Electronic Patient Portal Research Articles

Updates in digital shared care: Launching into the 21st century.

The recent Intergenerational Report (2023) highlighted that the Australian healthcare system will face increasing economic and logistical challenges, with projected growth in health spending due to an ageing population and an increasing number of chronic diseases. Shared care, amodel emphasising collaboration between nursing andallied health, general practice and specialist care providers, has emerged as one solution. This paper explores the contemporary shared care landscape in Australia, highlighting the digital transformation of healthcare, the adoption of eHealth technologies, and their impact on improving patient carecoordination. The roles of shared electronic health records, secure electronic communication and consultation, electronic patient portals and telehealth in enhancing healthcare accessibility and management of chronic diseases are individually explored. Infrastructure for future inter-electronic medical record integrations are then discussed. Innovative care models combining novel technology and shared care hold promise for more efficient, patient‑centric healthcare systems. Given Australia's unique healthcare challenges, it provides the ideal environment to lead the way in the digital transformation of shared care.

Implementation of an electronic patient portal in routine mental health care of hospitals in Germany – evaluation of attitudes of healthcare providers

BackgroundThe use of digital tools such as electronic patient portals in different health care disciplines and settings has been increasing, but the rate of implementation in clinical practice still lags behind expectations. While studies have linked the use of electronic patient portals to positive health outcomes for patients, studies addressing the viewpoints of healthcare providers are rare.MethodsWe performed an online survey of attitudes of healthcare providers towards an electronic patient portal for mental health hospitals. The portal was developed by five communal providers of mental health care in different regions in Germany. The survey was carried out during the early phase of implementation of the portal.ResultsTwenty project leaders and 37 clinicians from five different mental health hospitals answered the questionnaire (response rate: 45% and 28%). Overall, acceptance of online applications among respondents was high. The healthcare providers mentioned perceived benefits (e.g. accessibility of new patient groups, use of therapy-free periods) as well as a number of technical, structural, organizational and staffing barriers for successful implementation in hospital settings (e.g. workload of healthcare providers and lack of staff, limited digital competences, unstable WLAN).ConclusionThe perceived barriers and facilitators of the implementation of online applications and electronic patient portals in mental health hospitals identified by healthcare providers may be taken into account. Improving commitment of the healthcare providers to implementation and use of digital interventions may help foster digitalisation in mental health hospitals.

Association between food insecurity and healthcare utilization among patients at a breast oncology center.

143 Background: A breast cancer (BC) diagnosis often creates or exacerbates financial stress. As a result, many patients with BC struggle with a lack of consistent access to nutritious food due to limited resources, a condition termed “food insecurity” (FI). We investigated the association between FI and healthcare utilization among breast oncology patients at our urban academic medical center. Methods: Screening for health-related social needs (HRSN) was conducted primarily through the electronic patient portal, at appointment registration for a breast oncology clinic visit. The 8-item HRSN survey included 2 questions on access to food resources and 1 question quantifying emergency department (ED) visits over the past year. Any level of food hardship or concern constituted a positive FI screen. We conducted a retrospective analysis among patients evaluated between 11/2/22 and 4/20/24. Clinical and demographic data were obtained from the electronic health record (EHR). We evaluated the association between FI and health care utilization measures (ED visits, inpatient admissions) with a Pearson's Chi-squared test and univariate logistic regression. Results: A total of 2820 patients were screened for HRSN and provided responses to at least 1 FI question, of which 19.7% (555) reported some level of FI. Food-insecure patients self-reported significantly higher rates of ED visits in the past 12 months compared to food-secure patients: 43.2% vs 22.6% reported at least 1 ED visit, respectively (p<0.001), and 25.0% vs 8.45% reported multiple ED visits, respectively (p<0.001). Overall, FI was associated with 2.5 times the odds of self-reporting at least 1 ED visit (univariate OR 2.47, p<0.001). Similarly, on review of EHR data, 33.3% of food-insecure patients had at least 1 ED visit (vs 20.0% of food-secure patients, p<0.001), and 6.13% had 3 or more ED visits (vs 2.83%, p<0.001) during the study period. On univariate analysis, food-insecure patients had double the odds of having at least 1 ED visit documented in the EHR (univariate OR 2.00, p<0.001). We examined reasons for ED presentations among 186 food-insecure patients with ED visits during the study period, and found that 23.8% had at least 1 cancer-related complaint (oncological treatment-related (16.8%) and/or BC symptom-related (8.6%)). The incidence of inpatient admissions during the study period was similar among food-insecure vs food-secure patients (19.8% vs 18.4%, p=0.467). Conclusions: In this analysis of FI and health care delivery measures, ED utilization was significantly higher among food-insecure patients. A quarter of food-insecure patients who presented to the ED had oncological complaints. FI may be a marker of unmet healthcare needs in patient with cancer, and targeted interventions focused on symptom monitoring and management are warranted to optimize healthcare utilization.

