Electronic Health Record Patient Portal Research Articles

Leveraging large language models for generating responses to patient messages-a subjective analysis.

This study aimed to develop and assess the performance of fine-tuned large language models for generating responses to patient messages sent via an electronic health record patient portal. Utilizing a dataset of messages and responses extracted from the patient portal at a large academic medical center, we developed a model (CLAIR-Short) based on a pre-trained large language model (LLaMA-65B). In addition, we used the OpenAI API to update physician responses from an open-source dataset into a format with informative paragraphs that offered patient education while emphasizing empathy and professionalism. By combining with this dataset, we further fine-tuned our model (CLAIR-Long). To evaluate fine-tuned models, we used 10 representative patient portal questions in primary care to generate responses. We asked primary care physicians to review generated responses from our models and ChatGPT and rated them for empathy, responsiveness, accuracy, and usefulness. The dataset consisted of 499794 pairs of patient messages and corresponding responses from the patient portal, with 5000 patient messages and ChatGPT-updated responses from an online platform. Four primary care physicians participated in the survey. CLAIR-Short exhibited the ability to generate concise responses similar to provider's responses. CLAIR-Long responses provided increased patient educational content compared to CLAIR-Short and were rated similarly to ChatGPT's responses, receiving positive evaluations for responsiveness, empathy, and accuracy, while receiving a neutral rating for usefulness. This subjective analysis suggests that leveraging large language models to generate responses to patient messages demonstrates significant potential in facilitating communication between patients and healthcare providers.

The effect of a bundle intervention for ambulatory otorhinolaryngology procedures on same-day case cancellation rate and associated costs.

Cancellations within 24 h of planned elective surgical procedures reduce operating theatre efficiency, add unnecessary costs and negatively affect patient experience. We implemented a bundle intervention that aimed to reduce same-day case cancellations. This consisted of communication tools to improve patient engagement and new screening instruments (automated estimation of ASA physical status and case cancellation risk score plus four screening questions) to identify patients in advance (ideally before case booking) who needed comprehensive pre-operative risk stratification. We studied patients scheduled for ambulatory surgery with the otorhinolaryngology service at a single centre from April 2021 to December 2022. Multivariable logistic regression and interrupted time-series analyses were used to analyse the effects of this intervention on case cancellations within 24 h and costs. We analysed 1548 consecutive scheduled cases. Cancellation within 24 h occurred in 114 of 929 (12.3%) cases pre-intervention and 52 of 619 (8.4%) cases post-intervention. The cancellation rate decreased by 2.7% (95%CI 1.6-3.7%, p < 0.01) during the first month, followed by a monthly decrease of 0.2% (95%CI 0.1-0.4%, p < 0.01). This resulted in an estimated $150,200 (£118,755; €138,370) or 35.3% cost saving (p < 0.01). Median (IQR [range]) number of days between case scheduling and day of surgery decreased from 34 (21-61 [0-288]) pre-intervention to 31 (20-51 [1-250]) post-intervention (p < 0.01). Patient engagement via the electronic health record patient portal or text messaging increased from 75.9% at baseline to 90.8% (p < 0.01) post-intervention. The primary reason for case cancellation was patients' missed appointment on the day of surgery, which decreased from 7.2% pre-intervention to 4.5% post-intervention (p = 0.03). An anaesthetist-driven, clinical informatics-based bundle intervention decreases same-day case cancellation rate and associated costs in patients scheduled for ambulatory otorhinolaryngology surgery.

Improving Hypertension Control in the Black Patient Population: A Quality Improvement Study of Workflow Redesign Using the Electronic Health Record to Integrate Self-Monitoring, Education, and Reporting.

Nearly half of American adults have hypertension (HTN), and non-Hispanic Black patients are diagnosed at a higher rate than others. Our local clinic population reflected disproportionate rates of uncontrolled HTN among Black patients. A quality improvement pre-/postintervention design was used to evaluate an educational intervention to reduce blood pressure (BP) and improve self-monitoring of BP in Black patients using the Chronic Care Model. A team-based approach was used to redesign clinic workflows and patient education, prescribe self-paced videos from an electronic health record (EHR) patient portal, and provide home BP cuffs. Black participants (n = 79) improved viewing of prescribed videos (7.9% to 68.5%), knowledge scores (67.9 to 75.2), and mean systolic BP (-20.3 mm Hg; P > .001). This team-based approach enhanced patient engagement, self-monitoring skills, EHR-reported BP, and overall BP control for a cohort of Black patients with uncontrolled BP.

