Surgical Advance Care Planning: Initial Validation of Patient Portal Messages for a Multisite Randomized Controlled Trial.

Patient portal secure messaging can support age-friendly dementia care, yet little is known about care partner use of the portal and how message concerns relate to age-friendly issues. We conducted a two-part observational study. We first assessed the feasibility of automating care partner identification from patient portal messages by developing and testing a natural language processing (NLP) rule-based classification system from portal messages of 1973 unique patients 65 and older. Second, two independent reviewers manually coded a randomly selected sample of portal messages for 987 persons with dementia to identify the frequency of expressed needs from the 4M domains of an Age-Friendly Health System (medications, mentation, mobility, and what matters). A total of 267 (13.53%) of 1973 messages sent from older adults' portal accounts were identified through manual coding as sent by a nonpatient author. The NLP model performance to identify nonpatient authors demonstrated an AUC of 0.90. Most messages sent from the accounts of persons with dementia contained content relevant to the 4Ms (60%, 601/987), with the breakdown as follows: medications-36% (357/987), mobility-10% (101/987), mentation-16% (153/987), and what matters (aligning care with specific health goals and care preferences)-21%, 207/987. Patient portal messaging offers an avenue to identify care partners and meet the informational needs of persons with dementia and their care partners.

593 Background: The use of the patient portal functionality in the electronic health record (EHR) has led to improved patient satisfaction and provides an alternative channel for patient-care team communication. However, the adoption of the patient portal is not equitable across age, race, ethnicity, and health literacy groups. Enhancements in the EHR mirror the recent evolution of cancer therapy delivery, such as the widespread use of oral anticancer medications (OAMs). Because of decreased direct clinical contact, patients on OAM benefit from enhanced communication provided by patient portal messaging. We characterized patient portal signup and messaging use among vulnerable oncology patients identified as having newly initiated an OAM during the study period, highlighting areas to improve patient portal adoption and thus patient communication with their oncology care teams. Methods: We conducted a retrospective analysis of patients newly initiated on an OAM at Tufts Medical Center between October 1, 2022 and March 31, 2024. Vulnerability was defined as meeting at least one of the following criteria: age≥75 years; non-English language; or subsidized insurance (Medicaid only or Medicare with Medicaid as a secondary insurance). Active portal use was defined as having at least one message in the portal; meaningful use was defined as patient-provider bidirectional messaging. Portal messaging proxy use was determined by message content screening. Fisher’s exact test evaluated the impact of vulnerability on portal signup rate. Logistic regressions were performed to identify factors associated with portal signup and meaningful use. Results: Among the study population of 280 patients who were newly initiated on OAM, 56% patients met the vulnerability criteria: 20% by age≥75 years, 26% by non-English language, and 30% by subsidized insurance. Among the non-English speakers, the most common language spoken was a Chinese dialect (75%). Medicaid-only was the more common insurance (57%), compared to Medicare with Medicaid as a secondary among patients with subsidized insurance. While the overall portal signup rate was 74%, it was 64% among vulnerable patients vs. 87% in non-vulnerable patients (P<0.0001). Non-English language was associated with lower rate of portal signup (P<0.0001), but none of the vulnerable characteristics was associated with decreased meaningful use once signup was accomplished. Messaging by proxy was found in 17% of vulnerable vs 2.8% of non-vulnerable patients who signed up for portal. OAM mention in portal content analysis was low at 31% among patients who signed up. Conclusions: While patient portal signup was lower among vulnerable patients, once adopted, vulnerable patients demonstrated comparable meaningful use and greater proxy engagement. Patient portal adoption requires a targeted approach with patient navigation and patient proxy, focusing on the signup stage.

