s12911-019-0926-5.

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Under HIPAA privacy laws, only the patient or the patient's representative has a right to access his or her medical record. The patient or a representative may also amend the EHR, share it, or to obtain a copy of it. Although this is the case, the patient does not have the right of proprietary ownership. For example, the patient cannot destroy his or her medical record; ownership of the record remains with the provider who created or has custody of the record.

Patient Access Information for Individuals: Get it, Check it, Use it! (2020, January 31). Retrieved February 7, 2020, from https://www.healthit.gov/topic/patient-access-information-individuals-get-it-check-it-use-it

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Office of the National Coordinator for Health IT

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Video 3 - Your Health Information, Your Rights

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Brandi Schimpf BSN, R. C., & Kathy Deanda RN, M. (2019, September). Integration of Real-Time Electronic Health Records and Wireless Technology in a Mobile Stroke Unit. Retrieved from ScienceDirect: https://www-sciencedirect-com.ju.idm.oclc.org/science/article/pii/S1052305719302770.

Bresnick, J. (2017, December 12). Healthy IT Analytics. Retrieved from Understanding the basics of Clinical Decision Support Systems: https://healthitanalytics.com/features/understanding-the-basics-of-clinical-decision-support-systems.

Georgiou, Andrew, Li, Julie, Thomas, Judith, … I, J. (2019, April 11). Impact of health information technology on the management and follow-up of test results – a systematic review. Retrieved from
https://academic.oup.com/jamia/article/26/7/678/5445904.

Green, J. (2019). How the EHR can transform your administrative processes. EHR in Practice.  Retrieved from https://www.ehrinpractice.com/administrative-processes-ehr-transformation.html.

Healthcare Information and Management Systems Society. (n.d.). Terminology Standards. Retrieved by https://www.himss.org/terminology-standards.

HealthIT.gov. (2019). How can electronic health records improve the efficiency of my staff? Retrieved from https://www.healthit.gov/faq/how-can-electronic-health-records-improve-efficiency-my-staff.

HealthIT.gov (2018). Medical practice efficiencies & cost savings. Retrieved from https://www.healthit.gov/topic/health-it-and-health-information-exchange-basics/medical-practice-efficiencies-cost-savings.

HHS Office of the Secretary,Office for Civil Rights, & Ocr. (2020, January 31). Your Medical Records. Retrieved February 2, 2020, from https://www.hhs.gov/hipaa/for-individuals/medical-records/index.html.

Huber, T. P., Shortell, S. M., & Rodriguez, H. P. (2017). Improving Care Transitions Management: Examining the Role of Accountable Care Organization Participation and Expanded Electronic Health Record Functionality. Health Services Research, 52(4), 1494–1510. https://doi-org.ju.idm.oclc.org/10.1111/1475-6773.12546.

Klein, T.M., Augustin, M. & Otten, M. How should electronic health records be designed? A cross-sectional study in patients with psoriasis. BMC Med Inform Decis Mak 19, 218 (2019). https://doi.org/10.1186/s12911-019-0926-5.

Mason, C., M.S.H.I. (2018). SNOMED CT and the EHR: Why should a HIM professional care? Journal of AHIMA, 89(9), 48-50. Retrieved from https://ju.idm.oclc.org/login?url=https://search-proquest-com.ju.idm.oclc.org/docview/2105009678?accountid=28468.

Patient Access Information for Individuals: Get it, Check it, Use it! (2020, January 31). Retrieved February 7, 2020, from https://www.healthit.gov/topic/patient-access-information-individuals-get-it-check-it-use-it.

Taya Irizarry RN, M., MPH, J. S., & Marci Lee Nilsen RN, P. (2017, March 30). JMIR Publications. Retrieved from Patient Portals as a Tool for Health Care Engagement; A Mixed-Method Study of Older Adults with Varying Levels of Health Literacy and Prior Patient Portal Use: https://www.jmir.org/2017/3/e99/?

What information does an Electronic Health Record (EHR) contain? (2019, April). Retrieved from
https://www.healthit.gov/faq/what-information-does-electronic-health-record-ehr-contain.

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Advantages of the Electronic Health Record

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Advantages of the Electronic Health Record

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* Improved Patient Care
* Increase Patient Participation
*Improved Care Coordination
*Improved Diagnostics & Patient Outcomes
*Practice Efficiencies and Cost Savings

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Electronic health records EHRs benefit hospitals and patients

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The use of patient electronic health records has enabled more far reaching access for not only physicians and healthcare clinicians but has provided incredible patient support. The use of things such as patient portals is at an all time high, allowing patients to access their health information, keep up with appointments. They are able to directly ask questions to their provider, as well as maintain an up to date record of medications and procedures.
Installation of such programs encourage
*Patient involvement
* Patient and Physician line of communication
*An updated means for patient education
* More precise and accurate care for patients.

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Original Paper

¹ School of Nursing, University of Pittsburgh, Pittsbrugh, PA, United States

² Department of Psychology, Ohio State University, Columbus, OH, United States

³ University Center for Social and Urban Research, University of Pittsburgh, Pittsburgh, PA, United States

Corresponding Author

Corresponding Author:

Taya Irizarry, RN, MSN

School of Nursing

University of Pittsburgh

336 Victoria Building

3500 Victoria Street

Pittsbrugh, PA, 15261

United States

Phone: 1 412 624 4722

Fax:1 412 383 7227

Email: tai19@pitt.edu

ABSTRACT

Background: Growing evidence that patient engagement improves health outcomes and reduces health care costs has fueled health providers' focus on patient portals as the primary access point for personal health information and patient-provider communication. Whereas much attention has been given to identifying characteristics of older adults who do and do not adopt patient portals and necessary adaptions to portal design, little is known about their attitudes and perceptions regarding patient portal use as a tool for engagement in their health care within the context of health literacy, experience navigating Web-based health information, and previous patient portal use.

Objective: The specific aims of this study were to explore attitudes toward portal adoption and its perceived usefulness as a tool for health care engagement among adults (65 years and older) who have varying levels of health literacy and degrees of prior patient portal use.

Methods: A phone survey of 100 community dwelling adults gathered sociodemographic, health, and technology related information. Older adults were purposefully selected for 4 follow-up focus groups based on survey responses to health literacy and previous patient portal use. A mixed-method approach was used to integrate phone survey data with thematic analysis of 4 focus groups. Due to variability in attitudes between focus group participants, an individual case analysis was performed and thematic patterns were used as the basis for subgroup formation.

Results: Differences in health literacy, comfort navigating health information on the Web, and previous portal experience explained some but not all differences related to the 7 themes that emerged in the focus groups analysis. Individual cases who shared attitudes were arranged into 5 subgroups from least to most able and willing to engage in health care via a patient portal. The subgroups' overall portal adoption attitudes were: (1) Don't want to feel pushed into anything, (2) Will only adopt if required, (3) Somebody needs to help me, (4) See general convenience of the portal for simple tasks and medical history, but prefer human contact for questions, and (5) Appreciates current features and excited about new possibilities .

Conclusions: Most of the older adults are interested in using a patient portal regardless of health literacy level, previous patient portal adoption, or experience navigating health information on the Web. Research targeting informal caregivers of older adults who are unable or unwilling to engage with information technology in health care on their own is warranted. Health care organizations should consider tailored strategies to meet the needs of older adults (and their informal caregivers) and explore alternative workflows that integrate patient portal information into phone conversations and face-to-face contact with health care providers.

J Med Internet Res 2017;19(3):e99

doi:10.2196/jmir.7099

Citation

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KEYWORDS

Introduction

Although the intention of patient portals is to promote patient engagement, numerous large-scale survey studies have demonstrated that older adults are less likely to adopt portals even though they utilize the greatest proportion of health care resources [-]. Low adoption rates are most pronounced among older adults who have less access to and experience with technology, less education, and who demonstrate low health literacy and numeracy skills [,] . These barriers have been aptly described as the "gray digital divide" [].

Qualitative studies examining the known barriers that contribute to the gray digital divide discuss a strong need for supplementary support to assist vulnerable patients with portal navigation, particularly those with limited health literacy [,]. In addition, user-satisfaction, usability, and task analysis studies [-] have focused on older adults' experiences navigating portal functionality and evaluating their performance of specific tasks. Results from these studies indicate that previous computer experience and adequate health literacy and numeracy are strong contributing factors to ones' ability to successfully perform health management tasks using a patient portal.

Methods

Design

A mixed-method study design was chosen for the purpose of complementarity [], meaning findings from quantitative and qualitative methods were integrated in a complementary fashion to produce a more complete understanding of the phenomena of interest. Integration occurred at multiple stages. First, a phone survey was used to assess sociodemographic and other health- and technology-related characteristics in a sample of 100 community dwelling older adults. Second, subsamples of older adults were purposefully selected to participate in follow-up focus groups based on responses to health literacy score and patient portal use. Third, the quantitative data from the phone survey and thematic analysis results of the focus group were integrated to form a rich description of older adults' experiences with navigating health information on the Web and attitudes toward the patient portal's usefulness as a tool for engagement in their health care. Finally, distinct patterns among individuals across all 4 focus groups were identified, resulting in the formation of subgroups ranging from least to mostly likely to adopt a patient portal. Refer to for an overview of the study design. Ethics approval for this research was obtained through the University of Pittsburgh Institutional Review Board (REN16060086/PRO15050313).

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Figure 1. Overview of mixed-method study design.
View this figure

Sample

A convenience sample of English-speaking community-dwelling older adults (defined as living in an independent residence, ie, not in an assisted living facility or nursing home) who were at least 65 years of age and cognitively equipped to answer a full battery of questions were recruited from the institutional review board (IRB)-approved research registry maintained by University of Pittsburgh's University Center for Social and Urban Research (UCSUR). The registry (n=1000) was assembled from a variety of population-based surveys conducted by UCSUR in the Pittsburgh area; thus, it is generally representative of the regional population.

A final sample of 100 registry participants was contacted by phone by experienced interviewers and a 45-minute survey was completed. Each participant received US $10 for participation. Seventy-five of the phone survey participants agreed to be contacted for possible participation in a follow-up focus group. Those who agreed were then stratified by level of health literacy and portal use based on responses to two survey items: (1) whether or not the participant had experience using a patient portal (yes, no), and (2) level of health literacy (high, low). Purposive sampling was used to include representation of participants in terms of age, race, and gender in each of the 4 focus groups. The first 10 participants who met criteria for one of the 4 groups and were willing and able to commit to a common meeting date and time were invited to participate.

Phone Survey Data Collection

The selection of survey measures was based on evidence-based criteria related to the gray digital divide. Instruments were selected from the core battery for demographics, health and disability from the Quality of Life Technology (NSF 0540865), and the core battery from the Center for Research and Education in Aging and Technology Enhancement (CREATE) which includes sociobehavioral factors proposed by the Institute of Medicine for inclusion in the electronic health record [].