Characterizing health-related social needs and their association with medication adherence in a diverse cohort of patients with breast cancer.

139 Background: Food insecurity, housing instability, and transportation challenges are modifiable health-related social needs (HRSN) that have been associated with worse health outcomes in patients with cancer. Nonadherence to medications is also associated with decreased survival and other poor outcomes. Less is known about the association between HRSN and medication adherence in this patient population. Methods: We implemented screening for HRSN among breast oncology patients at our urban academic medical center, primarily through the electronic patient portal. Patients were offered an 8-item HRSN survey with questions covering food insecurity, housing, transportation needs, and emergency department visits. Any level of food hardship, housing instability, or transportation challenges reported during the study period (11/2/22-4/20/24) constituted a positive screen for that HRSN. We also screened patients for nonadherence to medications (any medication) using the 3-item DOSE-Nonadherence questionnaire. Pearson's Chi-squared tests and univariate logistic regressions were used to compare differences between subsets. Results: During the 18-month study period, 2945 patients completed at least 1 item on the HRSN questionnaire, of which 765 (26.0%) screened positive for at least 1 HRSN. Among patients who responded to each HRSN domain, 555/2820 (19.7%) screened positive for food insecurity, 374/2650 (14.1%) for housing instability, and 255/2656 (9.6%) for transportation needs. Food-insecure patients also reported more housing (43.1% v 5.6%, p<0.001) and transportation needs (27.7% v 4.0%, p<0.001) compared to food-secure patients. When comparing the cohort of patients who screened positive for at least 1 HRSN vs those who screened negative, there was a higher proportion of Hispanics (55.3% vs 25.1%, p<0.001), non-Hispanic Blacks (15.3% v 10.0%, p<0.001), and Spanish speakers (41.2% v 17.2%, p<0.001). Patients with any HRSN were more likely to self-report medication nonadherence compared to those with a negative HRSN screen (44.2% v 35.3%, OR 1.45, 95% CI 1.18-1.79). When looking at each individual HRSN domain, food-insecure patients were more likely to self-report medication nonadherence than food-secure patients (45.9% v 35.9%, OR 1.51, CI 1.19-1.92); this was also true for patients with housing instability (45.7% v 36.4%, OR 1.47, CI 1.12-1.92) and transportation needs (49.1% v 36.5%, OR 1.68, CI 1.23-2.31). Conclusions: More than a quarter of breast cancer patients self-reported at least 1 HRSN, with food insecurity being most frequently reported. Patients with at least 1 HRSN had 45% increased odds of medication nonadherence. Further research is warranted to understand the financial, social, psychological, and healthcare-related factors that may underlie this association, and to design interventions targeting at-risk cancer populations.

Leveraging the electronic health record patient portal to enhance clinical trial recruitment.

