Patient Portal Research Articles

Patient and family engagement in patient safety practices: A Making Healthcare Safer rapid response review

Background Patient and family engagement (PFE) is a developing area in reducing patient harm. This review addresses two questions: 1) What PFE patient safety practices (PSPs) have been used to prevent, report, or mitigate harms to patients and in what settings have they been used? 2) What evidence of effectiveness and unintended effects of PFE PSPs has been published since the Making Healthcare Safer (MHS) III report? Methods We searched PubMed and the Cochrane Library for studies published between January 2019 and April 2023. We included reviews of and primary studies on safety, quality, or utilization outcomes associated with any intervention focused on PFE in reporting and/or reducing patient safety events and harms. Results We retrieved 768 citations and found one systematic review and five studies meeting the inclusion criteria. The studies were either multi-component patient fall interventions or patient portals and information tools. Patient fall intervention PFE PSPs demonstrated significant decreases in overall rate of fall (15%–71% reductions) and fall with injury (34%–67% reductions) across three studies and a 17% decrease in the hospital length of stay in one study. Across three studies employing portals and information tools, PFE PSPs facilitated the identification of errors and significantly decreased the hospital length of stay and readmissions. Conclusions Research on PFE PSPs provides emerging evidence of the effectiveness of including PFE as a component of interventions targeting specific preventable harms. More research is needed to support the measurement of and better determine the overall effectiveness of a broader implementation of PFE PSPs.

Optimizing Word Embeddings for Patient Portal Message Datasets with a Small Number of Samples.

Patient portal messages often relate to specific clinical phenomena (e.g., patients undergoing treatment for breast cancer) and, as a result, have received increasing attention in biomedical research. These messages require natural language processing and, while word embedding models, such as word2vec, have the potential to extract meaningful signals from text, they are not readily applicable to patient portal messages. This is because embedding models typically require millions of training samples to sufficiently represent semantics, while the volume of patient portal messages associated with a particular clinical phenomenon is often relatively small. We introduce a novel adaptation of the word2vec model, PK-word2vec, for small-scale messages. PK-word2vec incorporates the most similar terms for medical words (including problems, treatments, and tests) and non-medical words from two pre-trained embedding models as prior knowledge to improve the training process. We applied PK-word2vec on patient portal messages in the Vanderbilt University Medical Center electric health record system sent by patients diagnosed with breast cancer from December 2004 to November 2017. We evaluated the model through a set of 1000 tasks, each of which compared the relevance of a given word to a group of the five most similar words generated by PK-word2vec and a group of the five most similar words generated by the standard word2vec model. We recruited 200 Amazon Mechanical Turk (AMT) workers and 7 medical students to perform the tasks. The dataset was composed of 1,389 patient records and included 137,554 messages with 10,683 unique words. Prior knowledge was available for 7,981 non-medical and 1,116 medical words. In over 90% of the tasks, both reviewers indicated PK-word2vec generated more similar words than standard word2vec (p=0.01).The difference in the evaluation by AMT workers versus medical students was negligible for all comparisons of tasks' choices between the two groups of reviewers (p = 0.774 under a paired t-test). PK-word2vec can effectively learn word representations from a small message corpus, marking a significant advancement in processing patient portal messages.

Forgotten clientele: A systematic review of patient-centered pathology reports.

Patient portals, designed to give ready access to medical records, have led to important improvements in patient care. However, there is a downside: much of the information available on portals is not designed for lay people. Pathology reports are no exception. Access to complex reports often leaves patients confused, concerned and stressed. We conducted a systematic review to explore recommendations and guidelines designed to promote a patient centered approach to pathology reporting. In consultation with a research librarian, a search strategy was developed to identify literature regarding patient-centered pathology reports (PCPR). Terms such as "pathology reports," "patient-centered," and "lay-terms" were used. The PubMed, Embase and Scopus databases were searched during the first quarter of 2023. Studies were included if they were original research and in English, without date restrictions. Of 1,053 articles identified, 17 underwent a full-text review. Only 5 studies (≈0.5%) met eligibility criteria: two randomized trials; two qualitative studies; a patient survey of perceived utility of potential interventions. A major theme that emerged from the patient survey/qualitative studies is the need for pathology reports to be in simple, non-medical language. Major themes of the quantitative studies were that patients preferred PCPRs, and patients who received PCPRs knew and recalled their cancer stage/grade better than the control group. Pathology reports play a vital role in the decision-making process for patient care. Yet, they are beyond the comprehension of most patients. No framework or guidelines exist for generating reports that deploy accessible language. PCPRs should be a focus of future interventions to improve patient care.