Sociodemographics

Demographic variables included age (years), gender, race (white, African American, other), marital status (single or divorced or widowed, married or living with partner), education (high school degree or general educational development [GED], associate or vocational training, bachelor's, master's degree), and income (less than or US $14,999, US $15,000-US $39,000, US $40,000-US $69,000, US $70,000 or more).

Health Status and Disease Burden

Health characteristics included the number of comorbidities endorsed from a list of 12 potential conditions with the option of "other" and responses to 2 questions about perceived health status: (1) "In general, would you say your health is" (poor or fair, good, very good, or excellent), and (2) "How often are your daily activities limited due to your physical health" (never or seldom, sometimes, often, or always).

Health Literacy

The brief health literacy screen (BHLS), a subjective health literacy screening measure [], includes 3 Likert-scale questions addressing one's confidence completing medical forms, reading hospital materials, and understanding written health information. On the basis of previous research [,], the response cutoff that optimized sensitivity and specificity for low health literacy was ≤ 3 (ie, "somewhat" or "some of the time"), meaning only participants who scored a 4 or 5 on all 3 questions were considered to have adequate health literacy (although we refer to the dichotomy as high and low literacy for simplicity in the study results). These questions have been previously shown to correlate with the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and Rapid Estimate of Adult Literacy in Medicine as criterion standards [-].

Level of Engagement in Health and Health Care

Technology Use and Attitudes

Two items of the Technology and Computer/Web Experience Questionnaire [] were included in the survey. First, use of technology was measured by whether participants ever searched on the Web for health-related information: "During the past three months, did you or someone who helps you look online for information about any of the following topics: health condition or treatment, medications, health service availability, health professionals, and or health care facilities?" (yes or no). Second, they were asked to rate their attitudes about technology on a scale from 1 (not at all) to 10 (completely) for each of the following descriptors: "To what extent do you believe that technology makes life:" (1) easy and convenient, (2) complicated, (3) gives people control over their daily lives, (4) makes people dependent, (5) comfortable, (6) stressful, (7) brings people together, (8) makes people isolated, (9) increases personal safety and security, and (10) reduces privacy. Negative descriptors were reverse scored and a final score was an average of the total sum, thus a higher score means a more positive attitude.

Portal Use

Previous use of a patient portal was determined by a yes or no response to the question, "Have you ever used a patient portal on your own?" Answers were dichotomized as no or yes (all or some of the time). Further clarification was gained by asking, "Does someone help you access the portal or access the portal on your behalf?" If yes, some or all the time .

Focus Group Data Collection

Health Literacy

Since previous research had identified health literacy and numeracy as contributing factors for patient engagement and patient portal use [,], in addition to screening for health literacy using BHLS, we administered the newest vital sign (NVS) to focus group participants. The NVS is a 6-item objective health literacy measure of both reading comprehension and numeracy abilities []. Each participant was taken to a private space before the focus group discussions and given a copy of the nutrition label and the NVS questions. Scoring of the NVS is based upon number of correct answers with 0-1=high likelihood of limited health literacy, 2-3=possibility of limited health literacy, and 4-6=adequate health literacy skills. The NVS time to completion was also recorded; any participant taking longer than 7 minutes to complete the screening questions is considered to have low health literacy. The NVS has been previously shown to correlate with the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and Rapid Estimate of Adult Literacy in Medicine short form (REALM-SF) as criterion standards [,].

Attitudes Toward Technology and Portal Use

Experienced moderators facilitated the focus groups using a topical guide geared toward understanding participants' attitudes toward technology, experiences of accessing health-related information on the Web, and perceived ability to use and benefit from patient portal functions. In addition to the open discussion, an interactive patient portal demonstration, developed by Czaja and colleagues at CREATE [,], University of Miami, was used to stimulate conversation about common features of patient portals and to seek participants' reactions.

Each of the 4 focus group sessions lasted approximately 1 hour and participants were provided light refreshments and US $40 for participation. The focus group discussions were audio recorded, transcribed verbatim by trained transcriptionists, and reviewed for accuracy by the focus group facilitators before being uploaded in to Atlas.ti version 7.5 (Scientific Software Development GmbH), the software program chosen to organize data for coding and visualization. The transcripts were supplemented with session notes and linked to participant survey data.

Phone Survey Analysis

Descriptive statistical analyses of all variables of interest (demographics, health characteristics, engagement, health literacy, technology use and attitudes, and portal use) were organized by level of study participation: (1) participants who only completed the phone survey (n=26), (2) those contacted for possible follow-up focus group participation (n=51), and (3) focus group participants (n=23). In order to determine differences between the 3 groups, chi-square test of association was used for dichotomous variables (gender, race, marital status, technology use for health-related activities, health literacy, and portal use). Post hoc testing using standardized adjusted residuals was used to determine the source of any significant result using a threshold of ±2 []. Kruskal-Wallis H was used for ordinal and continuous variables (age, education, income, all health characteristics, engagement and technology attitudes). Subsequent pairwise comparisons were performed using Dunn [] procedure with a Bonferroni correction for multiple comparisons and adjusted P values were presented. SPSS version 24.0 software (SPSS Inc) was used for all analyses.

Focus Groups Analysis

The thematic analysis [] of qualitative transcript data of the focus groups was initiated by a lead coder who used open coding to describe the views of participants regarding the following topics: (1) experience with technology for health-related information and (2) impressions about the patient portal demonstration and its potential usefulness in promoting personal engagement in health care. A second coder then reviewed the initial codes and added new codes when she felt existing codes were needed. Both coders met to reach consensus on final codes. A third coder joined the team to collapse codes into themes through a process of consensus. Descriptive statistical analyses of demographics, health characteristics, engagement, health literacy, technology use and attitudes, and portal use were performed to in order to identify quantitative differences and similarities between focus groups.

Case Analysis

The stratification of focus groups by patient portal use and health literacy explained some but not all differences in attitudes toward accessing Web-based health information, portal adoption, and perceptions of usefulness of patient portal functionality. Due to the variability in attitudes between individuals within the focus groups, an individual case analysis was performed by all 3 coders in order to identify potential patterns. The case analysis began by linking passages from the transcript to individuals, which made it possible to connect the codes from individuals to the themes identified in the focus groups. Individuals' thematic patterns were then displayed in a matrix and subgroups were identified based upon the similarities and differences between them (). In addition, characteristics including demographics, health characteristics, health literacy, and technology use and attitudes were calculated for each subgroup in order to identify possible quantitative similarities and differences.

Results

Quantitative Results by Level of Study Participation

Survey results by level of study participation and group difference statistics are displayed in . Significant group differences were found for race ( P=.03), searching on the Web for health information ( P=.01), education ( P=.01), income ( P=.001), health status ( P=.003), and engagement ( P=.001). No statistically significant group differences were found for any of the other variables (age, gender, marital status, limited due to physical health, health literacy, or attitude toward technology). The post hoc analysis revealed statistically significant differences between the phone survey group, the follow-up call, and focus group attendees, but not between the follow-up call group and focus group attendees (see and ). Post hoc testing indicated more African American or other focus group attendees than would be expected by chance (adjusted residual 2.6). This finding supports the success of the purposive sampling technique, which was meant to encourage the most racially diverse participant representation possible. Post hoc testing also indicated fewer survey participants searched on the Web for health information than would be expected by chance (adjusted residual −2.6). The purposive sampling method did not control for technology-related variables, therefore, this finding suggests that people who are more familiar with accessing Web-based health information may be more willing to participate in research related to technology in health care.

Quantitative Results by Focus Group

Of the 40 volunteers who committed to one of the 4 focus groups, only 23 attended the sessions. There was no follow-up with the participants who didn't make it to the sessions, so the reason for not attending in unknown. The yes portal, low literacy group and no portal, low literacy group had 4 participants, the yes portal, high literacy group had 7, and the no portal, high literacy group had 8. Survey results per focus group are displayed in . The no portal, low literacy group had the widest age range (65-82 years) and included 2 participants in their early eighties. Three out of 4 of the focus groups had an equal proportion of males and females. The no portal, high literacy group had fewer males (n=3) and was the most racially diverse with 3 African Americans and 3 others who did not identify themselves as white, but did not specify. The majority of participants in all focus groups had education beyond high school or GED, with half having a college degree. Both yes portal groups had more white and married participants, as well as more participants with higher average income.

The majority of participants reported their perceived health status was "good," to "excellent," and only 2 in the yes portal high literacy group and 2 in the no portal low literacy group reported "poor or fair" health. All the groups had at least one participant report his or her physical condition limits daily activities "sometimes." The no portal low literacy group had 1 participant who reported "often" being physically limited. This same participant reported having 5 comorbidities, where the range across all other groups was 0-3.

The NVS scores for the high literacy groups (yes portal and no portal) ranged from 2-6 and 0-6, respectively. The NVS scores for the low literacy groups (yes portal and no portal) ranged from 5-6 and 0-5, respectively. The BHLS and NVS scores were not always in alignment, meaning fewer participants were found to have high literacy using the NVS than with the BHLS screening instrument. No notable differences were found in PAM scores, searching on the Web for health-related information, or attitudes toward technology with the exception that for the technology items the average scores for the no portal low literacy group were slightly lower.

Qualitative Results by Focus Group

Seven major themes were identified and arranged in order from least to most positive experience and attitudes toward technology use for health care and portal adoption. The 7 themes included: (1) limited or poor relationship with technology, (2) fears and frustrations with technology and portal, (3) prefers phone over secure messaging for communication (outside of clinical visit), (4) willing to adopt the portal with support, (5) good relationship with technology, (6) Internet as source of health information, and (7) portal is helpful. The following detailed explanation of each of the 7 themes includes all the original codes that informed the theme and is framed by the focus group stratification criteria (previous portal use and health literacy level).

Limited or Poor Relationship With Technology

Participants in every focus group expressed at least some degree of negativity toward technology use in health care as well as in everyday encounters. Difference in reasons why varied by literacy level. The most common negative sentiment among participants in the high health literacy groups was difficulty troubleshooting without having access to live technical support and feeling pressured to adopt new communication methods (eg, instant messaging, video calls) that seemed unnecessary. In contrast, many participants in the no portal, low health literacy group mentioned having had little experience using computers and did not have the Internet access in their homes. Many no portal, low literacy group participants noted that they had no computer training as part of their job and retired before computers were a regular part of the working environment. Many felt afraid of making a mistake or felt stigmatized by their lack of knowledge and therefore either avoided using computers all together or relied heavily on family members to help them.

Fear and Frustration With Technology and Portal

Fears about personal health data security risks were shared in every focus group. Those participants in the high health literacy groups were more articulate in describing specific instances in which they felt uncomfortable, whereas those in the low health literacy groups spoke more generally about security fears. Despite the level of specific risk described, some participants cited the risk as being too great, whereas others felt it was an everyday risk we all must "get used to." In all instances, participants felt that speaking over the phone with a trusted health care professional was the safest and most secure way to share health information.