Real world challenges in maintaining data integrity in electronic health records in a cancer program

Electronic Health Record (EHR) systems increase clerical workload, promote copy-paste and error propagation. Documentation error rate in cancer diagnosis and treatment was examined in 776 patient records. Fifteen percent of the charts contained an error. Modern EHR systems, patient portals and engagement tools may facilitate the maintenance of accurate information.

Rationale, design, and protocol for a hybrid type 1 effectiveness-implementation trial of a proactive smoking cessation electronic visit for scalable delivery via primary care: the E-STOP trial

BackgroundCigarette smoking remains the leading cause of preventable disease and death in the United States. Primary care offers an ideal setting to reach adults who smoke cigarettes and improve uptake of evidence-based cessation treatment. Although U.S. Preventive Services Task Force Guidelines recommend the 5As model (Ask, Advise, Assess, Assist, Arrange) in primary care, there are many barriers to its implementation. Automated, comprehensive, and proactive tools are needed to overcome barriers. Our team developed and preliminarily evaluated a proactive electronic visit (e-visit) delivered via the Electronic Health Record patient portal to facilitate evidence-based smoking cessation treatment uptake in primary care, with promising initial feasibility and efficacy. This paper describes the rationale, design, and protocol for an ongoing Hybrid Type I effectiveness-implementation trial that will simultaneously assess effectiveness of the e-visit intervention for smoking cessation as well as implementation potential across diverse primary care settings.MethodsThe primary aim of this remote five-year study is to examine the effectiveness of the e-visit intervention vs. treatment as usual (TAU) for smoking cessation via a clinic-randomized clinical trial. Adults who smoke cigarettes are recruited across 18 primary care clinics. Clinics are stratified based on their number of primary care providers and randomized 2:1 to either e-visit or TAU. An initial baseline e-visit gathers information about patient smoking history and motivation to quit, and a clinical decision support algorithm determines the best evidence-based cessation treatment to prescribe. E-visit recommendations are evaluated by a patient’s own provider, and a one-month follow-up e-visit assesses cessation progress. Main outcomes include: (1) cessation treatment utilization (medication, psychosocial cessation counseling), (2) reduction in cigarettes per day, and (3) biochemically verified 7-day point prevalence abstinence (PPA) at six-months. We hypothesize that patients randomized to the e-visit condition will have better cessation outcomes (vs. TAU). A secondary aim evaluates e-visit implementation potential at patient, provider, and organizational levels using a mixed-methods approach. Implementation outcomes include acceptability, adoption, fidelity, implementation cost, penetration, and sustainability.DiscussionThis asynchronous, proactive e-visit intervention could provide substantial benefits for patients, providers, and primary care practices and has potential to widely improve reach of evidence-based cessation treatment.Trial registrationNCT05493254.

Abstract 18538: Results of a Self-Management Intervention to Improve Hypertension in Black Patients Using the Electronic Health Record Patient Portal

Introduction: Nearly half of American adults (47%) have hypertension (HTN), and non-Hispanic Black patients are disproportionately represented among those diagnosed (56% versus 48% for White, 46% for Asian, and 39% Hispanic adults). Models of care to reduce blood pressure for the Black patient population are not consistently implemented, in large part due to systemic and structural barriers to care. Hypothesis: The purpose of this study was to improve access to and use of digital education, skills for self-measured blood pressure (SMBP) monitoring, use of the electronic health record (EHR) patient portal, and blood pressure from baseline to 3 months in a cohort of Black Americans. Methods: A pre-post intervention design was used to evaluate the team-based, nurse-led intervention. Patients received coaching on HTN goals, screening for social determinants of health (SDOH), medication review, self-paced portal-based videos, and teach-back for BP cuff use. Post-implementation blood pressure (BP) and self-management (knowledge, cuff-use, patient portal use, and attendance at follow-up) were measured using the HELM tool, Chronic Care Model (CCM) and American Heart Association (AHA) HTN toolkit. 12-month follow-up is ongoing. Results: Black participants (n=80) averaged 59 (SD 10) years of age; most were female (n=58, 73%), employed (n=59, 75%), non-smokers (n=66, 84%), with average BMI 34.5 (SD8). From 0-3-months, views of portal-pushed videos increased to 69%, knowledge scores improved pre- (M = 67.9, SD = 16.7 to post (M = 75.2, SD = 17.4), and mean systolic BP was significantly reduced by 20.3mmHg (95%CI 16.11, 24.44). Average systolic BP pre was 152.13 (SD = 16.87) and post was 131.85 (SD = 13.13), t (79) = 9.71, p&lt; .001. Sustainability at 12-months is ongoing. Conclusions: A team-based, nurse-led model improves patient engagement, adoption of portal-prescribed education, skills for SMBP, EHR-reported BP, and visit follow-up for Black patients with uncontrolled BP.

