Timely nudges promote patient portal enrollment and sustained engagement: a randomized controlled trial

e14013 Background: Patient portals support self-management, including symptom reporting and control, patient engagement, care coordination, and patient-provider communication, yet not all patients may be deriving the benefits of such digital health tools. Prior studies have not considered how enrollment or use may vary by cancer site, particularly among patients with rare and/or complex diagnoses like malignant brain tumors. Methods: We retrospectively examined portal enrollment and use at an NCI-designated comprehensive cancer center from January 2015 - February 2022 among patients 18+ years old diagnosed with cancer during this time period. We used multivariable logistic regression to generate odds ratios (ORs) for portal enrollment, and Poisson regression to determine incidence rate ratios (IRRs) for number of logins and number of healthcare team interactions (portal messages or appointment requests) by cancer site. Cancer site was categorized using ICD-10-CM codes C00-C96 as brain, breast, colorectal, endocrine, gynecologic, head/neck, leukemia, liver, lung, lymphoma, male genitourinary, melanoma, multiple myeloma, non-melanoma skin, pancreas, soft tissue, upper gastrointestinal (GI), urinary, and other. Regression models controlled for gender, race/ethnicity, relationship status, age, rurality, residential distance from the cancer center, and time since diagnosis. We conducted a subset analysis among patients with a malignant brain tumor diagnosis. Results: We identified 10,365 cancer patients, with 39% enrolled in the patient portal. Enrolled patients had a median of 203.5 total logins and 20 total healthcare team interactions. Enrollment and use significantly varied by cancer type. Patients with lung (OR: 0.24 [0.19 - 0.29]) and liver (OR: 0.27 [0.18 - 0.40]) cancers were the least likely to enroll in the portal. Patients with malignant brain tumors (IRR: 0.74 [0.73 - 0.76]; IRR: 0.57 [0.54 - 0.60]) and upper GI cancer (IRR: 0.64 [0.62 - 0.66]; IRR: 0.46 [0.41 - 0.51]) had the lowest login and interaction rates, respectively. In malignant brain tumors subset analyses, being single (OR: 0.14 [0.04 - 0.53]) or older (OR: 0.94 [0.90 - 0.97]) was significantly associated with lower portal enrollment. Rural residents (IRR: 0.90 [0.86 - 0.94]), divorced (IRR: 0.18 [0.16 - 0.21]) or single patients (IRR: 0.50 [0.47 - 0.52]), and older patients (IRR: 0.98 [0.97 - 0.98]) had lower login rates, while men had higher login rates (IRR: 1.95 [1.88 - 2.01]). Divorced, widowed, and single patients had lower portal interaction rates (IRR: 0.15 [0.08 - 0.26], IRR: 0.47 [0.29 - 0.76], IRR: 0.84 [0.73 - 0.96], respectively), while men had a higher interaction rate (IRR: 2.71 [2.39 - 3.10]). Conclusions: Interventions to support portal enrollment and use among patients with lung, liver, and upper GI cancers and subsets of patients with malignant brain tumors may enhance care quality among these patients with complex diagnoses at high risk for poor outcomes.

Introduction:Patient portal enrollment following pediatric emergency department (ED) visits allows access to critical results, physician documentation, and telehealth follow-up options. Despite these advantages, there are many challenges to portal invitation and enrollment. Our primary objective was to improve patient portal enrollment rates for discharged pediatric ED patients.Methods:A multidisciplinary team of staff from two ED sites developed successful portal enrollment interventions through sequential Plan-Do-Study-Act cycles from October 2020 to October 2021. Interventions included a new invitation process, changes to patient paperwork on ED arrival, staff portal education, and changes to discharge paperwork and the portal website. The team utilized statistical process control charts to track the percentage of eligible discharged patients who received a portal invitation (process measure) and enrolled in the patient portal.Results:Before the study’s initiation, less than 1% of eligible patients received patient portal invites or enrolled in the patient portal. Statistical process control charts revealed significant changes in enrollment and baseline shift at both a large academic ED campus and a satellite ED site by May 2021. Improvements in invitation rates were also observed at both campuses. Changes were sustained for over 6 months at both locations.Conclusions:High-reliability interventions and a multidisciplinary approach allowed for significant and sustained improvement in patient portal invitation and enrollment rates in eligible pediatric ED patients. Future study will examine enrollment patterns across patient demographics and further high-reliability interventions.