387 Background: The increasing prevalence of video/remote visits in the clinical setting has posed researchers with unique challenges related to clinical trial recruitment. Without the ability to speak to potential participants face to face, researchers rely on making phone calls which are frequently screened, declined, or never returned. Patients contacted in this way may never access the trials and care opportunities available to them. Electronic health record (EHR) patient portals, such as MyChart (Epic), allow individuals to access their medical records and communicate with their providers via instant messaging. This EHR tool may offer researchers a new method of participant recruitment to clinical trials. Methods: An electronic report, built around the Five- or Ten-Year Colonoscopy Trial’s (FORTE/NRG-CC005) eligibility criteria, was used to identify potential study participants. The local research team then generated an investigator endorsed, IRB-approved introductory script to send to patients via the MyChart instant messaging function. Once delivered, the message status was monitored to determine whether the patient had opened/read the introductory message. Patients who responded and expressed interest in trial participation were then sent additional information through MyChart and asked to schedule a time to speak to research staff over the phone. Results: In the two years that the FORTE trial was opened at our institution (October 2021 to August 2023), prior to implementing this MyChart practice, the research team attempted to contact 108 eligible patients via outreach phone calls. Of the 108, only 10 were reached by the study team and 0 consented to the trial. Between August 2023 and May 2024, 28 eligible patients were sent the MyChart script resulting in a response rate of 85.7% (24/28). Of the respondents, 20.8% (5/24) declined participation and did not want additional study information; 41.7% (10/24) requested more information but later declined participation, and 37.5% (9/24) expressed interest in trial participation. To date, of these 9 interested patients, 4 have enrolled to FORTE, and 5 are in the screening process. Conclusions: Preliminary observations suggest that recruiting patients to clinical trials through an electronic health record portal is an effective tool for enhancing enrollment. Further research is warranted to prospectively evaluate this recruitment strategy.

Implementation of hereditary cancer risk assessment in primary care: Intervention strategies and proximal outcomes.

279 Background: Family history-based risk assessment for hereditary breast and ovarian cancer and Lynch syndrome is guideline recommended and has strong evidence supporting its implementation into clinical practice, especially primary care. Yet, adoption has been impeded by limited awareness of genetic evaluation guidelines among primary care providers (PCPs), time constraints in screening during appointments, and limited resources for follow-up within primary care. To close this gap, we implemented a hereditary cancer risk assessment program that addresses these barriers and evaluated proximal implementation outcomes. Methods: We used intervention mapping for adaptation (IM-Adapt), a modified version of Intervention Mapping to guide the adaptation and implementation of the evidence-based 7-question family history screening (FHS-7) at a primary care clinic within an academic medical center. FHS-7 was adapted for administration via electronic patient portal prior to PCP visit or in-person at PCP visit. All clinic patients were offered screening and follow-up genetic counseling and testing per guidelines. Administrative, programmatic, and electronic medical record data were analyzed for program evaluation. Results: Between February 2023 and March 2024, 4,540 primary care patients were offered hereditary cancer risk assessment and 3,497 (77%) completed screening. Patient portals were used to complete screening more frequently than in-person at the clinic (86.6% vs 13.4%). Among patients with qualifying family history of cancer (n=1,267, 36%), 1,117 (88%) were eligible for navigation as they completed their primary care appointment and did not undergo genetic counseling within the last 5 years. Of the eligible patients, 62% were successfully contacted by a navigator and offered genetic counseling. Program implementation was facilitated by key personnel (clinical champion, informatics staff, genetic patient navigator) and adaptations to fit the implementation setting (adapting FHS7 for patient self-report rather than administration by PCP, patient population with high patient-portal adoption rate and in-house genetic service resources). Conclusions: We demonstrate the feasibility of hereditary cancer risk assessment within primary care and describe actionable aspects of the implementation context that influence screening uptake that can be incorporated into the design of future implementation for maximum impact. Findings advance the state of science in identification of unaffected individuals with inherited cancer susceptibility and genetic service delivery.

Electronic Surgical Consent Delivery Via Patient Portal to Improve Perioperative Efficiency

Many health systems use electronic consent (eConsent) for surgery, but few have used surgical consent functionality in the patient portal (PP). Incorporating the PP into the consent process could potentially improve efficiency by letting patients independently review and sign their eConsent before the day of surgery. To evaluate the association of eConsent delivery via the PP with operational efficiency and patient engagement. This mixed-methods study consisted of a retrospective quantitative analysis (February 8 to August 8, 2023) and a qualitative analysis of semistructured patient interviews (December 1, 2023, to January 31, 2024) of adult surgical patients in a health system that implemented surgical eConsent. Statistical analysis was performed between September 1, 2023, and June 6, 2024. Patient demographics, efficiency metrics (first-start case delays), and PP access logs were analyzed from electronic health records. Qualitative outcomes included thematic analysis from semistructured patient interviews. In the PP-eligible cohort of 7672 unique patients, 8478 surgical eConsents were generated (median [IQR] age, 58 [43-70] years; 4611 [54.4%] women), of which 5318 (62.7%) were signed on hospital iPads and 3160 (37.3%) through the PP. For all adult patients who signed an eConsent using the PP, patients waited a median (IQR) of 105 (17-528) minutes to view their eConsent after it was electronically pushed to their PP. eConsents signed on the same day of surgery were associated with more first-start delays (odds ratio, 1.59; 95% CI, 1.37-1.83; P < .001). Themes that emerged from patient interviews included having a favorable experience with the PP, openness to eConsent, skimming the consent form, and the importance of the discussion with the surgeon. These findings suggest that eConsent incorporating PP functionality may reduce surgical delays and staff burden by allowing patients to review and sign before the day of surgery. Most patients spent minimal time engaging with their consent form, emphasizing the importance of surgeon-patient trust and an informed consent discussion. Additional studies are needed to understand patient perceptions of eConsent, PP, and barriers to increased uptake.