Examining how information presentation methods and a chatbot impact the use and effectiveness of electronic health record patient portals: An exploratory study

ObjectivesExamining information presentation strategies that may facilitate patient education through patient portals is important for effective health education. MethodsA randomized exploratory study evaluated information presentation (text or videos) and a chatbot in patient education and examined several performance and outcome variables (e.g., search duration, Decisional Conflict Scale, and eye-tracking measures), along with a simple descriptive qualitative content analysis of the transcript of chatbot. ResultsOf the 92 participants, those within the text conditions (n = 46, p < 0.001), had chatbot experiences (B =−74.85, p = 0.046), knew someone with IBD (B =−98.66, p = 0.039), and preferred to engage in medical decision-making (B =102.32, p = 0.006) were more efficient in information-searching. Participants with videos spent longer in information-searching (mean=666.5 (SD=171.6) VS 480.3 (SD=159.5) seconds, p < 0.001) but felt more informed (mean score=18.8 (SD=17.6) VS 27.4 (SD=18.9), p = 0.027). The participants’ average eye fixation duration with videos was significantly higher (mean= 473.8 ms, SD=52.9, p < 0.001). ConclusionsParticipants in video conditions were less efficient but more effective in information seeking. Exploring the trade-offs between efficiency and effectiveness for user interface designs is important to appropriately deliver education within patient portals. Practice implicationsThis study suggests that user interface designs and chatbots impact health information’s efficiency and effectiveness.

Feasibility of Implementation of a Mobile Digital Personal Health Record to Coordinate Care for Children and Youth With Special Health Care Needs in Primary Care: Protocol for a Mixed Methods Study.

Electronic health record (EHR)-integrated digital personal health records (PHRs) via Fast Healthcare Interoperability Resources (FHIR) are promising digital health tools to support care coordination (CC) for children and youth with special health care needs but remain widely unadopted; as their adoption grows, mixed methods and implementation research could guide real-world implementation and evaluation. This study (1) evaluates the feasibility of an FHIR-enabled digital PHR app for CC for children and youth with special health care needs, (2) characterizes determinants of implementation, and (3) explores associations between adoption and patient- or family-reported outcomes. This nonrandomized, single-arm, prospective feasibility trial will test an FHIR-enabled digital PHR app's use among families of children and youth with special health care needs in primary care settings. Key app features are FHIR-enabled access to structured data from the child's medical record, families' abilities to longitudinally track patient- or family-centered care goals, and sharing progress toward care goals with the child's primary care provider via a clinician dashboard. We shall enroll 40 parents or caregivers of children and youth with special health care needs to use the app for 6 months. Inclusion criteria for children and youth with special health care needs are age 0-16 years; primary care at a participating site; complex needs benefiting from CC; high hospitalization risk in the next 6 months; English speaking; having requisite technology at home (internet access, Apple iOS mobile device); and an active web-based EHR patient portal account to which a parent or caregiver has full proxy access. Digital prescriptions will be used to disseminate study recruitment materials directly to eligible participants via their existing EHR patient portal accounts. We will apply an intervention mixed methods design to link quantitative and qualitative (semistructured interviews and family engagement panels with parents of children and youth with special health care needs) data and characterize implementation determinants. Two CC frameworks (Pediatric Care Coordination Framework; Patient-Centered Medical Home) and 2 evaluation frameworks (Consolidated Framework for Implementation Research; Technology Acceptance Model) provide theoretical foundations for this study. Participant recruitment began in fall 2022, before which we identified >300 potentially eligible patients in EHR data. A family engagement panel in fall 2021 generated formative feedback from family partners. Integrated analysis of pretrial quantitative and qualitative data informed family-centered enhancements to study procedures. Our findings will inform how to integrate an FHIR-enabled digital PHR app for children and youth with special health care needs into clinical care. Mixed methods and implementation research will help strengthen implementation in diverse clinical settings. The study is positioned to advance knowledge of how to use digital health innovations for improving care and outcomes for children and youth with special health care needs and their families. ClinicalTrials.gov NCT05513235; https://clinicaltrials.gov/study/NCT05513235. DERR1-10.2196/46847.