The objectives of this review were (1) to examine characteristics associated with enrollment and utilization of portals among patients with diabetes and (2) to identify barriers and facilitators of electronic patient portal enrollment and utilization. PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were systematically searched for papers reporting original research using quantitative or qualitative methods on characteristics, barriers, and facilitators associated with portal enrollment and utilization among patients with diabetes in the United States. The search was limited to articles published between February 1, 2005 (the date of the national symposium on personal health records) and January 1, 2014. Sixteen articles were identified. Of these, nine were quantitative, three were qualitative, and four used mixed-methods. Several demographic characteristics, having better-controlled diabetes, and providers who engaged in and encouraged portal use were associated with increased portal enrollment and utilization. Barriers to portal enrollment included a lack of patient (1) capacity, (2) desire, and (3) awareness of portal/portal functions. Barriers to portal utilization included (1) patient capacity, (2) lack of provider and patient buy-in to portal benefits, and (3) negative patient experiences using portals. Facilitators of portal enrollment and utilization were providers and family members recommending and engaging in portal use. Improved usability, increased access, educating patients how to use and benefit from portals, and greater endorsement by providers and family members might increase portal enrollment and utilization. As more providers and hospitals offer portals, addressing barriers and leveraging facilitators may help patients with diabetes achieve potential benefits.

6557 Background: Patient portals support patient access, engagement, and care coordination, yet could also widen the digital divide and exacerbate disparities among vulnerable populations. There is emerging evidence that racial/ethnic minority patients are less likely to use portals, yet prior research has not examined potential rural differences. We identified sociodemographic factors associated with portal enrollment and use among a racially and geographically diverse population of cancer patients. Methods: We retrospectively examined portal enrollment and use at an NCI-designated comprehensive cancer center from January 2015 until February 2022 among patients 18+ years old with a neoplastic disease diagnosis (ICD-10-CM C00-D49). Potential predictors included gender, race/ethnicity, marital status, age, rural (Rural-Urban Continuum Codes [RUCC] 4-9) vs nonrural (RUCC 1-3) residence, residential distance from the cancer center, and time since diagnosis. We used multivariable logistic regression to generate odds ratios (ORs) for portal enrollment and having ever sent a portal message, and Poisson regression to determine incidence rate ratios (IRRs) for number of logins and number of healthcare team interactions (portal messages or appointment requests), controlling for ICD-10 diagnosis (SAS 9.4). Results: We identified 11,333 patients (average age 67 years, 59% female, 24% rural, 10% Non-Hispanic Black, 1% Hispanic, 20% non-melanoma skin cancer, 14% breast cancer, 9% lung cancer). 36% of patients had enrolled in the portal, and of these, 80% had sent at least one message. Patients logged in a median of 203.5 times and had a median of 19 portal interactions. Rural residents were less likely to enroll in the portal than urban patients (28% vs 38%, p < 0.0001). Non-Hispanic Black patients and Hispanic/Latinx patients were less likely to enroll in the portal compared with non-Hispanic White patients (22% and 27%, respectively, vs 38.5%, p < 0.0001). Women, younger patients, more recently diagnosed cancer patients, and patients who were married/ partnered were significantly more likely to enroll. In multivariable analysis controlling for cancer type, rural patients were half as likely to enroll in the portal (OR: 0.48 [0.43-0.54]). Among those enrolled, rural residents were 25% less likely to have ever sent a portal message (OR: 0.75 [(0.62-0.92]), and had nearly half the login and interaction rates (IRR: 0.66 [0.66-0.67]; IRR: 0.58 [0.58-0.59], respectively). Patients who were Non-Hispanic Black, Hispanic, or unmarried were also significantly less likely to enroll or engage in the portal. Conclusions: Patient portals remain underutilized among cancer patients, despite an increased reliance on virtual communications in the COVID era. Interventions to support portal engagement among rural residents and racial/ethnic minority patients are needed to avoid potentially exacerbating health disparities.