Participants with more experience navigating the health care system and seeing several medical specialists shared experiences where they felt burdened by the task of circulating the most current health information even though all health care providers had access to the same electronic health record. These people also described instances where medical history in the patient portal was outdated or incorrect which led to a sense of frustration, as it was not clear what action should be taken to correct it. A few participants from the high literacy group who had experience using the patient portal secure message function recounted instances in which they either did not get a response, or they were not entirely certain that they understood the response. In either case, they experienced anxiety and frustration. They also expressed discomfort with the idea that other staff aside from the primary health care provider could respond to personal secure messages via the patient portal because they did not personally know them.

Prefers Phone Over Secure Messaging for Communication (Outside of Clinical Visit)

Those who experienced anxiety and frustration using the patient portal's secure message feature were convinced that phone was the only way to communicate, ask questions, and clarify information. The no portal high literacy group voiced the most opposition to secure messaging in health care encounters and the most strongly in support of direct clinician communication by phone. When probed further, there were instances where the participant felt comfortable speaking with a nurse, nurse practitioner, or physician assistant (as opposed to an office manager) as long as they worked closely with his or her provider and felt they had enough clinical expertise. Those with no portal experience in both the high and low literacy groups were more positive about the potential for secure messaging and the idea of having access to their provider outside the clinical visit.

Willing to Adopt Portal With Support

Participants in both the low health literacy groups expressed an interest in portal training. Those with less experience with computers had less confidence in their ability to learn and expressed an interest in having someone access the system on their behalf. The high literacy portal users expressed fear and anxiety around doing something wrong and had recommendations for a "task specific" training in which users would learn the purpose of each function (eg, information searches, secure messaging, appointment, and medication refill requests) and gain hands-on experience with navigation, use, and troubleshooting.

Happy to Engage With Technology

Participants who were eager to learn new things, had exposure to computer use at work, or sought out resources to learn computer skills, expressed appreciation for the conveniences of technology. They were eager to share what they had learned in terms of accessing computers outside of the home, where to take computer classes, and ways to troubleshoot. The level of enthusiasm and interest did not parallel levels of health literacy or portal use. However, participants in the high literacy no portal group were the most philosophical in their debate about technology degrading the quality of human relationships, and were the least willing to discuss potential benefits to their personal lives. High literacy portal users who had negative experiences with information sharing among providers or negative experiences with the portal expressed both positive and negative feelings about their relationship with technology in the health care setting, yet generally felt the positives outweighed the negatives.

Internet as a Good Source of Health Information

The degree to which participants felt the information they received from their providers was enough for them was variable across all focus groups. Some participants from the high literacy portal user group felt the portal lacked individualized information and that it was more helpful to search on the Web. In contrast, some low literacy groups (portal and nonportal users) believed the health information presented in the portal was the more trusted and reliable, and therefore it made them feel more confident about the information in comparison to looking up information on the Internet.

Sees Portal as Beneficial

Convenience features of the portal were perceived as useful by participants regardless of whether they had used a particular function before and whether or not they could personally see themselves using it. Overall, participants in good health thought it was helpful to have all their personal medical information, including clinician contact numbers, all in one place for easy reference, but felt that other more complex functions would be helpful for people who were managing a serious illness or chronic condition or were acting as a caregiver. In most cases, they considered their current non-technological methods (eg, paper copy of their post-visit summary) to be satisfactory. Participants who had experience with serious illness and chronic disease management were vocal about the convenience of having timely access to lab results and having them stored electronically, but felt that the kind of communication they needed to have with their providers was too involved for secure messaging.

Qualitative Case Results

Individual cases who shared attitudes toward engaging in one's health care via technology and portal adoption were arranged into 5 subgroups from least to most able and willing to engage in health care via a patient portal. All individual participants were placed in a subgroup except for 1 from the no portal, high literacy group who could not be categorized due to minimal verbal participation, and therefore scarcity of codes attributed to her. presents the matrix of individuals in relationship to the themes and demonstrates the prevalence of themes in each focus group. presents a description of the 5 subgroups, including the number of individuals from each of the 4 original focus groups, and summarizes the general attitudes toward adoption of technology for health care engagement and adoption of the portal.

Quantitative Case Results

The smallest of the 5 subgroups (n=2) comprised women who expressed complete comfort with technology and were previous portal users. Although neither of them had a college degree, they both scored a 6 out 6 on the NVS and completed the literacy measure in less than 3 minutes (far less time than of any other subgroup where at least half of the group had a college degree). They were both married, nearly the same age (70 and 71 years), reported an income over US $70,000 a year, and expressed having good, but not excellent health. All other subgroups were more diverse in terms of demographics, NVS scores, and attitudes toward technology. Subgroup 3 expressed interest in using technology yet acknowledged they needed assistance to do so. This group had the widest range in age, NVS scores and completion time, and the highest number of comorbidities.

Discussion

Principal Findings

This study used a mixed-method approach to gain greater insight into the experiences and attitudes toward the patient portal as an engagement tool among older adults with varying levels of health literacy and patient portal experience. Numerous topics revealed in the focus groups were consistent with current literature on the adoption of patient portals by older adults including fears about security issues, interest in convenience features (eg, appointment scheduling, prescription refills), and lack of access to a computer or Internet as a major barrier to portal adoption []. The unique contributions of this study are the findings regarding attitudes of older adults toward adoption of a patient portal for engagement in health care, specifically in the context of health literacy and previous experience navigating Web-based health information.

Focus group participants were assembled based on health literacy level (assessed using the BHLS) and previous experience using a patient portal. This stratification explained some but not all differences in attitudes toward portal adoption and perceptions of usefulness of patient portal functionality. Neither the health literacy scores from the BHLS nor the NVS was directly correlated with previous patient portal adoption or perceived usefulness except in the case of subgroup 5 which comprised 2 women who scored 6 out of 6 on the NVS, expressed complete comfort with technology, and were regular portal users. The qualitative findings revealed that health literacy was a contributing factor to confidence accessing and evaluating health care information on the Web (this evidence is corroborated by Diviani []). However, health literacy was not directly related to one's motivation to engage in health care via a patient portal as evidenced by the case analysis and subsequent subgroupings.

Qualitative findings also revealed that previous experience accessing and evaluating health care information on the Web was not entirely correlated with prior patient portal adoption or perceptions about its potential usefulness. In fact, some members of the no portal focus groups (both high and low health literacy) who did not have experience navigating health information on the Web were motivated to explore their health care institution's patient portal following the patient portal simulation, that included examples of how the patient portal functionality could be helpful within a personally relevant context. This finding is supported by Melenhorst, Rogers, and Bouwhuis [] who identified the "decisive role of perceived benefits" as the main motivator of adoption among older adult users.

Presently, most patient portals are introduced via an email with a time-sensitive link and sign-on instructions, or a postcard given in a clinical visit or sent through the mail. These methods may be appropriate for younger generations who are more comfortable with navigating the Web-based environment including sharing personal information and social interaction. However, this research demonstrates that older adults require an initial introduction that highlights contextually relevant benefits and addresses their particular needs and concerns. Both high and low health literacy groups felt that specific task-based training was an important, yet lacking, resource that would help build confidence and understanding of when, why, and how to navigate the features included in patient portals.

Whereas a patient portal adoption campaign tailored to older adults could convince and encourage greater numbers of older adults to use patient portals, many participants in this as well as other studies [,] express fear that they won't always understand the personal health information available to them and felt that the secure message function was a poor substitute for direct clinician-patient interaction necessary to clarify things. This sentiment remained strong across all focus groups as evidenced by the case analysis matrix () and was especially true for older adults managing complex conditions. Frequent portal users also described instances where medical history in the patient portal was outdated or incorrect which led to a sense of frustration and concern, as it was not clear what action to take to correct it. A possible solution for these issues, concerns, and frustrations may be restructuring care team workflows. Examples include making it possible for patients and informal caregivers to call and talk to a clinic representative who can answer simple questions, verify and update information presented in the patient portal (which would then update the electronic health record), and triage more serious issues when appropriate. In addition, further integration of patient portal use during face-to-face encounters with health care providers and phone interactions with clinic representatives could transform the patient portal into an information resource for all parties and may incentivize older adults and caregivers to use it as a tool for health care engagement outside of clinical visits. Refer to for a brief description of findings, implications, and recommendations.

Reliability, Validity, Trustworthiness, and Rigor

Quantitative and qualitative procedures were performed according to the assumptions of each paradigm. Survey methods, including sampling, use of validated measures, the collection of data using standard formatting by trained phone interviewers, and standard analysis techniques ensured reliability and validity of quantitative analysis []. Trustworthiness and rigor of qualitative focus group phase of the study included purposive sampling to ensure as much heterogeneity with regard to participant characteristics as possible []. The focus groups were led by an experienced facilitator using a semistructured guide and field observer. All focus group sessions were audiorecorded, transcribed verbatim, and open coding was initially performed to provide thick description of exchanges during the focus groups []. Three researchers performed thematic analyses independently and interpretation of the findings and meaning making was achieved by consensus []. Quantitative and qualitative data sources were integrated using matrices [] and merged according to recommended methods [].

Limitations

This study used a convenience sample of older adults from a Pittsburgh regional research registry. Whereas a strong effort was made to achieve the most representative sample of those in jeopardy of experiencing the gray digital divide, the comparison between phone survey, follow-up, and focus group attendees revealed statistically significant differences between survey participates and focus group participants. Most notably, focus group participants were more educated, with higher income, better health status, higher engagement scores, and more experience with searching for health information on the Web than survey participants. Alternative recruitment methods designed to target older adults that are least likely to be interested in focus group participation, such as semistructured interviews over the phone or home visits, are warranted. However, the sample characteristics of the focus group participants are representative of the average older American adult population, and therefore helpful for understanding general attitudes toward technology in health care and portal adoption.

In regards to the focus group sample, characteristics of interest were generally comparable across groups; however, both low literacy groups were nearly half the size of the high literacy groups despite having had the same number of participant invitations accepted. A more equal representation of low literacy participants may have added further clarification of the differences in attitudes and preferences as compared with the high literacy groups. Also, 3 of the 4 groups were 75% white. Having more input from a wider range of racial backgrounds may have added more detail regarding differences in adoption attitudes toward the patient portal related to race. Additionally, this study was conducted in English, which limited our findings to fluent English speakers. Whereas most patient portals are currently in English only, continued work in other languages is necessary to meet the needs of our increasingly diverse communities. Descriptive statistics of the focus groups and subgroups were explored and reported in order to provide a rich multidimensional description; however, the small sample size of the focus groups and subgroups did not allow for statistical inferences between participant characteristics and the attitudes toward health care engagement via a patient portal.

Finally, the question, "Does someone help you access the portal or access the portal on your behalf?" (If yes, some or all of the time) was asked in the survey phase; however due to the minimal number of positive answers within any of the groups, it was not possible to explore the concept in a mixed-method approach (although the data is reported). Instead, the role of the caregiver proxy was discussed in detail qualitatively. Further research focused on addressing older adult informal caregivers' attitudes and experiences as proxy users is needed.