Human Factors Engineering and Usability as Key Drivers for Design of Device Suited for Urine Filtration and Enrichment

Evidence-based practices (EBPs) are not always straightforward to implement in a design process, as impacts can be difficult to assess in practice and appropriate methods are not yet established. User-centered design (UCD) offers opportunities to improve implementation of EBPs. UCD refers to the use of rigorous and validated engineering tools to design technology interfaces focused on user goals, such as device safety, effectiveness, efficiency, and user satisfaction. UCD has the potential to improve six core elements of patient-centered care: (i) education and shared knowledge, (ii) free flow of information, (iii) patient engagement, (iv) teamwork, (v) attention to non-medical aspects of care, and (vi) respect for patient preferences. Technological advances in medicine over the past few decades have provided patients with a variety of inventions, such as electronic health record patient portals, home-based medical devices, and smartphone apps. Effective application of UCD principles results in patient-centered inventions that are more likely to ease patients’ treatment burden, improve their care experience, increase patient engagement, and enable patients to become more self-sufficient. Here, the URICH device design process is used as case-example to demonstrate the inclusion of usability testing and all users as early as possible in the product design and development process.

Measuring symptom burden in patients with cancer during a pandemic: the MD Anderson symptom inventory for COVID-19 (MDASI-COVID)

BackgroundSymptom expression in SARS-CoV-2 infection (COVID-19) may affect patients already symptomatic with cancer. Patient-reported outcomes (PROs) can describe symptom burden during the acute and postacute stages of COVID-19 and support risk stratification for levels of care. At the start of the COVID-19 pandemic, our purpose was to rapidly develop, launch through an electronic patient portal, and provide initial validation for a PRO measure of COVID-19 symptom burden in patients with cancer.MethodsWe conducted a CDC/WHO web-based scan for COVID-19 symptoms and a relevance review of symptoms by an expert panel of clinicians treating cancer patients with COVID-19 to create a provisional MD Anderson Symptom Inventory for COVID-19 (MDASI-COVID). English-speaking adults with cancer who tested positive for COVID-19 participated in the psychometric testing phase. Patients completed longitudinal assessments of the MDASI-COVID and the EuroQOL 5 Dimensions 5 Levels (EQ-5D-5L) utility index and visual analog scale, which were presented through an electronic health record patient portal. To test the validity of the MDASI-COVID to distinguish between known groups of patients, we hypothesized that patients hospitalized, including having a hospitalization extended, for COVID-19 versus those not hospitalized would experience higher symptom burden. Correlation of mean symptom severity and interference scores with relevant EQ-5D-5L scores tested concurrent validity. The reliability of the MDASI-COVID was evaluated by calculating Cronbach alpha coefficients and test-retest reliability was evaluated by calculating Pearson correlation coefficients between the initial assessment and a second assessment no more than 14 days later.ResultsThe web-based scan found 31 COVID-19-related symptoms; rankings of a 14-clinician expert panel reduced this list to 11 COVID-specific items to be added to the core MDASI. Time from literature scan start in March 2020 to instrument launch in May 2020 was 2 months. Psychometric analysis established the MDASI-COVID’s reliability, known-group validity, and concurrent validity.ConclusionsWe were able to rapidly develop and electronically launch a PRO measure of COVID-19 symptom burden in patients with cancer. Additional research is needed to confirm the content domain and predictive validity of the MDASI-COVID and define the symptom burden trajectory of COVID-19.

New Ways for Patients to Make Sense of Their Electronic Health Record Data Using the Discovery Web Application: Think-Aloud Evaluation Study.

In the United States, patients can access their electronic health record (EHR) data through patient portals. However, current patient portals are mainly focused on a single provider, with very limited data sharing capabilities and put low emphasis on independent sensemaking of the EHR data. This makes it very challenging for patients to switch between different portals and aggregate the data to obtain a complete picture of their medical history and to make sense of it. Owing to this fragmentation, patients are exposed to numerous inconveniences such as medical errors, repeated tests, and limited self-advocacy. To overcome the limitations of EHR patient portals, we designed and developed Discovery-a web-based application that aggregates EHR data from multiple providers and present them to the patient for efficient exploration and sensemaking. To learn how well Discovery meets the patients' sensemaking needs and what features should such applications include, we conducted an evaluation study. We conducted a remote study with 14 participants. In a 60-minute session and relying on the think-aloud protocol, participants were asked to complete a variety of sensemaking tasks and provide feedback upon completion. The audio materials were transcribed for analysis and the video recordings of the users' interactions with Discovery were annotated to provide additional context. These combined textual data were thematically analyzed to surface themes that reflect how participants used Discovery's features, what sensemaking of their EHR data really entails, and what features are desirable to support that process better. We found that Discovery provided much needed features and could be used in a variety of everyday scenarios, especially for preparing and during clinical visits and also for raising awareness, reflection, and planning. According to the study participants, Discovery provided a robust set of features for supporting independent exploration and sensemaking of their EHR data: summary and quick overview of the data, finding prevalence, periodicity, co-occurrence, and pre-post of medical events, as well as comparing medical record types and subtypes across providers. In addition, we extracted important design implications from the user feedback on data exploration with multiple views and nonstandard user interface elements. Patient-centered sensemaking tools should have a core set of features that can be learned quickly and support common use cases for a variety of users. The patients should be able to detect time-oriented patterns of medical events and get enough context and explanation on demand in a single exploration view that feels warm and familiar and relies on patient-friendly language. However, this view should have enough plasticity to adjust to the patient's information needs as the sensemaking unfolds. Future designs should include the physicians in the patient's sensemaking process and improve the communication in clinical visits and via messaging.