To identify factors that affect appointment adherence and investigate the association of electronic patient portal (ePP) enrollment and patient adherence rates to appointments in the Neurology Resident Clinic (NRC). Patients scheduled for an appointment during the months of October 2015, February 2016, and June 2016 in the NRC were included. ePP enrollment, date of clinic appointment, method of referral to the clinic, and key demographic criteria were collected. χ2 tests were performed to assess the association of appointment status (i.e., no-show, showed, and canceled) with demographic, comorbidity, and visit information. Patients with ePP enrollment had significantly lower rates of no-show (19% vs 27%) and higher rates of showed (59% vs 48%) compared to patients without ePP enrollment. Younger patients (18-49) had the highest rates of no-show (28%), while older patients (65+) had the lowest rates of no-show (17%). Caucasian patients had significantly lower rates of no-show compared to non-Caucasian patients (14% vs 24%). Non-English-speaking patients had high rates of no-show (34%). Patients with a physician referral had significantly lower rates of no-show (20% vs 28%) and higher rates of showed (61% vs 44%) compared to patients with a self-referral. Our study indicates that ePP enrollment, age, race, and physician referral might be associated with reduced no-show rates in the NRC.

Electronic patient portals are associated with improved health outcomes in primary care settings. We assessed the relationship between patient portal enrollment and retention in care and HIV viral suppression in an urban HIV care clinic. In multivariable models, people with HIV with an active portal account had higher odds of HIV viral suppression (Odds Ratio [OR]: 2.02, 95% CI [1.3–3.7]) and higher odds of retention in care (OR: 2.2 95% CI[1.4–3.4]) than those without an active portal account. Our findings suggest that portal enrollment is associated with improved HIV care outcomes among people with HIV.

Bringing nurses into the boardroom

419 Background: The patient portal is part of an electronic health record (EHR) that allows patients to communicate with their healthcare team. The portal also provides a platform for patients to receive and complete symptom surveys that can be directly integrated into the EHR, allowing clinical care teams to monitor symptoms and provide cancer symptom management. The Improving Management of symPtoms during And following Cancer Treatment (IMPACT) consortium, supported by the National Cancer Institute’s Cancer MoonshotSM, aims to improve symptom control for cancer patients through assessment and symptom management interventions deployed via the EHR. This initiative presents an opportunity to examine portal enrollment and variation in use, factors critical to successful implementation, especially among groups that have high cancer symptom burden. To this end, we examine: 1) relationships between portal enrollment prior to the launch of IMPACT interventions and neighborhood broadband access, demographic, and social characteristics; and 2) frequency of pre-intervention portal use for any purpose among enrollees. Methods: Data are derived from two of three IMPACT research centers. Enrollment in and frequency of portal use, mode of accessing the portal (web vs. phone), social, demographic, and cultural factors were extracted from the EHR. Rural Urban Commuting Area (RUCA) codes were used to classify population density and degree of rurality. Broadband access was estimated using 2015-2019 American Community Survey estimates matched to zip codes from enrolled IMPACT patients and classified as a patient’s residence being in a community with high (≥85% of households) or low (< 85% of households) access. Bivariate comparisons and adjusted odds ratios were used to describe all associations. Results: Forty-seven percent of patients (22,596/48,034) were enrolled in the portal prior to the intervention. Patients in zip codes with low broadband access and those who were men, > 65 years old, not White, of Hispanic ethnicity, or disabled or not employed had significantly lower odds of being enrolled in the portal. If enrolled, 21% (n = 4825) used the portal at least once a week. Less variation was found in the average frequency of portal use, but patients younger than 40, and those who were Black, disabled, unemployed, or those who used a mobile device to access the portal had the lowest odds of accessing it at least once a week. Conclusions: Significant disparities in portal enrollment exist across demographic groups and among those with limited broadband access. Among those enrolled, most used the portal less than once a week. Fewer differences in frequency of use were observed by sociodemographic factors. Improving portal enrollment and frequency of use may be critical for symptom management interventions deployed via patient portals.