Conclusions

The study used quantitative and qualitative methods in a complementary fashion to produce a more complete understanding of older adults' attitudes toward using a patient portal as a health care engagement tool within the context of health literacy, previous experience with patient portal, and accessing Web-based information. Only a minority of older adults believe that the security risks or trouble learning something new is not worth it; most of the older adults are interested in using a patient portal regardless of health literacy level, previous patient portal adoption, or experience navigating health information on the Web. Health care organizations should consider the following strategies to align people, process, and technology in order to meet the needs of the older adults they serve: (1) create a patient portal adoption campaign tailored to the needs of older adult so that the benefits are communicated in a contextually relevant way, (2) offer task-specific training so they feel they have the support they need to confidently use the functionality, (3) specifically target informal caregiver proxy users as part of the adoption campaign and training, and (4) explore alternative workflows that give patients access to personnel with the skills to review and respond to questions over the phone about personal health information within the portal, as well as change, up-date, validate missing or inaccurate information, and triage more serious issues when appropriate. Such organizational strategies would transform the patient portal from a repository of information with a secure message function to a tool designed to support engagement, information sharing, and enhanced communication between care teams, patients, and informal caregivers.

Acknowledgments

Funding for this study was granted by the Aging Institute of University of Pittsburgh Medical Center (UPMC), Pittsburgh. No review or approval of this manuscript for publication was required.

Conflicts of Interest

None declared.

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Abbreviations

BHLS: brief health literacy screen

GED: general educational development

PAM-13: Patient Activation Measure

REALM-SF: Rapid Estimate of Adult Literacy in Medicine short form

S-TOFHLA: Short Test of Functional Health Literacy in Adults

Edited by G Eysenbach; submitted 07.12.16; peer-reviewed by C Kruse, C Cutler, C Lyles PhD, A Paglialonga; comments to author 08.02.17; revised version received 19.02.17; accepted 20.02.17; published 30.03.17

©Taya Irizarry, Jocelyn Shoemake, Marci Lee Nilsen, Sara Czaja, Scott Beach, Annette DeVito Dabbs. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 30.03.2017.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

ABSTRACT

Background: Growing evidence that patient engagement improves health outcomes and reduces health care costs has fueled health providers' focus on patient portals as the primary access point for personal health information and patient-provider communication. Whereas much attention has been given to identifying characteristics of older adults who do and do not adopt patient portals and necessary adaptions to portal design, little is known about their attitudes and perceptions regarding patient portal use as a tool for engagement in their health care within the context of health literacy, experience navigating Web-based health information, and previous patient portal use.

Objective: The specific aims of this study were to explore attitudes toward portal adoption and its perceived usefulness as a tool for health care engagement among adults (65 years and older) who have varying levels of health literacy and degrees of prior patient portal use.

Methods: A phone survey of 100 community dwelling adults gathered sociodemographic, health, and technology related information. Older adults were purposefully selected for 4 follow-up focus groups based on survey responses to health literacy and previous patient portal use. A mixed-method approach was used to integrate phone survey data with thematic analysis of 4 focus groups. Due to variability in attitudes between focus group participants, an individual case analysis was performed and thematic patterns were used as the basis for subgroup formation.

Results: Differences in health literacy, comfort navigating health information on the Web, and previous portal experience explained some but not all differences related to the 7 themes that emerged in the focus groups analysis. Individual cases who shared attitudes were arranged into 5 subgroups from least to most able and willing to engage in health care via a patient portal. The subgroups' overall portal adoption attitudes were: (1) Don't want to feel pushed into anything, (2) Will only adopt if required, (3) Somebody needs to help me, (4) See general convenience of the portal for simple tasks and medical history, but prefer human contact for questions, and (5) Appreciates current features and excited about new possibilities .

Conclusions: Most of the older adults are interested in using a patient portal regardless of health literacy level, previous patient portal adoption, or experience navigating health information on the Web. Research targeting informal caregivers of older adults who are unable or unwilling to engage with information technology in health care on their own is warranted. Health care organizations should consider tailored strategies to meet the needs of older adults (and their informal caregivers) and explore alternative workflows that integrate patient portal information into phone conversations and face-to-face contact with health care providers.

J Med Internet Res 2017;19(3):e99

doi:10.2196/jmir.7099

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KEYWORDS

Introduction

Although the intention of patient portals is to promote patient engagement, numerous large-scale survey studies have demonstrated that older adults are less likely to adopt portals even though they utilize the greatest proportion of health care resources [-]. Low adoption rates are most pronounced among older adults who have less access to and experience with technology, less education, and who demonstrate low health literacy and numeracy skills [,] . These barriers have been aptly described as the "gray digital divide" [].

Qualitative studies examining the known barriers that contribute to the gray digital divide discuss a strong need for supplementary support to assist vulnerable patients with portal navigation, particularly those with limited health literacy [,]. In addition, user-satisfaction, usability, and task analysis studies [-] have focused on older adults' experiences navigating portal functionality and evaluating their performance of specific tasks. Results from these studies indicate that previous computer experience and adequate health literacy and numeracy are strong contributing factors to ones' ability to successfully perform health management tasks using a patient portal.

Methods

Design

A mixed-method study design was chosen for the purpose of complementarity [], meaning findings from quantitative and qualitative methods were integrated in a complementary fashion to produce a more complete understanding of the phenomena of interest. Integration occurred at multiple stages. First, a phone survey was used to assess sociodemographic and other health- and technology-related characteristics in a sample of 100 community dwelling older adults. Second, subsamples of older adults were purposefully selected to participate in follow-up focus groups based on responses to health literacy score and patient portal use. Third, the quantitative data from the phone survey and thematic analysis results of the focus group were integrated to form a rich description of older adults' experiences with navigating health information on the Web and attitudes toward the patient portal's usefulness as a tool for engagement in their health care. Finally, distinct patterns among individuals across all 4 focus groups were identified, resulting in the formation of subgroups ranging from least to mostly likely to adopt a patient portal. Refer to for an overview of the study design. Ethics approval for this research was obtained through the University of Pittsburgh Institutional Review Board (REN16060086/PRO15050313).

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Figure 1. Overview of mixed-method study design.
View this figure

Sample

A convenience sample of English-speaking community-dwelling older adults (defined as living in an independent residence, ie, not in an assisted living facility or nursing home) who were at least 65 years of age and cognitively equipped to answer a full battery of questions were recruited from the institutional review board (IRB)-approved research registry maintained by University of Pittsburgh's University Center for Social and Urban Research (UCSUR). The registry (n=1000) was assembled from a variety of population-based surveys conducted by UCSUR in the Pittsburgh area; thus, it is generally representative of the regional population.

A final sample of 100 registry participants was contacted by phone by experienced interviewers and a 45-minute survey was completed. Each participant received US $10 for participation. Seventy-five of the phone survey participants agreed to be contacted for possible participation in a follow-up focus group. Those who agreed were then stratified by level of health literacy and portal use based on responses to two survey items: (1) whether or not the participant had experience using a patient portal (yes, no), and (2) level of health literacy (high, low). Purposive sampling was used to include representation of participants in terms of age, race, and gender in each of the 4 focus groups. The first 10 participants who met criteria for one of the 4 groups and were willing and able to commit to a common meeting date and time were invited to participate.

Phone Survey Data Collection

The selection of survey measures was based on evidence-based criteria related to the gray digital divide. Instruments were selected from the core battery for demographics, health and disability from the Quality of Life Technology (NSF 0540865), and the core battery from the Center for Research and Education in Aging and Technology Enhancement (CREATE) which includes sociobehavioral factors proposed by the Institute of Medicine for inclusion in the electronic health record [].

Sociodemographics

Demographic variables included age (years), gender, race (white, African American, other), marital status (single or divorced or widowed, married or living with partner), education (high school degree or general educational development [GED], associate or vocational training, bachelor's, master's degree), and income (less than or US $14,999, US $15,000-US $39,000, US $40,000-US $69,000, US $70,000 or more).

Health Status and Disease Burden

Health characteristics included the number of comorbidities endorsed from a list of 12 potential conditions with the option of "other" and responses to 2 questions about perceived health status: (1) "In general, would you say your health is" (poor or fair, good, very good, or excellent), and (2) "How often are your daily activities limited due to your physical health" (never or seldom, sometimes, often, or always).

Health Literacy

The brief health literacy screen (BHLS), a subjective health literacy screening measure [], includes 3 Likert-scale questions addressing one's confidence completing medical forms, reading hospital materials, and understanding written health information. On the basis of previous research [,], the response cutoff that optimized sensitivity and specificity for low health literacy was ≤ 3 (ie, "somewhat" or "some of the time"), meaning only participants who scored a 4 or 5 on all 3 questions were considered to have adequate health literacy (although we refer to the dichotomy as high and low literacy for simplicity in the study results). These questions have been previously shown to correlate with the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and Rapid Estimate of Adult Literacy in Medicine as criterion standards [-].

Level of Engagement in Health and Health Care

Technology Use and Attitudes

Two items of the Technology and Computer/Web Experience Questionnaire [] were included in the survey. First, use of technology was measured by whether participants ever searched on the Web for health-related information: "During the past three months, did you or someone who helps you look online for information about any of the following topics: health condition or treatment, medications, health service availability, health professionals, and or health care facilities?" (yes or no). Second, they were asked to rate their attitudes about technology on a scale from 1 (not at all) to 10 (completely) for each of the following descriptors: "To what extent do you believe that technology makes life:" (1) easy and convenient, (2) complicated, (3) gives people control over their daily lives, (4) makes people dependent, (5) comfortable, (6) stressful, (7) brings people together, (8) makes people isolated, (9) increases personal safety and security, and (10) reduces privacy. Negative descriptors were reverse scored and a final score was an average of the total sum, thus a higher score means a more positive attitude.

Portal Use

Previous use of a patient portal was determined by a yes or no response to the question, "Have you ever used a patient portal on your own?" Answers were dichotomized as no or yes (all or some of the time). Further clarification was gained by asking, "Does someone help you access the portal or access the portal on your behalf?" If yes, some or all the time .

Focus Group Data Collection

Health Literacy

Since previous research had identified health literacy and numeracy as contributing factors for patient engagement and patient portal use [,], in addition to screening for health literacy using BHLS, we administered the newest vital sign (NVS) to focus group participants. The NVS is a 6-item objective health literacy measure of both reading comprehension and numeracy abilities []. Each participant was taken to a private space before the focus group discussions and given a copy of the nutrition label and the NVS questions. Scoring of the NVS is based upon number of correct answers with 0-1=high likelihood of limited health literacy, 2-3=possibility of limited health literacy, and 4-6=adequate health literacy skills. The NVS time to completion was also recorded; any participant taking longer than 7 minutes to complete the screening questions is considered to have low health literacy. The NVS has been previously shown to correlate with the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and Rapid Estimate of Adult Literacy in Medicine short form (REALM-SF) as criterion standards [,].