Abstract MP13: Disparities in Home Blood Pressure Monitoring Among Adults Diagnosed With Hypertension Receiving Primary Care in a Large Academic Health System

Background: Uncontrolled hypertension (HTN) remains a major global public health challenge. Home blood pressure monitoring (HBPM) in combination with co-interventions is an effective strategy for managing and controlling HTN. Our objective was to examine disparities in HBPM among patients diagnosed with HTN in an academic health system. Methods: Using a cross-sectional design, we invited patients with an HTN diagnosis in their electronic health record (EHR) and primary care visit in the past 12 months to complete an anonymous online survey through the EHR patient portal. We used logistic regression to examine disparities in self-reported home blood pressure (BP) monitor ownership (yes/no), frequency of HBPM in the past month (&lt; once or ≥ once), and sharing of BP readings with healthcare provider in the past 6 months (yes/no). Results: We recruited 4,181 adult patients; 48%, ≥ 65 years old; 55%, female; 63%, White; 28%, Black; and 4% Asian adults. About 86% owned a home BP monitor. Those who self-identified as Black race (odds ratio [OR] = 0.73, 95% confidence interval [CI]: 0.58-0.91), other race (odds ratio [OR] = 0.62, 95% confidence interval [CI]: 0.41-0.95) and who were unemployed (OR = 0.54, 0.42-0.70) had lower odds of having a home BP monitor than patients who were White adults and were employed, respectively. Adults aged ≥ 65 years had lower odds of checking BP at home ≥ once a month than their counterparts who were &lt; 65 years old (OR = 0.75, 0.62-0.91). Although women (OR = 1.51, 1.29-1.77) and adults who earned &gt; $100,000 (OR = 1.42, 1.11-1.81) were more likely to check their BP in the previous month than men and those earned &lt; $50,000, they (Female: OR = 0.83, 0.71-0.97; Income &gt; $100,000: OR = 0.77, 0.60-0.99) were less likely to share home BP readings with healthcare provider. Conclusions: We observed substantial disparities in HBPM among adults with HTN. Although HBPM has the potential to advance equity in HTN control, factors such as age, race, and socioeconomic status should be considered in the design and implementation of such programs.

1976. Using a Patient Portal as a Recruitment Tool to Diversify the Pool of Participants in COVID-19 Vaccine Clinical Trials

Abstract Background Because the COVID-19 pandemic disproportionately affected racial/ethnic minorities in the US, there was a push to ensure diversity in COVID-19 vaccine clinical trials. Historically, minority groups have been underrepresented in research. We assessed the feasibility of recruiting racial/ethnic minorities through an electronic health record (EHR) patient portal. Methods The UPenn Health System EHR was used to identify individuals ages 40 and older, living in zip codes with high rates of SARS-CoV-2 test positivity, with a risk factor associated with severe COVID-19 disease. Eligible individuals with an activated patient portal account were sent a message inviting them to participate in the COVID-19 vaccine clinical trial. A follow-up phone call was made to those who did not respond or declined, and reasons for or against participation were coded to extract themes. Results In August 2020, a total of 13,779 patients fit the inclusion criteria, of which 5,614 (40.7%) had an activated patient portal account and were invited to participate. The majority, 5,426 (96.7%), identified as black, and 73 (1.3%) identified as Hispanic/Latinx. Only 301 (5.4%) of messaged individuals responded. Among respondents, 55 of 206 (26.7%) blacks, 5 of 7 (71.4%) Hispanic/Latinx, and 50 of 76 (65.8%) whites expressed interest. Among the 115 respondents who expressed interest, 24 agreed to a screening visit, and 9 were ultimately enrolled in the trial, which consisted of 6 black, 3 white, and 1 Hispanic/Latinx individual. During phone outreach to those who did not respond and those who declined, common reasons for declining included underlying health conditions, fears of an unproven vaccine, not wanting to be experimented upon, the rapid speed of vaccine development, and the lack of time to participate in a trial. Patient portal response rates by race/ethnicity Conclusion Because of low rates of patient portal account activation and use, compounded with vaccine hesitancy, recruitment of racial/ethnic minorities into COVID-19 vaccine clinical trials through patient portal messaging yielded a small number of participants. Strategies to increase use of the patient portal combined with approaches to address concerns of trial participation should be considered to increase enrollment of racially/ethnically diverse groups into vaccine clinical trials. Disclosures All Authors: No reported disclosures.