Digital determinants of health (DDoH), including access to technological tools and digital health literacy, function independently as barriers to health. Assessment for DDoH is not routine within most health care systems, although addressing DDoH could help mitigate differential health outcomes and the digital divide. This study aims to assess the role of individual-level DDoH factors on patient enrollment in and use of the patient portal. We developed a multimodal, cross-sectional survey and deployed it to 11,424 individuals based on their preferred mode and language documented within the electronic medical record. Based on the Technology Acceptance Model, enrollment in and intent to use the patient portal were the outcomes of interest. Perceived usefulness and ease of use were assessed to determine construct validity, and exploratory investigations included individual-level DDoH, including internet and device access, availability of technological support, medical complexity, individual relationship with the health care system, and digital health literacy. Counts (n) and proportions (%) were used to describe response categories, and adjusted and unadjusted odds ratios are reported. This study included 1850 respondents (11,424 invited, 16.2% response rate), who were mostly female (1048/1850, 56.6%) and White (1240/1850, 67%), with an average age of 63 years. In the validation of the Technology Acceptance Model, measures of perceived ease of use (ie, using the patient portal will require a lot of mental effort; the patient portal will be very easy to use) and perceived usefulness (ie, the usefulness of the patient portal to send and receive messages with providers, schedule appointments, and refill medications) were positively associated with both enrollment in and intent to use the patient portal. Within adjusted models, perceived ease of use and perceived usefulness constructs, in addition to constructs of digital health literacy, knowing what health resources are available on the internet (adjusted odds ratio [aOR] 3.5, 95% CI 1.8-6.6), portal ease of use (aOR 2.8, 95% CI 1.6-5), and portal usefulness (aOR 2.4, 95% CI 1.4-4.2) were significantly associated with patient portal enrollment. Other factors associated with patient portal enrollment and intent to use included being comfortable reading and speaking English, reported use of the internet to surf the web or to send or receive emails, home internet access, and access to technology devices (computer, tablet, smartphone, etc). Assessing for and addressing individual-level DDoH, including digital health literacy, access to digital tools and technologies, and support of the relational aspects between patients, social support systems, and health care providers, could help mitigate disparities in health. By focusing efforts to assess for and address individual-level DDoH, an opportunity exists to improve digitally driven health care delivery outcomes like access and structural outcomes like bias built within algorithms created with incomplete representation across communities.

Mitigating disparity? Recurrence rates and palliative care referrals by race and ethnicity across a large urban health system (514)

The study sought to assess, for children in one large health system, (1) characteristics of active users of the patient portal (≥1 use in prior 12 months), (2) portal use by adolescents, and (3) variations in pediatric patient portal use. We analyzed data from the electronic health record regarding pediatric portal use during 2017-2018 across a health system (39871 pediatric patients). Altogether, 63.5% of pediatric patients were active portal users. Children (proxies) who were boys, privately insured, white, and spoke English were more likely to be active users. Common uses involved messaging with physicians, medications, allergies, letters, and laboratory results. By 15 years of age, >50% of adolescents used the portal by themselves (without a proxy). Pediatric portal use varied widely across practices. Pediatric or adolescent portal use is quite high, but large variations exist. Use of the portal for pediatric care may reflect varying pediatric patient engagement.