Attitudes Toward Technology and Portal Use

Experienced moderators facilitated the focus groups using a topical guide geared toward understanding participants' attitudes toward technology, experiences of accessing health-related information on the Web, and perceived ability to use and benefit from patient portal functions. In addition to the open discussion, an interactive patient portal demonstration, developed by Czaja and colleagues at CREATE [,], University of Miami, was used to stimulate conversation about common features of patient portals and to seek participants' reactions.

Each of the 4 focus group sessions lasted approximately 1 hour and participants were provided light refreshments and US $40 for participation. The focus group discussions were audio recorded, transcribed verbatim by trained transcriptionists, and reviewed for accuracy by the focus group facilitators before being uploaded in to Atlas.ti version 7.5 (Scientific Software Development GmbH), the software program chosen to organize data for coding and visualization. The transcripts were supplemented with session notes and linked to participant survey data.

Phone Survey Analysis

Descriptive statistical analyses of all variables of interest (demographics, health characteristics, engagement, health literacy, technology use and attitudes, and portal use) were organized by level of study participation: (1) participants who only completed the phone survey (n=26), (2) those contacted for possible follow-up focus group participation (n=51), and (3) focus group participants (n=23). In order to determine differences between the 3 groups, chi-square test of association was used for dichotomous variables (gender, race, marital status, technology use for health-related activities, health literacy, and portal use). Post hoc testing using standardized adjusted residuals was used to determine the source of any significant result using a threshold of ±2 []. Kruskal-Wallis H was used for ordinal and continuous variables (age, education, income, all health characteristics, engagement and technology attitudes). Subsequent pairwise comparisons were performed using Dunn [] procedure with a Bonferroni correction for multiple comparisons and adjusted P values were presented. SPSS version 24.0 software (SPSS Inc) was used for all analyses.

Focus Groups Analysis

The thematic analysis [] of qualitative transcript data of the focus groups was initiated by a lead coder who used open coding to describe the views of participants regarding the following topics: (1) experience with technology for health-related information and (2) impressions about the patient portal demonstration and its potential usefulness in promoting personal engagement in health care. A second coder then reviewed the initial codes and added new codes when she felt existing codes were needed. Both coders met to reach consensus on final codes. A third coder joined the team to collapse codes into themes through a process of consensus. Descriptive statistical analyses of demographics, health characteristics, engagement, health literacy, technology use and attitudes, and portal use were performed to in order to identify quantitative differences and similarities between focus groups.

Case Analysis

The stratification of focus groups by patient portal use and health literacy explained some but not all differences in attitudes toward accessing Web-based health information, portal adoption, and perceptions of usefulness of patient portal functionality. Due to the variability in attitudes between individuals within the focus groups, an individual case analysis was performed by all 3 coders in order to identify potential patterns. The case analysis began by linking passages from the transcript to individuals, which made it possible to connect the codes from individuals to the themes identified in the focus groups. Individuals' thematic patterns were then displayed in a matrix and subgroups were identified based upon the similarities and differences between them (). In addition, characteristics including demographics, health characteristics, health literacy, and technology use and attitudes were calculated for each subgroup in order to identify possible quantitative similarities and differences.

Results

Quantitative Results by Level of Study Participation

Survey results by level of study participation and group difference statistics are displayed in . Significant group differences were found for race ( P=.03), searching on the Web for health information ( P=.01), education ( P=.01), income ( P=.001), health status ( P=.003), and engagement ( P=.001). No statistically significant group differences were found for any of the other variables (age, gender, marital status, limited due to physical health, health literacy, or attitude toward technology). The post hoc analysis revealed statistically significant differences between the phone survey group, the follow-up call, and focus group attendees, but not between the follow-up call group and focus group attendees (see and ). Post hoc testing indicated more African American or other focus group attendees than would be expected by chance (adjusted residual 2.6). This finding supports the success of the purposive sampling technique, which was meant to encourage the most racially diverse participant representation possible. Post hoc testing also indicated fewer survey participants searched on the Web for health information than would be expected by chance (adjusted residual −2.6). The purposive sampling method did not control for technology-related variables, therefore, this finding suggests that people who are more familiar with accessing Web-based health information may be more willing to participate in research related to technology in health care.

Quantitative Results by Focus Group

Of the 40 volunteers who committed to one of the 4 focus groups, only 23 attended the sessions. There was no follow-up with the participants who didn't make it to the sessions, so the reason for not attending in unknown. The yes portal, low literacy group and no portal, low literacy group had 4 participants, the yes portal, high literacy group had 7, and the no portal, high literacy group had 8. Survey results per focus group are displayed in . The no portal, low literacy group had the widest age range (65-82 years) and included 2 participants in their early eighties. Three out of 4 of the focus groups had an equal proportion of males and females. The no portal, high literacy group had fewer males (n=3) and was the most racially diverse with 3 African Americans and 3 others who did not identify themselves as white, but did not specify. The majority of participants in all focus groups had education beyond high school or GED, with half having a college degree. Both yes portal groups had more white and married participants, as well as more participants with higher average income.

The majority of participants reported their perceived health status was "good," to "excellent," and only 2 in the yes portal high literacy group and 2 in the no portal low literacy group reported "poor or fair" health. All the groups had at least one participant report his or her physical condition limits daily activities "sometimes." The no portal low literacy group had 1 participant who reported "often" being physically limited. This same participant reported having 5 comorbidities, where the range across all other groups was 0-3.

The NVS scores for the high literacy groups (yes portal and no portal) ranged from 2-6 and 0-6, respectively. The NVS scores for the low literacy groups (yes portal and no portal) ranged from 5-6 and 0-5, respectively. The BHLS and NVS scores were not always in alignment, meaning fewer participants were found to have high literacy using the NVS than with the BHLS screening instrument. No notable differences were found in PAM scores, searching on the Web for health-related information, or attitudes toward technology with the exception that for the technology items the average scores for the no portal low literacy group were slightly lower.

Qualitative Results by Focus Group

Seven major themes were identified and arranged in order from least to most positive experience and attitudes toward technology use for health care and portal adoption. The 7 themes included: (1) limited or poor relationship with technology, (2) fears and frustrations with technology and portal, (3) prefers phone over secure messaging for communication (outside of clinical visit), (4) willing to adopt the portal with support, (5) good relationship with technology, (6) Internet as source of health information, and (7) portal is helpful. The following detailed explanation of each of the 7 themes includes all the original codes that informed the theme and is framed by the focus group stratification criteria (previous portal use and health literacy level).

Limited or Poor Relationship With Technology

Participants in every focus group expressed at least some degree of negativity toward technology use in health care as well as in everyday encounters. Difference in reasons why varied by literacy level. The most common negative sentiment among participants in the high health literacy groups was difficulty troubleshooting without having access to live technical support and feeling pressured to adopt new communication methods (eg, instant messaging, video calls) that seemed unnecessary. In contrast, many participants in the no portal, low health literacy group mentioned having had little experience using computers and did not have the Internet access in their homes. Many no portal, low literacy group participants noted that they had no computer training as part of their job and retired before computers were a regular part of the working environment. Many felt afraid of making a mistake or felt stigmatized by their lack of knowledge and therefore either avoided using computers all together or relied heavily on family members to help them.

Fear and Frustration With Technology and Portal

Fears about personal health data security risks were shared in every focus group. Those participants in the high health literacy groups were more articulate in describing specific instances in which they felt uncomfortable, whereas those in the low health literacy groups spoke more generally about security fears. Despite the level of specific risk described, some participants cited the risk as being too great, whereas others felt it was an everyday risk we all must "get used to." In all instances, participants felt that speaking over the phone with a trusted health care professional was the safest and most secure way to share health information.

Participants with more experience navigating the health care system and seeing several medical specialists shared experiences where they felt burdened by the task of circulating the most current health information even though all health care providers had access to the same electronic health record. These people also described instances where medical history in the patient portal was outdated or incorrect which led to a sense of frustration, as it was not clear what action should be taken to correct it. A few participants from the high literacy group who had experience using the patient portal secure message function recounted instances in which they either did not get a response, or they were not entirely certain that they understood the response. In either case, they experienced anxiety and frustration. They also expressed discomfort with the idea that other staff aside from the primary health care provider could respond to personal secure messages via the patient portal because they did not personally know them.

Prefers Phone Over Secure Messaging for Communication (Outside of Clinical Visit)

Those who experienced anxiety and frustration using the patient portal's secure message feature were convinced that phone was the only way to communicate, ask questions, and clarify information. The no portal high literacy group voiced the most opposition to secure messaging in health care encounters and the most strongly in support of direct clinician communication by phone. When probed further, there were instances where the participant felt comfortable speaking with a nurse, nurse practitioner, or physician assistant (as opposed to an office manager) as long as they worked closely with his or her provider and felt they had enough clinical expertise. Those with no portal experience in both the high and low literacy groups were more positive about the potential for secure messaging and the idea of having access to their provider outside the clinical visit.

Willing to Adopt Portal With Support

Participants in both the low health literacy groups expressed an interest in portal training. Those with less experience with computers had less confidence in their ability to learn and expressed an interest in having someone access the system on their behalf. The high literacy portal users expressed fear and anxiety around doing something wrong and had recommendations for a "task specific" training in which users would learn the purpose of each function (eg, information searches, secure messaging, appointment, and medication refill requests) and gain hands-on experience with navigation, use, and troubleshooting.

Happy to Engage With Technology

Participants who were eager to learn new things, had exposure to computer use at work, or sought out resources to learn computer skills, expressed appreciation for the conveniences of technology. They were eager to share what they had learned in terms of accessing computers outside of the home, where to take computer classes, and ways to troubleshoot. The level of enthusiasm and interest did not parallel levels of health literacy or portal use. However, participants in the high literacy no portal group were the most philosophical in their debate about technology degrading the quality of human relationships, and were the least willing to discuss potential benefits to their personal lives. High literacy portal users who had negative experiences with information sharing among providers or negative experiences with the portal expressed both positive and negative feelings about their relationship with technology in the health care setting, yet generally felt the positives outweighed the negatives.

Internet as a Good Source of Health Information

The degree to which participants felt the information they received from their providers was enough for them was variable across all focus groups. Some participants from the high literacy portal user group felt the portal lacked individualized information and that it was more helpful to search on the Web. In contrast, some low literacy groups (portal and nonportal users) believed the health information presented in the portal was the more trusted and reliable, and therefore it made them feel more confident about the information in comparison to looking up information on the Internet.

Sees Portal as Beneficial

Convenience features of the portal were perceived as useful by participants regardless of whether they had used a particular function before and whether or not they could personally see themselves using it. Overall, participants in good health thought it was helpful to have all their personal medical information, including clinician contact numbers, all in one place for easy reference, but felt that other more complex functions would be helpful for people who were managing a serious illness or chronic condition or were acting as a caregiver. In most cases, they considered their current non-technological methods (eg, paper copy of their post-visit summary) to be satisfactory. Participants who had experience with serious illness and chronic disease management were vocal about the convenience of having timely access to lab results and having them stored electronically, but felt that the kind of communication they needed to have with their providers was too involved for secure messaging.