Using a Patient Portal to Screen Patients for Symptoms After Starting New Medications.

Conduct systematic proactive pharmacovigilance screening for symptoms patients experienced after starting new medications using an electronic patient portal. We aimed to design and test the feasibility of the system, measure patient response rates, provide any needed support for patients experiencing potentially drug-related problems, and describe types of symptoms and problems patients report. We created an automated daily report of all new prescriptions, excluding likely non-new and various over-the-counter meds, and sent invitations via patient portal inviting patients to inquire if they had started the medication, and if "yes," inquire if they had they experienced any new symptoms that could be potential adverse drug effects. Reported symptoms were classified by clinical pharmacists using SOC MeDra taxonomy, and patients were offered follow-up and support as desired and needed. Of 11,724 included prescriptions for 9360 unique patients, 2758 (29.4%) patients responded. Of 2616 unique medication starts, patients reported at least 1 new symptom that represented a potential adverse drug reaction (ADR) in 678/2616 (25.9%). Nearly one-third of those experiencing new symptoms (30.3%) reported 2 or more new symptoms after initiating the drug. GI disorders accounted for 30% of the total reported ADRs. Systematic portal-based surveillance for potential adverse drug reactions was feasible, had higher response rates than other methods (such as automated interactive phone calling), and uncovered rates of potential ADRs (roughly 1 in 4 patients) consistent with other methods/studies.

Enhancing the Management of Benign Prostatic Hyperplasia: The Role of Electronic Health Record Patient Portal Distribution of the International Prostate Symptom Score.

Recent AUA guidelines for the management of benign prostatic hyperplasia (BPH) recommend routine collection of the International Prostate Symptom Score (IPSS) data, but routine collection can be challenging to fully implement. We investigated the impact of distributing the IPSS by electronic patient portal (EPP) on IPSS completion and its impact on BPH management. We performed a retrospective, longitudinal study of men undergoing a new patient visit (NPV) for BPH at our academic medical center. From September 2019 to November 2022, we identified patients undergoing an NPV for BPH. Prior to January 2021, the IPSS was collected in person at NPVs via paper forms; afterwards, the IPSS was distributed before the NPV using the EPP. Our primary outcome was IPSS completion; secondary outcomes were new BPH medications and BPH surgery ordered within 6 months. We identified 485 patients who underwent an NPV for BPH. EPP implementation significantly increased IPSS questionnaire completion (36.5% vs 56.9%, P < .0001). Following EPP implementation, we found that new BPH medications ordered at time of NPV decreased (10.4% vs 4.7%, P = .02). Although BPH surgery ordered within 6 months was similar, patients following EPP implementation had shorter time to BPH surgery compared to prior. Our study revealed that EPP distribution of the IPSS improves IPSS collection compliance, aligning our practice closer with AUA guidelines. Routine collection of the IPSS may impact clinical practice through the detection of more severe BPH, which reduces medical BPH management and time to definitive BPH therapy. Further work is needed to confirm findings.

Implementing paper-based patient-reported outcome collection within outpatient integrative health and medicine.