Effect of Electronic Outreach Using Patient Portal Messages on Well Child Care Visit Completion

Outreach messages to patients overdue for well child care (WCC) can be delivered different ways (ie, telephone calls and text messages). Use of electronic health record patient portals is increasingly common but their effectiveness is uncertain. To determine the effectiveness of patient portal outreach messages, with and without the date of the last WCC, on the scheduling and completion of WCC visits and completion of vaccinations. An intention-to-treat, multigroup, randomized clinical trial was conducted at 3 academic primary care practices from July 30 to October 4, 2021. The population included predominantly non-Hispanic Black, low-income children (age, 6-17 years) whose parent had an active portal account. Participants were randomized to the standard message, tailored message, or no message (control) group. Two messages were delivered to those in the message groups. Outcomes included WCC visit scheduled within 2 weeks of the first intervention message, WCC visit completed within 8 weeks (primary outcome), and receipt of COVID-19 vaccine within 8 weeks. Nine hundred forty-five patients participated (mean [SD] age, 9.9 [3.3] years, 493 [52.2%] girls, 590 [62.4%] non-Hispanic Black, 807 [85.4%] publicly insured). Scheduling rates were 18.4% in the standard message group (adjusted risk ratio [aRR], 1.97; 95% CI, 1.32-2.84) and 14.9% in the tailored message group (aRR, 1.57; 95% CI, 1.02-2.34) compared with the control group (9.5%). Well child care visit completion rates were 24.1% in the standard message group (aRR, 1.92; 95% CI, 1.38-2.60) and 19.4% in the tailored message group (aRR, 1.52; 95% CI, 1.06-2.13) compared with the control group (12.7%). Among eligible children, rates of receiving the COVID-19 vaccine were 16.7% in the standard message group compared with 4.8% in the tailored message (aRR, 3.41; 95% CI, 1.14-9.58) and 3.7% in the control groups (aRR, 4.84; 95% CI, 1.44-15.12). In this randomized clinical trial, outreach messages delivered via electronic health record patient portals increased the rates of scheduling and completing WCC visits and receiving the COVID-19 vaccine, providing a useful tool to help restore WCC in populations whose care was delayed during the pandemic. ClinicalTrials.gov Identifier: NCT04994691.

Electronic Health Record Patient Portal Use in Radiotherapy Treated Patients in the Era of COVID-19; Who's Getting Left Behind?

Purpose/Objective(s)COVID-19 has accelerated the utility of electronic health record (EHR) patient portal (PP) as a method for patients to communicate with oncology teams and improve the quality of care. This study examines the relationship between several sociodemographic characteristics with activation and use of PP system at an academic center by patients who underwent radiotherapy (RT). Use of PP among patients for up-to-date information on their care and to enhance their ability to manage their healthcare are linked with more favorable outcomes and quality of life. With the rapid integration of PP in oncologic management, differences in sociodemographic could account for disparities seen in PP use highlighting patients that should be receiving targeted efforts.Materials/MethodsEHR data were retrospectively analyzed regarding PP activation and use in all patients who underwent RT between the start of COVID-19 (March 2020) until February 2022 at an academic center. Summary statistics and odds ratios were used to examine the study cohort demographic characteristics regarding the outcome of PP activation.ResultsThere was a 10.4% increase in RT treated patients’ activation of PP from 69.8% before the COVID-19 pandemic (November 2017-March 2020) to 80.2% after the start of the pandemic. Concurrently, telemedicine use (requiring PP activation) among patients increased from 0.8% pre-pandemic to 40.2%. During the study period of interest, PP activation rate was 84.3% among White patients, 67.8% in Black/African American, 76.5% in Asians; 82.9% activation rate in Hispanics compared to 76.2% in non-Hispanics. Non-Hispanic White female was the group most likely to activate PP (OR 2.2; 95% CI 1.7-2.8), whereas non-Hispanic Black male was the least likely (OR 0.5; 95% CI 0.3-0.7). English speakers were significantly more likely to activate their PP (OR 3.7; 95% CI 2.1-6.5) compared to non-English speakers (OR 0.3; 95% CI 0.1-0.5). The highest activated PP by age range was amongst 20-30 years old (89.6%). PP activation was slightly lower in ages 30-40 (80.7%), and then recovered to 85.9% in 40-50 years old, after which there was a gradual decrease each subsequent decade reaching a low of 75.8% in ≥ 80 years. Breast cancer had the highest activation rate (92.7%) followed by head and neck (84%), prostate (81.3%), and lung cancer (66.5%). Married or divorced patients in comparison to single or widowed were more likely to activate PP. There was no correlation with having activated PP with a “no show” status for RT treatment.ConclusionOverall, activation of PP has increased in RT treated patients since the start of the pandemic. There are disparities in respect to race, speaking English, sex, and age. At the time of this study, the PP system was only available in English. The lower rate of activation identified in specific sex, race and age should prompt exploration of creative opportunities to increase patient activation and engagement in populations facing health disparities.