BackgroundPatient portal secure messaging (asynchronous electronic communication between physicians and their established patients) allows patients to manage their care through asynchronous, direct communication with their providers. This type of engagement with health information technology could have important benefits for patients with chronic conditions, and a more thorough understanding of the use and barriers of secure messaging among this population is needed. The objective of this study was to explore how experienced portal users engage with secure messaging to manage their chronic conditions.MethodsThree focus groups were conducted with 17 total patients who self-reported a cardiopulmonary condition. Participants were asked questions about their experience with patient portal secure messaging. Focus group transcripts were coded through inductive and deductive methods to reveal common themes.ResultsPatients’ motivation for using messaging included the speed and ease of such communication and direct access to a physician. Messaging was used by patients as an extension of the office visit and supported coordination of care among providers as well as patient collaboration with family members or caretakers. Patients identified challenges to using messaging, including technological barriers, worry about uncompensated physician time spent responding to messages, and confusion about what constitutes an appropriate ‘non-urgent’ message.ConclusionsThis study highlights the potential of patient portal messaging as a tool for care coordination to enhance chronic disease self-management. However, uncertainty about the appropriate use of portal messaging persists even among experienced users. Additional patient training in the proper use of secure messaging and its benefits for disease self-management may help to resolve these concerns.

Lung cancer is the leading cause of cancer morbidity and mortality in the United States. Annual screening with low-dose computed tomography (LDCT) reduces lung cancer mortality. However, annual adherence to screening is suboptimal. To improve annual adherence to lung cancer screening (LCS), additional patient education beyond shared-decision making is needed to normalize the screening process. Interventions which leverage digital modes of delivery might have broad reach, but only if patients actively engage with messages from clinical providers. Furthermore, there may be disparities in access to digital communication by patient demographics which will need to be addressed to advance health equity through digital technology. The objective of this study was to understand factors associated with engagement with patient portal messaging. This study was nested within a pragmatic clinical trial to test the “Patient Voices Video” relative to usual care to determine if participants opened video intervention communication delivered through the patient portal. The video-based intervention (Patient Voices Video) incorporated patient testimonials to acknowledge LCS receipt, reminds patients they are due in 12 months for next scan, and reassurance to reduce fear of LCS and role of loved ones to support health choices. Study participants were Kaiser Permanente Washington members aged 50-78 years with recent normal LCS scan and were randomized to either Patient Voices Video or usual care. Study analyses were restricted to those assigned to video arm. Participants randomized to the video arm received a web link via a patient portal message 3 weeks after normal scan. We generated descriptive statistics to summarize differences in proportions in pre-specified demographic factors associated with opening the video message in the patient portal among those in the video arm and registered in patient portal (n=614). Overall, 85% of participants opened their patient portal message. Patient factors associated with not opening patient portal message included: current tobacco use (currently smoking 56% in group that did not open portal message vs 42% in group that opened portal message) and race/ethnicity (18% non-White in group that did not open portal message vs 10% in group that opened portal message). A higher proportion (8%) of those in non-metro areas opened portal message compared to 3% not opening message. There were no differences in likelihood of opening the portal message by age, sex, prior LCS experience, or area deprivation. Patient portal messages can be a successful delivery mode for LCS interventions with high utilization, but disparities in reach are still prevalent by race and ethnicity and tobacco status. Citation Format: Anjali Vasavada, Lorella Palazzo, Matthew Triplette, Hongyuan Gao, Melissa Anderson, Casey Luce, Yu-Ru Su, James Ralston, Kristine Rogers, Nadia Bezman, Beverly B Green, Lisa Carter-Bawa, Karen J Wernli. Reach of digital interventions to address disparities in repeat lung cancer screening in Washington State [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr B037.

A comparison of rule-based and machine learning approaches for classifying patient portal messages