To investigate the feasibility of pre- and post-encounter patient-reported outcome (PRO) measure collection within an outpatient integrative health and medicine (IHM) clinic and to characterize factors associated with successful completion. We conducted a retrospective review of 27,464 outpatient IHM encounters including 9,520 chiropractic; 8,237 acupuncture; 5,847 massage; 2,345 IHM consultation; and 1,515 osteopathic manipulation treatment encounters at four clinics offering IHM over 18 months. Patients were asked to complete paper questionnaires rating pain, anxiety, and stress from 0-10 immediately pre- and post-encounter. Generalized linear mixed effect regression models were used to examine the relationship between demographic, clinical, and operational covariates and completing (1) pre-encounter and (2) paired (i.e., pre and post) PROs. Patients (N = 5587, mean age 49 years, 74% white, 77% female) generally presented for musculoskeletal conditions (81.7%), with a chief complaint of pain (55.1%). 21,852 (79.6%) encounters were among patients who completed pre-encounter PROs; 11,709/21,852 (53.6%) completed subsequent post-encounter PROs. Odds of PRO completion were more impacted by provider, operational, and clinical-level factors than patient factors. Covariates associated with increased odds of pre-encounter PRO completion included being female, having additional IHM encounters, and having a pain or anxiety complaint. Covariates associated with increased odds of paired PRO completion included being aged 31-40 vs. 51-60 years and having additional IHM encounters. Implementing a paper-based PRO collection system in outpatient IHM is feasible; however, collecting post-encounter PROs was challenging. Future endeavors should leverage the electronic health record and patient portals to optimize PRO collection and engage patients and clinical providers.

Patient Perspectives on Portal-Based Anxiety and Depression Screening in HIV Care: A Qualitative Study Using the Consolidated Framework for Implementation Research.

Electronic patient portals represent a promising means of integrating mental health assessments into HIV care where anxiety and depression are highly prevalent. Patient attitudes toward portal-based mental health screening within HIV clinics have not been well described. The aim of this formative qualitative study is to characterize the patient-perceived facilitators and barriers to portal-based anxiety and depression screening within HIV care in order to inform implementation strategies for mental health screening. Twelve adult HIV clinic patients participated in semi-structured interviews that were audio recorded and transcribed. The transcripts were coded using constructs from the Consolidated Framework for Implementation Research and analyzed thematically to identify the barriers to and facilitators of portal-based anxiety and depression screening. Facilitators included an absence of alternative screening methods, an approachable design, perceived adaptability, high compatibility with HIV care, the potential for linkage to treatment, an increased self-awareness of mental health conditions, the ability to bundle screening with clinic visits, and communicating an action plan for results. The barriers included difficulty navigating the patient portal system, a lack of technical support, stigmatization from the healthcare system, care team response times, and the novelty of using patient portals for communication. The patients in the HIV clinic viewed the use of a portal-based anxiety and depression screening tool as highly compatible with routine HIV care. Technical difficulties, follow-up concerns, and a fear of stigmatization were commonly perceived as barriers to portal use. The results of this study can be used to inform implementation strategies when designing or incorporating portal-based mental health screening into other HIV care settings.

Abstract PO1-10-03: Prevalence of and Factors Associated with Food Insecurity and Other Adverse Social Determinants of Health Among Breast Oncology Patients