Using a patient portal as a recruitment tool to diversify the pool of participants in COVID-19 vaccine clinical trials.

The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected racial/ethnic minorities in the United States, who are underrepresented in clinical trials. We assessed the feasibility of using the University of Pennsylvania Health System electronic health record patient portal to diversify the pool of participants in COVID-19 vaccine clinical trials. The patient portal was used to send invitations to eligible individuals living in zip codes with high rates of racial/ethnic minorities. The 5614 invited consisted of 96.7% black, 1.3% Hispanic/Latinx, and 1.5% white. The overall response rate was 5.4%, with lower response rates among Black (3.8%) and Hispanic/Latinx (9.6%) as compared to white individuals (91.6%). Among respondents, black individuals had lower rates of interest in participating (26.7%), as compared to white (65.8%) and Hispanic/Latinx (71.4%) individuals. Of 115 respondents who expressed interest, 9 enrolled in the clinical trial, which included 6 black, 3 white, and 1 Hispanic/Latinx. During phone outreach to nonresponders and decliners, common reasons for declining included mistrust of the COVID-19 vaccine, underlying health conditions, and logistical barriers to trial participation. Because of low rates of patient portal account activation and use, compounded with vaccine hesitancy, this method yielded a small number of interested individuals.

S255 Assessing the Impact of a Multi-Component Health System Intervention to Address Low Colorectal Cancer Screening Participation in Patients With a Family History of Colorectal Cancer

Introduction: In the United States, 3-10% of individuals have a family history of colorectal cancer (CRC). Population health strategies to increase CRC screening often exclude these individuals, and interventions to increase screening participation in this high-risk group are rare. We designed and implemented a multi-component health system intervention to increase CRC screening uptake among individuals with a family history of CRC that were excluded from mailed fecal immunochemical test (FIT) outreach in our health system. Methods: The study was performed in a large academic medical center with biannual mailed FIT outreach for individuals at average-risk for CRC. We included patients who did not receive mailed FIT outreach in 2021 due to a family history of CRC. We excluded patients with a personal history of inflammatory bowel disease, colectomy, or CRC. The intervention included both primary care provider (PCP) and patient components. The PCP component was sent via the electronic health record (EHR) and included CRC screening guidelines for patients with a family history of CRC and a pended colonoscopy order for each patient overdue for screening. The patient component was delivered via the EHR patient portal and a mailed letter and included education about familial risk and colonoscopy, and a prompt to schedule a colonoscopy. Preliminary outcomes were measured 2-months post-intervention and were whether: (1) the PCP signed the pended colonoscopy order and (2) the patient scheduled colonoscopy. We used descriptive statistics to describe the study cohort and paired t-tests to compare the study outcomes pre- and post-intervention. The primary outcome of colonoscopy completion will be measured 6 months post-intervention. Results: 152 patients received the intervention. The mean age was 61.3 years (s.d 7.0), 32.9% were male, and 42.1% were non-Hispanic White (Table). Colonoscopy orders increased from 32 (21.1%) to 92 (60.5%) from pre- to post-intervention (p< 0.0001) (Figure). Colonoscopies scheduled increased from 0 to 9 (5.9%) (p=0.002). Conclusion: We designed and evaluated the preliminary results of a health system intervention that aims to increase screening participation among individuals with a family history of CRC. There was a significant increase in both colonoscopies ordered and colonoscopies scheduled. This study demonstrates a successful population health strategy to increase provider and patient intention to screen in this high-risk population.Figure 1.: Screening colonoscopies ordered and screening colonoscopies scheduled pre- intervention versus post- intervention, n= 152 Table 1. - Intervention population characteristics, n= 152 Patient Characteristic Study Population (n=152) Age [years, mean (SD)] 61.3 (7.0) Male Sex [n (%)] 50 (32.9) White Race [n (%)] 72 (47.4) Non-Hispanic Ethnicity [n (%)] 116 (76.3) Private Insurance [n (%)] 149 (98.0) Married [n (%)] 83 (54.6) English Language Preference [n (%)] 147 (96.7) Social Vulnerability Index [median (IQR)] 25.9 (11.8-47.8) Current or Former Tobacco Use Disorder [n (%)] 38 (25.0) Current or Former Alcohol Use Disorder [n (%)] 13 (8.6) Body Mass Index ≥ 25 [n (%)] 100 (66.2) Hemoglobin A1c ≥ 5.7 [n (%)] 75 (52.8) Family Members with Documented CRC [median (IQR)] 1 (1-1) 1st Degree Family Members with Documented CRC [median (IQR)] 1 (1-1) Years since Last PCP Visit [median (IQR)] 1.01 (0.75-1.62) Years since Last GI Visit [median (IQR)] 2.3 (2.5-9.2) Breast Cancer Screening Up-To-Date [n (%)] 47 (47) Cervical Cancer Screening Up-To-Date [n (%)] 61 (83.6)