Classifying patient portal messages using Convolutional Neural Networks

We aimed to characterize patient portal messaging use after urologic surgery to identify administrative burden and evaluate postoperative clinical associations. Epic was queried for all urologic surgeries performed at the Mayo Clinic enterprise between 2019 and 2022. Data from the highest volume procedures were extracted including patient-generated portal messages to their provider and emergency department (ED) visits within 6 months of surgery. Factors associated with portal users and message volume, as well as the impact of portal use on risk of subsequent ED visit, were evaluated. We analyzed data from 23,621 urologic procedures, which generated 102,726 patient portal messages within 6 months of surgery. We found that 55% of our cohort sent at least 1 message. Stratifying by subspecialty, endourologic surgeries generated the fewest number of messages per surgery (3.83; SD, 8.76), whereas female pelvic medicine and reconstructive surgeries yielded the most (6.05; SD, 10.92). Younger age, female sex, and White race were associated with increased portal utilization. Multivariable time-to-event analysis revealed a 33% reduction in the risk of ED presentation within 90 days after surgery for patients using the patient portal compared with those who did not. While only half of patients sent portal messages after surgery, active users showed a 33% reduction in ED visits, suggesting its potential to reduce health care utilization. Encouraging broader portal adoption can improve outcomes. However, the message burden for urologists necessitates solutions. Resource allocation should prioritize strategies to help urologists manage messages while preserving the established clinical benefits.

<p dir="ltr"><b>ABSTRACT</b></p><p><br></p><p dir="ltr"><b>Objective: </b>Online patient portal messaging may accelerate access to endocrinology care providers for people with diabetes, yet the ways in which older adults use portal messaging as part of their care has not been well-characterized. This study aimed to explore the needs, concerns, and healthcare behaviors expressed in patient-initiated portal messages sent by older adults with type 2 diabetes to their endocrinology providers.</p><p><br></p><p dir="ltr"><b>Research Design and Methods:</b> We conducted a hybrid deductive and inductive thematic analysis of patient-initiated portal messages from adults aged ≥65 with type 2 diabetes receiving diabetes care at the hospital-based, outpatient endocrinology clinic. We included all older adults who had ≥1 visit with a provider in 2023. We analyzed the content from the first message of each thread. Linked electronic health record data were used to characterize the sample.</p><p><br></p><p dir="ltr"><b>Results: </b>Among 882 older patients with type 2 diabetes receiving outpatient endocrinology care, 427 (48.4%) sent ≥1 patient portal message (mean age 71.8 years; 54% female; 72% White). We identified eight themes among portal messages including (1) barriers to accessing medications and (2) glucose monitoring supplies, (3) medication questions, (4) unaffordability of care, (5) requests to interpret lab and diagnostic results, (6) transmission of glucose monitoring data, (7) nutrition and supplementation questions, and (8) general non-urgent medical questions, with corresponding subthemes detailing issues.</p><p><br></p><p dir="ltr"><b>Conclusions:</b> The content of patient-initiated portal messages sent by older adults to their endocrinologists discussed varied topics, with a large burden of administrative requests and challenges accessing medications and supplies, rather than clinical questions.</p><p><br></p><p><br></p><p dir="ltr"><b>Article Highlights</b></p><ul><li>Why did we undertake this study?</li></ul><p dir="ltr">The use of online patient portals for asynchronous communication between patients and providers has increased substantially.</p><p dir="ltr">· What is the specific question(s) we wanted to answer?</p><p dir="ltr">What is the thematic content of patient-initiated portal messages sent by older adults with type 2 diabetes to their endocrinology care providers?</p><ul><li>What did we find?</li></ul><p dir="ltr">Patient-initiated portal messages from older adults with type 2 diabetes mainly focused on medication and supply barriers, monitoring questions, lab interpretation, and other non-urgent care issues. Messages often included multiple updates and questions of varying complexity.</p><ul><li>What are the implications of our findings?</li></ul><p dir="ltr">The study highlights older adults’ concerns, needs, and digital communication challenges. The results also elucidate opportunities to reduce administrative tasks and burden for patients and providers.</p>