Qualitative Case Results

Individual cases who shared attitudes toward engaging in one's health care via technology and portal adoption were arranged into 5 subgroups from least to most able and willing to engage in health care via a patient portal. All individual participants were placed in a subgroup except for 1 from the no portal, high literacy group who could not be categorized due to minimal verbal participation, and therefore scarcity of codes attributed to her. presents the matrix of individuals in relationship to the themes and demonstrates the prevalence of themes in each focus group. presents a description of the 5 subgroups, including the number of individuals from each of the 4 original focus groups, and summarizes the general attitudes toward adoption of technology for health care engagement and adoption of the portal.

Quantitative Case Results

The smallest of the 5 subgroups (n=2) comprised women who expressed complete comfort with technology and were previous portal users. Although neither of them had a college degree, they both scored a 6 out 6 on the NVS and completed the literacy measure in less than 3 minutes (far less time than of any other subgroup where at least half of the group had a college degree). They were both married, nearly the same age (70 and 71 years), reported an income over US $70,000 a year, and expressed having good, but not excellent health. All other subgroups were more diverse in terms of demographics, NVS scores, and attitudes toward technology. Subgroup 3 expressed interest in using technology yet acknowledged they needed assistance to do so. This group had the widest range in age, NVS scores and completion time, and the highest number of comorbidities.

Discussion

Principal Findings

This study used a mixed-method approach to gain greater insight into the experiences and attitudes toward the patient portal as an engagement tool among older adults with varying levels of health literacy and patient portal experience. Numerous topics revealed in the focus groups were consistent with current literature on the adoption of patient portals by older adults including fears about security issues, interest in convenience features (eg, appointment scheduling, prescription refills), and lack of access to a computer or Internet as a major barrier to portal adoption []. The unique contributions of this study are the findings regarding attitudes of older adults toward adoption of a patient portal for engagement in health care, specifically in the context of health literacy and previous experience navigating Web-based health information.

Focus group participants were assembled based on health literacy level (assessed using the BHLS) and previous experience using a patient portal. This stratification explained some but not all differences in attitudes toward portal adoption and perceptions of usefulness of patient portal functionality. Neither the health literacy scores from the BHLS nor the NVS was directly correlated with previous patient portal adoption or perceived usefulness except in the case of subgroup 5 which comprised 2 women who scored 6 out of 6 on the NVS, expressed complete comfort with technology, and were regular portal users. The qualitative findings revealed that health literacy was a contributing factor to confidence accessing and evaluating health care information on the Web (this evidence is corroborated by Diviani []). However, health literacy was not directly related to one's motivation to engage in health care via a patient portal as evidenced by the case analysis and subsequent subgroupings.

Qualitative findings also revealed that previous experience accessing and evaluating health care information on the Web was not entirely correlated with prior patient portal adoption or perceptions about its potential usefulness. In fact, some members of the no portal focus groups (both high and low health literacy) who did not have experience navigating health information on the Web were motivated to explore their health care institution's patient portal following the patient portal simulation, that included examples of how the patient portal functionality could be helpful within a personally relevant context. This finding is supported by Melenhorst, Rogers, and Bouwhuis [] who identified the "decisive role of perceived benefits" as the main motivator of adoption among older adult users.

Presently, most patient portals are introduced via an email with a time-sensitive link and sign-on instructions, or a postcard given in a clinical visit or sent through the mail. These methods may be appropriate for younger generations who are more comfortable with navigating the Web-based environment including sharing personal information and social interaction. However, this research demonstrates that older adults require an initial introduction that highlights contextually relevant benefits and addresses their particular needs and concerns. Both high and low health literacy groups felt that specific task-based training was an important, yet lacking, resource that would help build confidence and understanding of when, why, and how to navigate the features included in patient portals.

Whereas a patient portal adoption campaign tailored to older adults could convince and encourage greater numbers of older adults to use patient portals, many participants in this as well as other studies [,] express fear that they won't always understand the personal health information available to them and felt that the secure message function was a poor substitute for direct clinician-patient interaction necessary to clarify things. This sentiment remained strong across all focus groups as evidenced by the case analysis matrix () and was especially true for older adults managing complex conditions. Frequent portal users also described instances where medical history in the patient portal was outdated or incorrect which led to a sense of frustration and concern, as it was not clear what action to take to correct it. A possible solution for these issues, concerns, and frustrations may be restructuring care team workflows. Examples include making it possible for patients and informal caregivers to call and talk to a clinic representative who can answer simple questions, verify and update information presented in the patient portal (which would then update the electronic health record), and triage more serious issues when appropriate. In addition, further integration of patient portal use during face-to-face encounters with health care providers and phone interactions with clinic representatives could transform the patient portal into an information resource for all parties and may incentivize older adults and caregivers to use it as a tool for health care engagement outside of clinical visits. Refer to for a brief description of findings, implications, and recommendations.

Reliability, Validity, Trustworthiness, and Rigor

Quantitative and qualitative procedures were performed according to the assumptions of each paradigm. Survey methods, including sampling, use of validated measures, the collection of data using standard formatting by trained phone interviewers, and standard analysis techniques ensured reliability and validity of quantitative analysis []. Trustworthiness and rigor of qualitative focus group phase of the study included purposive sampling to ensure as much heterogeneity with regard to participant characteristics as possible []. The focus groups were led by an experienced facilitator using a semistructured guide and field observer. All focus group sessions were audiorecorded, transcribed verbatim, and open coding was initially performed to provide thick description of exchanges during the focus groups []. Three researchers performed thematic analyses independently and interpretation of the findings and meaning making was achieved by consensus []. Quantitative and qualitative data sources were integrated using matrices [] and merged according to recommended methods [].

Limitations

This study used a convenience sample of older adults from a Pittsburgh regional research registry. Whereas a strong effort was made to achieve the most representative sample of those in jeopardy of experiencing the gray digital divide, the comparison between phone survey, follow-up, and focus group attendees revealed statistically significant differences between survey participates and focus group participants. Most notably, focus group participants were more educated, with higher income, better health status, higher engagement scores, and more experience with searching for health information on the Web than survey participants. Alternative recruitment methods designed to target older adults that are least likely to be interested in focus group participation, such as semistructured interviews over the phone or home visits, are warranted. However, the sample characteristics of the focus group participants are representative of the average older American adult population, and therefore helpful for understanding general attitudes toward technology in health care and portal adoption.

In regards to the focus group sample, characteristics of interest were generally comparable across groups; however, both low literacy groups were nearly half the size of the high literacy groups despite having had the same number of participant invitations accepted. A more equal representation of low literacy participants may have added further clarification of the differences in attitudes and preferences as compared with the high literacy groups. Also, 3 of the 4 groups were 75% white. Having more input from a wider range of racial backgrounds may have added more detail regarding differences in adoption attitudes toward the patient portal related to race. Additionally, this study was conducted in English, which limited our findings to fluent English speakers. Whereas most patient portals are currently in English only, continued work in other languages is necessary to meet the needs of our increasingly diverse communities. Descriptive statistics of the focus groups and subgroups were explored and reported in order to provide a rich multidimensional description; however, the small sample size of the focus groups and subgroups did not allow for statistical inferences between participant characteristics and the attitudes toward health care engagement via a patient portal.

Finally, the question, "Does someone help you access the portal or access the portal on your behalf?" (If yes, some or all of the time) was asked in the survey phase; however due to the minimal number of positive answers within any of the groups, it was not possible to explore the concept in a mixed-method approach (although the data is reported). Instead, the role of the caregiver proxy was discussed in detail qualitatively. Further research focused on addressing older adult informal caregivers' attitudes and experiences as proxy users is needed.

Conclusions

The study used quantitative and qualitative methods in a complementary fashion to produce a more complete understanding of older adults' attitudes toward using a patient portal as a health care engagement tool within the context of health literacy, previous experience with patient portal, and accessing Web-based information. Only a minority of older adults believe that the security risks or trouble learning something new is not worth it; most of the older adults are interested in using a patient portal regardless of health literacy level, previous patient portal adoption, or experience navigating health information on the Web. Health care organizations should consider the following strategies to align people, process, and technology in order to meet the needs of the older adults they serve: (1) create a patient portal adoption campaign tailored to the needs of older adult so that the benefits are communicated in a contextually relevant way, (2) offer task-specific training so they feel they have the support they need to confidently use the functionality, (3) specifically target informal caregiver proxy users as part of the adoption campaign and training, and (4) explore alternative workflows that give patients access to personnel with the skills to review and respond to questions over the phone about personal health information within the portal, as well as change, up-date, validate missing or inaccurate information, and triage more serious issues when appropriate. Such organizational strategies would transform the patient portal from a repository of information with a secure message function to a tool designed to support engagement, information sharing, and enhanced communication between care teams, patients, and informal caregivers.

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Patient Portals as a Tool for Health Care Engagement: A Mixed-Method Study of Older Adults With Varying Levels of Health Literacy and Prior Patient Portal Use

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Original Paper 1 School of Nursing, University of Pittsburgh, Pittsbrugh, PA, United States 2 Department of Psychology, Ohio State University, Columbus, OH, United States 3 University Center for Social and Urban Research, University of Pittsburgh, Pittsburgh, PA, United States Corresponding Author Taya Irizarry, RN, MSN School of Nursing University of

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Electronic Communication and Connectivity 

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Electronic Communication and Connectivity 

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A flow of information between physicians, clinicians and patients is becoming very vital piece in communication and connectivity. It has become a tool to drastically enhance patient outcomes and care. From the sharing of information between different services, different providers and as well as in transit, patient safety and care has drastically increased.

One such study dove in to the use of Onboard Technology that would be placed on the Ambulance to share real time and up to date information to improve the out comes of patients who are experiencing stroke. With the use of cellular data and GPS tracking they are able pinpoint the exact location of the patient. With the utilization of communications of digital imaging they are able to quickly access of send CT results.

The seamless communication and transfer of information improves timely interventions, real time updates, and sharing of pertinent details to improve patient care and out comes.

EHR:
* Produces Real time resutls
* Shares pertinent information with ease
* Improved Communication between different service lines, and clinician

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The use of an EHR tremendously increase the decision support for Clinicians. It seamlessly brings together vital pieces of information such as lab values, radiology reports, nursing assessments to better provide care for the patients.

"If we really want to make sure that every human being gets great care, then you have to make sure that you are assisted by technology" says Dr. Joe Kinman.
In a rapidly evolving technological world, it is imperative that we keep up to provide the best patient care and best support decisions with regards to their care.