Abstract Background: Social determinants of health (SDOH), the non-medical factors that influence health status, have a profound impact on breast cancer (BC) outcomes and contribute to survival disparities. Food insecurity (FI), defined as a lack of consistent access to adequate food resources, is a modifiable SDOH associated with treatment disruptions, medication nonadherence, and decreased quality of life. To identify at-risk patients and inform future interventions, we implemented SDOH screening of patients seen in breast oncology clinic at our urban academic medical center. Methods: Screening was conducted through an 8-item questionnaire on the electronic patient portal. The questions covered FI, housing and transportation challenges, and emergency department (ED) visits. We conducted a retrospective analysis of SDOH data collected among patients scheduled for a breast oncology appointment between 11/1/22 and 5/25/23. Any level of food hardship or concern constituted a positive FI screen. Descriptive statistics were used to determine the prevalence of FI and other SDOH, to assess differences in FI rates by age, race/ethnicity, and clinical stage, and to compare characteristics of food-insecure vs food-secure patients. We also conducted a multivariable logistic regression analysis to estimate the odds ratio (OR) and 95% confidence interval (CI) associated with sociodemographic/clinical factors and FI. Results: A total of 2,585 patients were seen in our breast oncology practice, of which 1,189 (46.0%) were screened for SDOH, including 41.2% non-Hispanic White (NHW), 9.6% non-Hispanic Black (NHB) and 21.0% Hispanic patients. Among patients who responded to each SDOH question, 15.5% (146/940) reported some level of FI; 8.7% (84/962) were unable to pay their rent or mortgage on time; for 5.8% (57/989), lack of transportation interfered with their treatment. The FI rate differed significantly by race and ethnicity: 4.5% of NHW, 15.2% of NHB, and 41.8% of Hispanic patients reported FI (p&amp;lt; 0.001). In multivariable analysis, NHB and Hispanic patients also had significantly higher odds of FI compared to NHW patients (OR=3.68, 95% CI=1.7-7.7, p&amp;lt; 0.001 for NHB and OR=15.0, 95% CI=8.8-27.1, p&amp;lt; 0.001 for Hispanic patients). Patients with metastatic disease had higher rates of FI compared to other breast oncology patients (23.6% vs 14.8%, p=0.048), and a metastatic BC diagnosis was associated with over twice the odds of FI (OR=2.18, 95% CI=1.1-4.2, p=0.02). Among food-insecure patients, 41.1% were unable to pay their rent or mortgage on time and 22.6% reported transportation difficulties interfering with treatment (vs 2.6% and 2.4%, respectively, for food-secure patients (p&amp;lt; 0.001)). Compared to food-secure patients, those who were food-insecure had significantly higher rates of self-reported ED visits in the past 12 months: 18.8% vs. 33.6% reported at least 1 ED visit, respectively, and 5.2% vs. 16.4% reported multiple ED visits, respectively (p&amp;lt; 0.001). Conclusions: In this analysis of SDOH data among patients seen in breast oncology clinic, FI was the most common social health risk reported, with nearly a quarter of patients with metastatic BC reporting FI. Racial/ethnic minorities were also at considerably higher risk for FI. ED utilization was significantly higher among food-insecure patients. Targeted interventions to reduce FI in at-risk populations are warranted to improve clinical and healthcare utilization outcomes. Sociodemographic and Clinical Characteristics and Other Reported Social Determinants of Health Among Food-Secure vs Food-Insecure Patients Citation Format: Claire Sathe, David DeStephano, Anita Gul, Melissa Beauchemin, Justine Kahn, Melissa Accordino, Katherine Crew, Ngozika Emezienna, Dawn Hershman. Prevalence of and Factors Associated with Food Insecurity and Other Adverse Social Determinants of Health Among Breast Oncology Patients [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-10-03.

Clinician and staff experiences with frustrated patients during an electronic health record transition: a qualitative case study

BackgroundElectronic health record (EHR) transitions are known to be highly disruptive, can drastically impact clinician and staff experiences, and may influence patients’ experiences using the electronic patient portal. Clinicians and staff can gain insights into patient experiences and be influenced by what they see and hear from patients. Through the lens of an emergency preparedness framework, we examined clinician and staff reactions to and perceptions of their patients’ experiences with the portal during an EHR transition at the Department of Veterans Affairs (VA).MethodsThis qualitative case study was situated within a larger multi-methods evaluation of the EHR transition. We conducted a total of 122 interviews with 30 clinicians and staff across disciplines at the initial VA EHR transition site before, immediately after, and up to 12 months after go-live (September 2020-November 2021). Interview transcripts were coded using a priori and emergent codes. The coded text segments relevant to patient experience and clinician interactions with patients were extracted and analyzed to identify themes. For each theme, recommendations were defined based on each stage of an emergency preparedness framework (mitigate, prepare, respond, recover).ResultsIn post-go-live interviews participants expressed concerns about the reliability of communicating with their patients via secure messaging within the new EHR portal. Participants felt ill-equipped to field patients’ questions and frustrations navigating the new portal. Participants learned that patients experienced difficulties learning to use and accessing the portal; when unsuccessful, some had difficulties obtaining medication refills via the portal and used the call center as an alternative. However, long telephone wait times provoked patients to walk into the clinic for care, often frustrated and without an appointment. Patients needing increased in-person attention heightened participants’ daily workload and their concern for patients’ well-being. Recommendations for each theme fit within a stage of the emergency preparedness framework.ConclusionsApplication of an emergency preparedness framework to EHR transitions could help address the concerns raised by the participants, (1) mitigating disruptions by identifying at-risk patients before the transition, (2) preparing end-users by disseminating patient-centered informational resources, (3) responding by building capacity for disrupted services, and (4) recovering by monitoring integrity of the new portal function.