<p dir="ltr"><b>ABSTRACT</b></p><p><br></p><p dir="ltr"><b>Objective: </b>Online patient portal messaging may accelerate access to endocrinology care providers for people with diabetes, yet the ways in which older adults use portal messaging as part of their care has not been well-characterized. This study aimed to explore the needs, concerns, and healthcare behaviors expressed in patient-initiated portal messages sent by older adults with type 2 diabetes to their endocrinology providers.</p><p><br></p><p dir="ltr"><b>Research Design and Methods:</b> We conducted a hybrid deductive and inductive thematic analysis of patient-initiated portal messages from adults aged ≥65 with type 2 diabetes receiving diabetes care at the hospital-based, outpatient endocrinology clinic. We included all older adults who had ≥1 visit with a provider in 2023. We analyzed the content from the first message of each thread. Linked electronic health record data were used to characterize the sample.</p><p><br></p><p dir="ltr"><b>Results: </b>Among 882 older patients with type 2 diabetes receiving outpatient endocrinology care, 427 (48.4%) sent ≥1 patient portal message (mean age 71.8 years; 54% female; 72% White). We identified eight themes among portal messages including (1) barriers to accessing medications and (2) glucose monitoring supplies, (3) medication questions, (4) unaffordability of care, (5) requests to interpret lab and diagnostic results, (6) transmission of glucose monitoring data, (7) nutrition and supplementation questions, and (8) general non-urgent medical questions, with corresponding subthemes detailing issues.</p><p><br></p><p dir="ltr"><b>Conclusions:</b> The content of patient-initiated portal messages sent by older adults to their endocrinologists discussed varied topics, with a large burden of administrative requests and challenges accessing medications and supplies, rather than clinical questions.</p><p><br></p><p><br></p><p dir="ltr"><b>Article Highlights</b></p><ul><li>Why did we undertake this study?</li></ul><p dir="ltr">The use of online patient portals for asynchronous communication between patients and providers has increased substantially.</p><p dir="ltr">· What is the specific question(s) we wanted to answer?</p><p dir="ltr">What is the thematic content of patient-initiated portal messages sent by older adults with type 2 diabetes to their endocrinology care providers?</p><ul><li>What did we find?</li></ul><p dir="ltr">Patient-initiated portal messages from older adults with type 2 diabetes mainly focused on medication and supply barriers, monitoring questions, lab interpretation, and other non-urgent care issues. Messages often included multiple updates and questions of varying complexity.</p><ul><li>What are the implications of our findings?</li></ul><p dir="ltr">The study highlights older adults’ concerns, needs, and digital communication challenges. The results also elucidate opportunities to reduce administrative tasks and burden for patients and providers.</p>

BackgroundAdvance care planning allows patients to articulate their future care preferences should they no longer be able to make decisions on their own. Early advance care planning in outpatient settings provides benefits such as less aggressive care and fewer hospitalizations, yet it is underutilized due to barriers such as provider time constraints and communication complexity. Novel methods, such as patient portals, provide a unique opportunity to conduct advance care planning previsit planning for outpatient care. This follow-up to our pilot study aimed to conduct pragmatic testing of a novel electronic health record-tethered framework and its effects on advance care planning delivery in a real-world primary care setting.ObjectiveOur intervention tested a previsit advance care planning workflow centered around a framework sent via secure electronic health record-linked patient portal in a real-world clinical setting. The primary objective of this study was to determine its impact on frequency and quality of advance care planning documentation.MethodsWe conducted a pragmatic trial including 2 sister clinical sites, one site implementing the intervention and the other continuing standard care. A total of 419 patients aged between 50 and 93 years with active portal accounts received intervention (n=200) or standard care (n=219). Chart review analyzed the presence of advance care planning and its quality and was graded with previously established scoring criteria based on advance care planning best practice guidelines from multiple nations.ResultsA total of 19.5% (39/200) of patients who received previsit planning responded to the framework. We found that the intervention site had statistically significant improvement in new advance care planning documentation rates (P<.01) and quality (P<.01) among all eligible patients. Advance care planning documentation rates increased by 105% (19/39 to 39/39) and quality improved among all patients who engaged in the previsit planning framework (n=39). Among eligible patients aged between 50 and 60 years at the intervention site, advance care planning documentation rates increased by 37% (27/96 to 37/96). Advance care planning documentation rates increased 34% among high users (27/67 to 36/67).ConclusionsAdvance care planning previsit planning using a secure electronic health record-supported patient portal framework yielded improvement in the presence of advance care planning documentation, with highest improvement in active patient portal users and patients aged between 50 and 60 years. Targeted previsit patient portal advance care planning delivery in these populations can potentially improve the quality of care in these populations.