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Reporting and Population Health Management

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Reporting and Population Health Management

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Population Health Management: A Primer Posted 9.4.2018

NCQA knows the challenges health plans face when engaging population health management principles into their organization. So, we created a Population Health Management Resource Guide in sponsorship with Janssen Scientific Affairs, LLC. It is a resource for health plans seeking to create a population health management strategy and incorporate such principles.

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Population Health Management: A Primer - NCQA

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NCQA knows the challenges health plans face when engaging population health management principles into their organization. So, we created a Population Health Management Resource Guide in sponsorship with Janssen Scientific Affairs, LLC. It is a resource for health plans seeking to create a population health management strategy and incorporate such principles.

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Free-flowing information needs to exist for the administrative process to be effective.  Administrative operations can be enhanced with the access to health information.  For that to take place, the EHR must have effective flow of information within the departments.  Silos between departments must be removed so all areas can have access to vital information and data necessary to assure the appropriate decision-making.

EHR improves the administrative process by:

* Improved scheduling of patient appointments

* More accurate billing/claims and coding

* Improves information availability

* Reduced paperwork—filling out forms,                 processing billing requests
* Eliminates the need for chart-pulling, storing,     and re-filing
* Reduced need for transcription

* Automatic delivery of data that needs to be         provided to public health agencies
* Less time and legwork needed to pull data or     reports, presentations, etc.

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Healthcare technology offers the potential for healthcare organizations and providers to improve their administrative operations. Even though an EHR's main function rests in collecting and managing clinical data, an organization's administrative processes can realize meaningful gains on several metrics when an EHR is incorporated into administrative operations.

The administrative processes of a health practice do not exist on an island independent of clinical operations, rather both functions require some level of coordination. When considering the goal of coordinating these two areas of an organization, the administrative arm of an organization can benefit greatly from accessing the clinical information collected and managed by an EHR. In sum, the key to improving a practice's administrative processes hinges on improving information flows within an organization and using this free exchange of information to improve decisions making.

When looking at the ways an EHR can transform your administrative processes these improvements a driven by two the removal of data silos and incorporating clinical data into an organization's administrative processes. When clinical data from an EHR can be used to better carry out administrative functions practices can better position themselves for success.

Removing silos between clinical and administrative data

Silos within an organization present two primary problems. The first relates to the sharing of mission-critical information across settings. If silos exist within an organization there is a high probability that not only information but a high probability that quality information is not being shared across settings. Therefore, a condition is created in which a single organization such as the hospital in question here functions more like multiple organizations that loosely coordinate to fulfill a broad mission.

When a department's information is contained within data silos interdepartmental decision making becomes difficult. When integrated with administrative software patient records are always available simultaneously to all appropriate staff, meaning your staff can more efficiently locate and process patient information.

Enhanced practice management

Effective practice management involves using nonclinical data but also using clinical data to make an informed decision in several areas. For example, by using clinical data a practice administrator can examine how their organization is performing on several financial and non-financial metrics such as better compliance with Physician Quality Reporting Initiative (PQRI), more accurate billing and reduction in lost charges and denials associated with late filing

The most effective way to leverage clinical data from an EHR for use in administrative processes is by using an integrated practice management system that can tap into clinical data and use this information to better manage the scheduling and the flow of patients through a practice. Further by tapping into clinical data administrators can ensure that billing processes are carried out more effectively using automated coding and claims management systems to make certain billing is more accurate and can get the most from reimbursement rates.

Given the benefits of integrating EHRs with administrative software, it is important to view an organization's administrative and clinical sides as complementing each other in how they operate particularly in the areas of improving operations and decision-making.

Jeff Green

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How EHR can transform your administrative processes

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Healthcare technology offers the potential for healthcare organizations and providers to improve their administrative operations. Even though an EHR's main function rests in collecting and managing clinical data, an organization's administrative processes can realize meaningful gains on several metrics when an EHR is incorporated into administrative operations.

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Abstract

To investigate the impact of health information technology (IT) systems on clinicians' work practices and patient engagement in the management and follow-up of test results.

A search for studies reporting health IT systems and clinician test results management was conducted in the following databases: MEDLINE, EMBASE, CINAHL, Web of Science, ScienceDirect, ProQuest, and Scopus from January 1999 to June 2018. Test results follow-up was defined as provider follow-up of results for tests that were sent to the laboratory and radiology services for processing or analysis.

There are some findings from controlled studies showing that health IT can improve the proportion of tests followed-up (15 percentage point change) and increase physician awareness of test results that require action (24-28 percentage point change). Taken as whole, however, the evidence of the impact of health IT on test result management and follow-up is not strong.

The development of safe and effective test results management IT systems should pivot on several axes. These axes include 1) patient-centerd engagement (involving shared, timely, and meaningful information); 2) diagnostic processes (that involve the integration of multiple people and different clinical settings across the health care spectrum); and 3) organizational communications (the myriad of multi- transactional processes requiring feedback, iteration, and confirmation) that contribute to the patient care process.

Existing evidence indicates that health IT in and of itself does not (and most likely cannot) provide a complete solution to issues related to test results management and follow-up.

INTRODUCTION

The results of laboratory tests and medical imaging reports directly impact clinical decision-making contributing to the diagnosis, treatment, prevention, and management of patient care. The World Alliance for Patient Safety has identified poor test follow-up as an international priority area for concern in patient care, and in 2017 the US Emergency Care Research Institute flagged inadequate test results follow-up as a key patient safety issue. Many clinicians, aware of the extent of poor test results management, have expressed concerns about systemic shortcomings in organizational follow-up procedures within and across health care settings.

Potential strategies to improve test results follow-up include the use of health information technology (IT) for the communication of test results using automated result notifications.,, The introduction of IT has been supplemented by initiatives to establish guidelines and recommendations for successful implementation, quality improvement, and evaluation. Attention has also been focused on the patient's role as a partner in the process of enhancing the safety of care., This is particularly relevant to situations where the failure to inform patients of their results has been described as legally indefensible in malpractice claims. Electronic health records (EHRs) are seen as the basis for greater patient involvement, particularly as they provide the means by which patients can access their own information using a secure electronic patient portal, which, in addition to allowing access to personal information, also facilitates communication with health professionals.

There is ample evidence that while IT is capable of helping to prevent medical errors, it also has the capacity to introduce its own class of errors. This is particularly relevant to test results management, where the way that information is collected, reported, and presented can have major safety consequences., Despite a growing evidence base of the diffusion of health IT applications, their impact on test results follow-up, management, and patient engagement has not been widely appraised and is not well understood., This systematic review integrates quantitative and qualitative research findings on how health IT has been used to engage with patients. The systematic review thus provides an overview of the current state of evidence about how health IT has been used to address the test results management and follow-up process and contributes to a better understanding of the gaps and challenges as identified by existing research. The aims of this systematic review were to:

1. Describe the types of health IT systems that are utilized in the management and follow-up of test results,

2. Investigate the impact of health IT systems on the rate of missed test results and other outcomes,

3. Identify the impact of health IT systems on clinicians' test results management work practices, and

4. Assess the impact of health IT on patient engagement and the follow-up of test results.

MATERIALS AND METHODS

Study identification

We conducted a search for health IT systems and clinician test results management in the following databases: MEDLINE, EMBASE, CINAHL, Web of Science, ScienceDirect, ProQuest, and Scopus for studies published between January 1999 and June 2018 in accordance with PRISMA guidelines. Our protocol was registered on the PROSPERO register of systematic reviews (CRD42016043148). Search strategies for all databases are presented in Appendix 1. We reviewed reference lists of all literature identified as potentially relevant. Table 1 provides a complete list of peer-reviewed and gray literature sources that were hand-searched.

Study selection

Two authors (JL, JT) independently reviewed titles and abstracts identified from the search. Papers without abstracts were retrieved and reviewed in full. The identification and selection process of studies is detailed in Figure 1. We resolved discrepancies through discussion or referral to a third researcher (AG). The same authors (JL, JT) retrieved and independently reviewed full text articles of all selected papers for inclusion in accordance with our eligibility criteria.

Original studies of all types were included if they reported the impact of any health IT system on the test results follow-up process in hospital and ambulatory care settings. Failure to follow up on a test is defined as failing to take the appropriate next steps after the test. For the purposes of this review, missed test results and/or failure to follow up test results occurs when there is no evidence that the responsible provider becomes aware of a result (laboratory or radiology). We excluded point of care testing. Studies were also excluded if they did not report original research, if the reported outcomes were not directly ascribable to the follow-up of test results (eg, when patients access their entire electronic medical records [EMRs]), or studies which evaluated the accuracy/specificity of a health IT system (eg, algorithm). Studies which explored provider opinions regarding potential patient access to test results, patient preferences, or expectations for potential future electronic access to test results and results of user testing of patient result access applications were excluded. The study selection process is presented in Figure 1.

Data extraction and synthesis

Information regarding health IT, its impact on the rate of missed test results, its effects on clinician test results follow-up work processes, and the patient's response to electronic access to their own results was extracted from included papers. Due to significant heterogeneity between studies, a meta-analysis of results was not performed. Descriptive statistics were used to summarize the body of evidence including the number of included studies, country of origin, year of publication, and study design. The details of individual studies including primary author, title, year, country, type of health IT, methodology, impact on missed test results follow-up, results type, study site, department/study population, and study size were extracted. Findings pertaining to each of the 4 objectives of the systematic review were extracted.

Two authors (JL, JT) assessed the quality of each included study using a tool applicable to the study design (Table 2). We used the Critical Appraisal Skills Programme (CASP) Qualitative Checklist to appraise qualitative studies. We assessed mixed-methods studies based on the methodological design of the study, or, for studies which included both qualitative and quantitative methods, according to the predominant method. For randomized controlled tests (RCTs) and quasi-experimental study designs, we applied the relevant "Study Quality Assessment Tools" developed by the US Department of Health and Human Services National Institutes of Health (NIH): National Heart, Lung, and Blood Institute. The selection of these tools allowed us to assess all RCTs, controlled trials, and quasi-experimental studies using a similar method with the same quality rating approach. For each study we recorded a quality assessment outcome of either poor, fair, or good.

RESULTS

A total of 57 studies were included in the systematic review, 53 (93%) of which were published between 2006 and 2018. The earliest study was published in 1999 with an apparent rise in studies from 2006 onward (see Figure 2). Most studies (72%, n = 41) were conducted in the US. Figure 2 presents a detailed breakdown of studies by year and country. The studies incorporated a range of research methods which included 7 RCTs (12% of studies), 32 observational studies (56%), 12 mixed-methods studies (21%), and 6 qualitative studies (11%). The quality of the evidence presented in this review overall was rated as mostly fair ( n = 35) and good ( n  = 20) with 2 studies rated as poor quality. A summary of included studies and their quality assessment is presented in .