Cancer care coordination in rural Hawaii: a focus group study

BackgroundRural populations consistently experience a disproportionate burden of cancer, including higher incidence and mortality rates, compared to the urban populations. Factors that are thought to contribute to these disparities include limited or lack of access to care and challenges with care coordination (CC). In Hawaii, many patients residing in rural areas experience unique challenges with CC as they require inter-island travel for their cancer treatment. In this focus group study, we explored the specific challenges and positive experiences that impact the CC in rural Hawaii cancer patients.MethodsWe conducted two semi-structured focus group interviews with cancer patients receiving active treatment for any type of cancer (n = 8). The participants were recruited from the rural areas of Hawaii, specifically the Hawaii county and Kauai. Rural was defined using the Rural-Urban Commuting Area Codes (RUCA; rural ≥ 4). The focus group discussions were facilitated using open-ended questions to explore patients’ experiences with CC.ResultsContent analysis revealed that 47% of the discussions were related to CC-related challenges, including access to care (27.3%), insurance (9.1%), inter-island travel (6.1%), and medical literacy (4.5%). Other major themes from the discussions focused on facilitators of CC (30.3%), including the use of electronic patient portal (12.1%), team-based approach (9.1%), family caregiver support (4.5%), and local clinic staff (4.5%).ConclusionOur findings indicate that there are notable challenges in rural patients’ experiences regarding their cancer care coordination. Specific factors such as the lack of oncologist and oncology services, fragmented system, and the lack of local general medical providers contribute to problems with access to care. However, there are also positive factors found through the help of facilitators of CC, notability the use of electronic patient portal, team-based approach, family caregiver support, and local clinic staff. These findings highlight potential targets of interventions to improve cancer care delivery for rural patients.Trial RegistrationNot required.

Post-operative Patient Portal Messaging is Associated With Return to the Emergency Department After Lumbar Spine Surgery.

Retrospective study. To explore the association between patients undergoing lumbar spine surgery who message their care team via an electronic patient portal (EPP) post-operatively and emergency department (ED) visits within 90 days of surgery. Secure patient messaging through electronic patient portals has grown over recent years. Despite its frequent utilization by patients to engage with their care team, its association with clinical outcomes remains unknown in spine surgery. This study was approved by our Institutional Review Board. Inclusion criteria were adults who underwent single-stage lumbar spine surgery between January 2016-June 2023. Patients with incomplete information, multi-stage surgeries, and those who died within 90 days of surgery were excluded. Patient sociodemographic, surgical, hospital readmission, and patient-provider engagement data were collected. A total of 13,135 patients were included. A total of 1,711 patients (13%) had a post-operative ED visit, and 4,791 patients (36%) used the patient portal to send a message after surgery. Sending a post-operative patient message after undergoing lumbar spine surgery was associated with an increased likelihood of having an ED visit that does not lead to readmission (1.29 (1.10-1.53), P = 0.002). Patients with high school degrees were more likely to have an ED visit without readmission (1.33 (1.08-1.65), P = 0.008). Patients at a higher risk of presenting to the ED post-operatively should be identified and may benefit from additional counseling and access to the care team virtually to limit unnecessary healthcare utilization. Focusing on patients who reach out via EPP messaging post-operatively may be a good target patient group to address first. Future research is needed to investigate the possible health literacy and other socioeconomic barriers affecting these patients so that appropriate, more cost-effective resources can be utilized to avoid clinically unnecessary and costly ED visits.

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.

Implementing a Clinical Decision Support Tool to Improve Physical Activity.