Impact of patient portal-based self-scheduling of diagnostic imaging studies on health disparities.

While many case studies have described the implementation of self-scheduling tools, which allow patients to schedule visits and imaging studies asynchronously online, none have explored the impact of self-scheduling on equitable access to care.1 Using an electronic health record patient portal, University of California San Francisco deployed a self-scheduling tool that allowed patients to self-schedule diagnostic imaging studies. We analyzed electronic health record data for the imaging modalities with the option to be self-scheduled from January 1, 2021 to September 1, 2021. We used descriptive statistics to compare demographic characteristics and created a multivariable logistic regression model to identify predictors of patient self-scheduling utilization. Among all active patient portal users, Latinx, Black/African American, and non-English speaking patients were less likely to self-schedule studies. Patients with Medi-Cal, California's Medicaid program, and Medicare insurance were also less likely to self-schedule when compared with commercially insured patients. Efforts to facilitate use of patient portal-based applications are necessary to increase equitability and decrease disparities in access.

Quality measures for the care of adult patients with obstructive sleep apnea: 2022 update after measure maintenance.

Lloyd R, Morgenthaler TI, Donald R, etal. Quality measures for the care of adult patients with obstructive sleep apnea: 2022 update after measure maintenance. J Clin Sleep Med. 2022;18(11):2673-2680.

QOL-09. SyMon-SAYS: A symptom monitoring and reporting program for children with cancer

Unrelieved symptom burden due to cancer treatments can lead to poor psychosocial functioning and decreased health-related quality of life (HRQOL) for patients and their families. Barriers at the patient, healthcare provider and system levels can contribute to poor symptom management. Funded by the US National Cancer Institute, we have developed the Symptom Monitoring & Systematic Assessment and Reporting System in Young Survivors (SyMon-SAYS) program. SyMon-SAYS is a technology-based program with the potential to minimize symptom management barriers by routinely collecting and interpreting patient-reported outcomes in pediatric oncology ambulatory settings in a manner that is efficient, actionable by clinicians, supports engagement of patients and families with their health and care, and improves clinical processes and outcomes. This is a single institution modified waitlist control 16-week randomized trial of 200 children (ages 8-17) with cancer and their parents/guardians. Participants in the intervention phase will complete a symptom checklist weekly via the electronic health record patient portal. Scores exceeding a pre-defined threshold will trigger an alert to the treatment team, which will review the report and take appropriate actions. Participants will complete a separate battery of questionnaires assessing HRQOL at baseline and weeks 8 and 16. The recruitment is in progress. As of today, we have recruited 57 patients/parents. 29 completed 16-week study (15 intervention & 14 wait-list). Preliminary results showed SyMon-SAYS system was easy (92%) and convenient (85%) to use. Parents were satisfied (74.1%) with the SyMon-SAYS program. Comparing to the waitlist control, intervention group parents reported significantly less concerns on not having enough time to discuss their child’s symptoms with treating clinicians (p=0.0022), and disagreed that it is not necessary to treat their child’s symptoms as they will go away (p=0.04). We anticipate completing the recruitment by the end of 2023.