Types of health IT systems utilized in the management and follow-up of test results

The literature reported a variety of health IT systems for the clinical management and follow-up of test results:

1. Electronic alerts (interruptive and non-interruptive) delivered to clinicians about results with abnormal/critical values,

2. Computerized provider order entry (CPOE) systems with electronic results viewing, and clinical information systems where results are viewed electronically, but orders are placed manually,

3. Electronic medical record (EMR)/electronic health record (EHR) systems,

4. Electronic results acknowledgment systems which require physicians to electronically document that they have seen a test result,

5. Electronic results tracking systems which allow users to track the progress of tests and status of results (eg, viewed, pending at discharge),,

6. EHR-based trigger algorithms which identify patients at risk of diagnostic delays, and

The categories were based on how each study reported their intervention. The health IT interventions varied according to whether they reported on the impact of an EMR/EHR system (eg, category 3), or as a dedicated feature of an EMR/EHR system (eg, category 1, 2, and 4). In part these differences reflect the development and increasing specialization of health IT systems over time.

Studies of health IT-facilitated patient engagement and follow-up of results featured two types of electronic systems: 1) patient portals and 2) personal health records (PHRs). Patient portals offer access to personal health information via a secure website, while integrated (tethered) PHRs are institutionally-managed and connected to a health care organization's EHR system thus offering patients direct access to their medical records., No studies evaluated patient-managed PHRs (ie, freestanding or untethered and not connected to a health care organization). The majority ( n = 13) of systems studied offered patients real-time access to test results as they became available. In the remaining 2 studies, patients were able to view results after a delay to allow prior review of results by clinicians.,

Impact of health IT systems on the rate of missed test results

Alerts

Observational studies by Singh et al., and Bhise et al. reported a range of between 0.2% and 16.7% failure to follow up test results with the use of an integrated, comprehensive EHR with a test results notification system. A cluster-RCT of an email notification system by Dalal et al. reported no significant difference in the rate of documented evidence of follow-up action for test results initially pending at hospital discharge.

The relationship between acknowledgment of electronic alerts and subsequent follow-up action was investigated in 2 studies by Singh et al., Failure to act on abnormal results ranged from 6.4% to 7.3% overall and did not differ significantly between acknowledged and unacknowledged alerts. A before and after study of a mandatory EHR notification system was undertaken by Laxmisan et al. across 2 sites. Logistic regression uncovered a significant intervention effect (preintervention OR 0.7; 95% CI, 0.5-1.0) after accounting for site-specific differences in follow-up, with a lower likelihood of timely follow-up at 1 site (OR 0.4; 95% CI, 0.2-0.7).

Computerized provider order entry (CPOE) and clinical information systems

Result acknowledgment systems

An Australian study investigated the impact of an electronic results acknowledgment system which incorporated escalation procedures (based on delineated levels of test follow-up responsibility) for dealing with unacknowledged results in an Australian hospital. The system led to the clinical acknowledgment of all results.

Impact of health IT interventions on clinicians' test results management work practices

The key findings from studies of the impact of health IT on test results management work practices spanned the following themes: 1) changes in workload, 2) hybrid paper/electronic systems, 3) effect of the organizational context, 4) time to test results follow-up, and 5) implications for patient outcomes.

Changes in workload

Hybrid paper/electronic systems

The use of multiple systems within a mixed-media (paper and electronic) environment for managing test results was reported to have negative impacts on test results follow-up work practices by 2 studies., Menon et al. found that 43% of 2554 PCPs surveyed used paper or a combination of paper and computer-based workarounds to support results management. A mixed-method study by Elder across 4 sites concluded that IT alone was insufficient to achieve the highest levels of safety when no site performed better against test results management measures despite varying levels of health IT adoption (partial CPOE to full EHR).

Effect of the organizational context

Time to test results follow-up

The effects of a real-time, automated paging system for critical laboratory values on internalists' response times was investigated in 1 RCT. The study found no significant difference in median response time to alerts between the control and intervention groups (39.5 mins vs 16 mins, respectively, p = 0.33). Park et al. reported on a study which examined the effects of sending SMS messages to doctors in wards, in addition to the hospital laboratory ringing doctors with critical results. They found a significant decrease in time to the ordering of treatment in the general wards (249 mins pre to 63 mins post SMS ( p < .001) but this combined intervention had no significant effect in changing test results follow-up times in the ICU. Lin et al.'s before and after study in an outpatient department found that episodes of hyperkalemia were more likely to be followed up within 4 days following the introduction of a system which flagged abnormal results and tracked the status of reports (90.0% post vs 62.2% pre; p  = 0.003).

Implications for patient outcomes

Studies measuring the impact on patient outcomes reported mostly positive results following the introduction of health IT systems. Benefits included reductions in time to diagnostic evaluation or completion of follow-up action from availability of results,,,, time to receipt of follow-up care for patients requiring referral to other practitioners,, time to diagnostic resolution,, and likelihood of diagnostic resolution.

Impact of health IT systems on patient engagement in the follow-up of test results

Patient utilization of patient portals

Key considerations related to patient access to results

Abnormal or critical test results

DISCUSSION

The issue of test results management and follow-up is multi-layered and interwoven. This interconnectedness is conceptualized in Figure 3, which is constructed from the key outcome measures identified within the existing research, as a basis for examining the significance and implications of the research. These layers can be described as: 1) the organizational-communication environment (eg, existing practices about how test results are communicated),, 2) the diagnostic process (eg, the numerous tasks among different people and across different clinical settings that need to be coordinated and synchronised for safe and effective test results management),, and 3) patient engagement in the test results follow-up process (eg, how and when do patients access test results, if at all?).,,

The organizational-communication environment

The communication of test results is reflective of existing patterns of accountability, responsibility, and authority that are shaped by clinical governance processes and the contextual characteristics present within different health care settings.,, These communication patterns are not direct one-way processes but multi-transactional processes requiring feedback, iteration, and confirmation., Communication processes are a critical component of the makeup and function of an organization linking people across space and time. The potential disruptive impact of health IT cannot really be appreciated without attention to its ability to change the role that communication plays in linking people and activities across space and time.,,,,

The diagnostic process

The diagnostic process is not a linear set of tasks but rather a series of tasks that involve multiple people (and different clinical settings) across the health care spectrum. This is evidenced by the array of outcome indicators reported by the existing literature to explore this issue.,,,, Health IT systems offer different ways to manage the test results follow-up process, including facilitating the access to and sharing of information, test tracking, and the provision of prompts/alerts., The evidence of the impact of health IT on test results management work practices draws attention to the importance of 1) enhancing the alignment of health IT with the diagnostic process and 2) accounting for the numerous tasks among different professionals and across different clinical settings that need to be coordinated and synchronized for safe and effective test results management., For instance, the evidence in this review indicates that systems which focus on ensuring physician review of results (via CPOE, alerts, results acknowledgment, and tracking systems) is, in some cases, insufficient in ensuring completion of subsequent steps of the follow-up process (eg, actioning a result).,

Patient engagement in the test results follow-up process

Many of the studies in this review highlighted the connection between test results follow-up, IT, and patient engagement. This is because attempts to engage patients in the care process invariably involve shared information (enabling patients to read, comment on, and share in decisions about their care) and timely and meaningful communication (enabling consumers to receive, send, and comprehend the information required).

The role of patient-centerd IT systems was investigated across a range (qualitative and quantitative) of studies revealing that patient access to, and ability to check, laboratory results (in real time) is a major reason for patient utilization of portals., The most important reported benefits included improved communication with physicians and the management of the patient condition., There were no findings that directly reported on issues of privacy and security even though the literature often cites these as key sources of concern. In situations involving life-threatening illnesses, cancer diagnoses, and incurable conditions, the evidence highlighted the preference for face-to-face consultations and the initial involvement of the responsible physician., Patient-managed PHRs provide a set of computer-based tools owned and administered by patients with access to personal clinical information., No studies in our review evaluated such a system; yet it is such technologies, organized around a person's own preferences, that may be emblematic of what is meant by IT-enabled patient-centered health care.,

Limitations

The aim of this systematic review was to examine the impact of health IT on test results follow-up across a number of dimensions (including clinical workflows and patient engagement) incorporating studies that used different methods (quantitative and qualitative). The results yielded numerous outcome measures that ranged from the rate of test results missed, to patient satisfaction rates and the number of workarounds. Although the heterogeneity of the studies makes it hard to provide 1 definitive result about the effect of health IT, the findings from this systematic review do nevertheless identify several factors that collectively contribute to the delivery of safe and effective test results management.

The publication (or non-publication) of research based on the direction (positive or negative) of the results can affect the validity of review conclusions. The scope and variability of findings from this systematic review was accentuated by our incorporation of 1) an array of search engines and databases including of gray literature sources and 2) extensive use of hand searches of relevant research literature.

CONCLUSION

FUNDING

This study was supported by an Australian National Health and Medical Research Partnership Grant APP1111925.

AUTHOR CONTRIBUTIONS

AG conceptualized the study and design. AG, JL, and JT were involved with the acquisition, analysis, and interpretation of data. JL and AG drafted the manuscript. All authors made critical revisions to the manuscript for important intellectual content.

Conflict of Interest Statement

None declared.

Appendix 1 - detailed search strategies

REFERENCES

National Academies Of Science Engineering and Medicine.

Improving Diagnosis in Health Care

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The National Acadamies Press

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impact of health information technology on the management and follow-up of test results - a systematic review

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To investigate the impact of health information technology (IT) systems on clinicians' work practices and patient engagement in the management and follow-up of test results. A search for studies reporting health IT systems and clinician test results management was conducted in the following databases: MEDLINE, EMBASE, CINAHL, Web of Science, ScienceDirect, ProQuest, and Scopus from January 1999 to June 2018.

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Health Information and Data

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Electronic Health Records: The Basics

An electronic health record (EHR) contains patient health information, such as:

Administrative and billing data

Patient demographics

Progress notes

Vital signs

Medical histories

Diagnoses

Medications

Immunization dates

Allergies

Radiology images

Lab and test results

An EHR is more than just a computerized version of a paper chart in a provider's office. It's a digital record that can provide comprehensive health information about your patients. EHR systems are built to share information with other health care providers and organizations - such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics - so they contain information from all clinicians involved in a patient's care.

For More Information

For more information on EHR systems, see the following resources.

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What information does an electronic health record (EHR) contain? | HealthIT.gov

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An electronic health record (EHR) contains patient health information, such as: Administrative and billing data Patient demographics Progress notes Vital signs Medical histories Diagnoses Medications Immunization dates Allergies Radiology images Lab and test results An EHR is more than just a computerized version of a paper chart in a provider's office.

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Standardized terminologies have been a great portal for facilitating interoperability between nomenclatures and information systems.  Examples of standard terminology include:
** Logical Observation Identifiers Names and Codes (LOINC)

** NANDA International

** Nursing Interventions Classification (NIC)

** Nursing Minimum Data Set (NMDS)

** Nursing Outcomes Classification (NOC)

** Systematic Nomenclature of Medicine Clinical Terms (SNOMED CT)
** Omaha System

** Peri-operative Nursing Data Set (PNDS)
**ICD-10
**Current Procedural Terminology (CPT)
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