Currently, only about half of U.S. adults achieve current physical activity guidelines. Routine physical activity is not regularly assessed, nor are patients routinely counseled by their healthcare provider on achieving recommended levels. The three-question physical activity vital sign (PAVS) was developed to assess physical activity duration and intensity and identify adults not meeting physical activity guidelines. Clinical decision support provided via a best practice advisory in an electronic health record (EHR) system can be triggered as a prompt, reminding healthcare providers to implement the best practice intervention when appropriate. Remote patient monitoring of physical activity can provide objective data in the EHR. This study aimed to evaluate the feasibility and clinical utility of embedding the PAVS and a triggered best practice advisor into the EHR in an ambulatory preventive cardiology practice setting to alert providers to patients reporting low physical activity and prompt healthcare providers to counsel these patients as needed. Three components based in the EHR were integrated for the purpose of this study: Patients completed the PAVS through their electronic patient portal prior to an office visit, a best practice advisory was created to prompt providers to counsel patients who reported low levels of physical activity, and remote patient monitoring via Fitbit synced to the EHR provided objective physical activity data. The intervention was pilot-tested in the Epic EHR for 1 year (July 1, 2021 to June 30, 2022). Qualitative feedback on the intervention from both providers and patients was obtained at the completion of the study. Monthly assessments of the use of the PAVS and best practice advisory and remote patient monitoring were completed. Patients' completion of the PAVS varied from 35% to 48% per month. The best practice advisory was signed by providers between 2% and 65% and was acknowledged by 2%-22% per month. The majority (58%) of patients were able to sync a Fitbit device to their EHR for remote monitoring. Although uptake of each component needs improvement, this pilot demonstrated the feasibility of incorporating a physical activity promotion intervention into the EHR. Qualitative feedback provided guidance for future implementation.

Self-Efficacy in Patients With Hypertension and Their Perceived Usage of Patient Portals.

Self-efficacy in individuals optimizes their hypertension management. Electronic patient portals are being increasingly used to support chronic disease management, as they raise the health literacy of patients and enable them in self-management. However, the association between the use of patient portals and self-efficacy in hypertension management remains unclear. The study aimed to determine the association between self-efficacy among patients with hypertension who are managed in primary care and their demographic characteristics and usage patterns of patient portals. A cross-sectional survey was conducted at a public primary care clinic in urban Singapore. Multi-ethnic adult patients with hypertension were invited to participate in a self-administered electronic questionnaire. Chi-square test was performed for bivariate analysis; adjusted logistic regression models were used for factors with P value <.1. A total of 310 patients (66.8% Chinese, 55.5% males, mean age of 63.1 years) completed the survey. Patient portal users had higher self-efficacy scores than non-users (mean score=63 vs 60, maximum = 80, P = .011). The factors associated with increased patient portal access included younger age <65 years (absolute odds ratio [AOR] = 2.634, 95%CI = 1.432-4.847; P = .002), monthly income >$5000 (AOR = 2.324, 95%CI = 1.104-4.892; P = .026), and post-secondary education level (AOR = 3.128, 95%CI = 1.675-5.839; P < .001). Most patients (93.1%) used the portal to check medical appointments but only1.3% of them used it to record home blood pressure measurements (HBPM). Patient portal usage was associated with higher self-efficacy scores in patients with hypertension. These users were younger, more educated, and earned more than the non-users, but only 1.3% of them used it for HBPM documentation.

Effect of a Telehealth Navigator Program on Video Visit Scheduling and Completion in Primary Care.

Patients and clinicians face challenges in participating in video telehealth visits. Patient navigation has been effective in other settings in enhancing patients' engagement with clinical programs. Our objective was to assess whether implementing a telehealth navigator program to support patients and clinicians affected video visit scheduling, video usage, and non-attendance. This was a quasi-experimental quality improvement project using difference-in-differences. We included data from 17 adult primary care sites at a large, urban public healthcare system from October 1, 2021 to October 31, 2022. Six sites received telehealth navigators and 11 sites were used as comparators. Navigators contacted patients (by phone) with upcoming video visits to assess and address potential barriers to successful video visit completion. They also provided on-site support to patients and clinicians regarding telehealth visits and usage of an electronic patient portal. The primary outcomes were difference-in-differences for the proportion of telehealth visits scheduled and, separately, completed as video visits and non-attendance for visits scheduled as video visits. There were 65 488 and 71 504 scheduled telehealth appointments at intervention and non-intervention sites, respectively. The adjusted difference-in-differences for the proportion of telehealth visits scheduled as video was -9.1% [95% confidence interval -26.1%, 8.0%], the proportion of telehealth visits completed as video visits 1.3% [-4.9%, 7.4%], and non-attendance for visits scheduled as video visits -3.7% [-6.0%, -1.4%]. Sites with telehealth navigators had comparatively lower video visit non-attendance but did not have comparatively different video visit scheduling or completion rates. Despite this, navigators' on-the-ground presence can help identify opportunities for improvements in care design.