Patient portal secure messages are not always authored by the patient account holder. Understanding who authored the message is particularly important in an oncology setting where symptom reporting is crucial to patient treatment. Natural language processing has the potential to detect messages not authored by the patient automatically. Patient portal secure messages from the Memorial Sloan Kettering Cancer Center were retrieved and manually annotated as a predicted unregistered proxy (ie, not written by the patient) or a presumed patient. After randomly splitting the annotated messages into training and test sets in a 70:30 ratio, a bag-of-words approach was used to extract features and then a Least Absolute Shrinkage and Selection Operator (LASSO) model was trained and used for classification. Portal secure messages (n = 2,000) were randomly selected from unique patient accounts and manually annotated. We excluded 335 messages from the data set as the annotators could not determine if they were written by a patient or proxy. Using the remaining 1,665 messages, a LASSO model was developed that achieved an area under the curve of 0.932 and an area under the precision recall curve of 0.748. The sensitivity and specificity related to classifying true-positive cases (predicted unregistered proxy-authored messages) and true negatives (presumed patient-authored messages) were 0.681 and 0.960, respectively. Our work demonstrates the feasibility of using unstructured, heterogenous patient portal secure messages to determine portal secure message authorship. Identifying patient authorship in real time can improve patient portal account security and can be used to improve the quality of the information extracted from the patient portal, such as patient-reported outcomes.

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

Providing Beyond Clinic Hours: A Single-center Analysis of Patient Portal Communication in Pediatric Orthopaedic Care

Secure messages and electronic visits ("e-visits") through patient portals provide patients with alternatives to face-to-face appointments, telephone contact, letters, and e-mails. Limited information exists on how portal messaging impacts face-to-face visits in primary care. We conducted a retrospective cohort study of 2,357 primary care patients who used electronic messaging (both secure messages and e-visits) on a patient portal. Face-to-face appointment frequencies (visits/year) of each patient were calculated before and after the first message in a matched-pairs analysis. We analyzed visit frequencies with and without adjustments for a first message surge in visits, and we examined subgroups of high message utilizers and long-term users. Primary care patients who sent at least one message (secure message or e-visit) had a mean of 2.43 (standard deviation [SD] 2.3) annual face-to-face visits before the first message and 2.47 (SD 2.8) after, a nonsignificant difference (p=0.45). After adjustment for a first message surge in visits, no significant visit frequency differences were observed (mean, 2.35 annual visits per patient both before and after first message; p=0.93). Subgroup analysis also showed no significant change in visit frequency for patients with higher message utilization or for those who had used the messaging feature longer. No significant change in face-to-face visit frequency was observed following implementation of portal messaging. Secure messaging and e-visits through a patient portal may not result in a change of adult primary care face-to-face visits.

Previous studies have consistently reported disparities in electronic health record portal enrollment. Among patients enrolled in a portal, it is less clear whether there are disparities in usage. We investigated whether disparities existed in portal usage among enrolled oncology patients regarding both sending portal messages to and receiving messages from oncology providers. This retrospective cohort study included patients ≥18 years old with cancer who were seen at an urban academic cancer center between January 2011 and February 2025 and enrolled in the patient portal. We developed Cox proportional hazards models for the outcomes of patients sending portal messages to and receiving messages from oncology providers as the first message in a thread. Time measurement began with the first cancer center visit or portal enrollment, whichever was later. Models were adjusted for demographic, socioeconomic, disease, and administrative visit variables. Among 101,678 patients, the median age was 62 years (IQR, 51-71), and 68,527 sent and 42,242 received messages. After adjustment, age ≥50 versus 18-29 years, Latinx and Pacific Islander versus White, single and widowed versus partnered, non-English preferred language, and Medicaid and Medicare versus private insurance were associated with reduced likelihood of sending and receiving messages. Black and American Indian/Alaska Native were associated with reduced likelihood of sending messages. Female provider was associated with increased likelihood of sending and receiving messages. Women were more likely to send messages. Among oncology patients enrolled in the patient portal, disparities existed in sending and receiving portal messages. Given the association of messaging with better survival among oncology patients in previous studies, future studies should determine how best to minimize messaging disparities beyond just addressing disparities in portal enrollment.