BackgroundThe digital transformation of medical data enables health systems to leverage real‐world data from electronic health records to gain actionable insights for improving hypertension care.Methods and ResultsWe performed a serial cross‐sectional analysis of outpatients of a large regional health system from 2010 to 2021. Hypertension was defined by systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or recorded treatment with antihypertension medications. We evaluated 4 methods of using blood pressure measurements in the electronic health record to define hypertension. The primary outcomes were age‐adjusted prevalence rates and age‐adjusted control rates. Hypertension prevalence varied depending on the definition used, ranging from 36.5% to 50.9% initially and increasing over time by ≈5%, regardless of the definition used. Control rates ranged from 61.2% to 71.3% initially, increased during 2018 to 2019, and decreased during 2020 to 2021. The proportion of patients with a hypertension diagnosis ranged from 45.5% to 60.2% initially and improved during the study period. Non‐Hispanic Black patients represented 25% of our regional population and consistently had higher prevalence rates, higher mean systolic and diastolic blood pressure, and lower control rates compared with other racial and ethnic groups.ConclusionsIn a large regional health system, we leveraged the electronic health record to provide real‐world insights. The findings largely reflected national trends but showed distinctive regional demographics and findings, with prevalence increasing, one‐quarter of the patients not controlled, and marked disparities. This approach could be emulated by regional health systems seeking to improve hypertension care.

Background: Upper respiratory infections (URIs) are a common cause of outpatient visits in adults. While most URIs are viral, antimicrobial prescribing rates remain high. The COVID-19 pandemic disrupted usual practices, necessitating an evaluation of the post-pandemic landscape for antimicrobial prescribing for URIs. This study sought to characterize factors contributing to variability in utilization in a large multi-state health system. Methods: Retrospective analysis of antimicrobial prescribing in patients ≥18 years of age for URI diagnosis codes in 863 outpatient sites (eight states), including office visits, urgent care, and telemedicine between July 1, 2023 to June 30, 2024. Primary outcome was antimicrobial prescribing rates for URIs overall and by individual URI diagnosis (sinusitis, bronchitis, pharyngitis, otitis media). HEDIS definitions were applied where appropriate. Logistic regression machine learning models were used with SHapley Additive exPlanations (SHAP) analysis to show feature contributions to antimicrobial prescribing. Results: A total of 84,724 patient encounters were included with four URI diagnoses. Antimicrobial prescribing rates varied by diagnosis (sinusitis: 60%, bronchitis: 48%, pharyngitis: 33%, otitis media: 35%, p<0.001). Prescribing ranged from 37%-58% across states (p<0.001). Sinusitis diagnosis and specific states had the strongest positive associations with antimicrobial prescribing, while race and social vulnerability index (SVI) were not associated. Conclusions: In this study in a large multi-state US health system, antimicrobials were most commonly prescribed for patients with sinusitis. Regional variation was also associated with increased prescribing. These data support efforts to standardize practices and address clinical variation.

BackgroundPractice recommendations for mammography screening were issued by the U.S. Preventive Services Task Force in 2009 and expansion of insurance coverage was provided under the Patient Protection and Affordable Care Act soon thereafter, yet the influence of these changes on screening practices in the United States is not known.MethodsTo determine changes in mammography screening and their associations with new practice recommendations and the Affordable Care Act, we examined patient-level data from 249,803 screening mammograms from January 1, 2008 through December 31, 2012 in a large community-based health system in the northwestern United States. Associations were determined by an intervention analysis of time-series data method.ResultsAmong women screened, 64% were age 50-74 years; 84% self-identified as white race; 62% had commercial insurance; and 70% were seen in facilities located in metropolitan areas. Practice recommendations were associated with decreased screening volumes among women age <40 (-37.4 mammograms/month; -39.4% change; P<0.001), 40-49 (-106.0 mammograms/month; -11.2% change; P<0.001), and ≥75 (-54.7 mammograms/month; -10.0% change; P<0.001), but not women age 50-74. Implementation of the Affordable Care Act was associated with increased screening among women age 50-74 (+184.3 mammograms/month; +7.2% change; P=0.001), but not women <40 or ≥75; increases for age 40-49 were of borderline statistical significance (+56.9 mammograms/month; +6% change; P=0.06). Practice recommendations were also associated with decreased screening for women with commercial insurance, while the Affordable Care Act was associated with increased screening for women with Medicare, Medicaid, or other noncommercial sources of payment.ConclusionsMammography screening volumes in a large community health system decreased among women age <50 and ≥75 in association with new U.S. Preventive Services Task Force practice recommendations, while insurance coverage changes under the Affordable Care Act were associated with increased screening volumes among women age 50-74.

The elusive goal of COVID-19 vaccine immunity