Willingness to be contacted via the patient portal for health screening, research recruitment, and at home self-test kits for health monitoring: A Pilot Quantitative Survey (Preprint)

Willingness to be contacted via the patient portal for health screening, research recruitment, and at home self-test kits for health monitoring: A Pilot Quantitative Survey (Preprint)

Real-Time Electronic Patient Portal Use Among Emergency Department Patients

Patients with inequitable access to patient portals frequently present to emergency departments (EDs) for care. Little is known about portal use patterns among ED patients. To describe real-time patient portal usage trends among ED patients and compare demographic and clinical characteristics between portal users and nonusers. In this cross-sectional study of 12 teaching and 24 academic-affiliated EDs from 8 health systems in California, Connecticut, Massachusetts, Ohio, Tennessee, Texas, and Washington, patient portal access and usage data were evaluated for all ED patients 18 years or older between April 5, 2021, and April 4, 2022. Use of the patient portal during ED visit. The primary outcomes were the weekly proportions of ED patients who logged into the portal, viewed test results, and viewed clinical notes in real time. Pooled random-effects models were used to evaluate temporal trends and demographic and clinical characteristics associated with real-time portal use. The study included 1 280 924 unique patient encounters (53.5% female; 0.6% American Indian or Alaska Native, 3.7% Asian, 18.0% Black, 10.7% Hispanic, 0.4% Native Hawaiian or Pacific Islander, 66.5% White, 10.0% other race, and 4.0% with missing race or ethnicity; 91.2% English-speaking patients; mean [SD] age, 51.9 [19.2] years). During the study, 17.4% of patients logged into the portal while in the ED, whereas 14.1% viewed test results and 2.5% viewed clinical notes. The odds of accessing the portal (odds ratio [OR], 1.36; 95% CI, 1.19-1.56), viewing test results (OR, 1.63; 95% CI, 1.30-2.04), and viewing clinical notes (OR, 1.60; 95% CI, 1.19-2.15) were higher at the end of the study vs the beginning. Patients with active portal accounts at ED arrival had a higher odds of logging into the portal (OR, 17.73; 95% CI, 9.37-33.56), viewing test results (OR, 18.50; 95% CI, 9.62-35.57), and viewing clinical notes (OR, 18.40; 95% CI, 10.31-32.86). Patients who were male, Black, or without commercial insurance had lower odds of logging into the portal, viewing results, and viewing clinical notes. These findings suggest that real-time patient portal use during ED encounters has increased over time, but disparities exist in portal access that mirror trends in portal usage more generally. Given emergency medicine's role in caring for medically underserved patients, there are opportunities for EDs to enroll and train patients in using patient portals to promote engagement during and after their visits.

Abstract PO2-12-09: Insomnia, Pain, Anxiety, Distress, Fatigue, and Functional Impairment in Patients with Breast Cancer

Abstract Background: SPPADE symptoms (Sleep disturbance, Pain, Physical function impairment, Anxiety, Depression/distress, and Energy deficits/fatigue) may result from cancer and its treatment. The aim of this analysis was to characterize SPPADE symptoms in patients with breast cancer. Methods. SPPADE data were drawn from the Enhanced, EHR-facilitated Cancer Symptom Control (E2C2) study, a stepped-wedge pragmatic cluster-randomized trial designed to evaluate a symptom management intervention in routine practice (NCT03892967). Symptom severity was measured on a 0-10 scale via a survey administered by patient portal, in-clinic tablet, or interactive voice response system (by phone) prior to, during, or soon after an outpatient oncology encounter. Scores of 4-6 were categorized as “moderate” and ≥7 as “severe.” In this analysis, only the data from each patient’s initial survey were included. Results. A total of 9,651 patients with breast cancer completed an initial E2C2 survey between March 2019 and January 2023. The proportion of patients with moderate or severe SPPADE symptoms were as follows: 22% moderate and 10% severe for insomnia; 18% moderate and 7% severe for pain; 17% moderate and 7% severe for anxiety; 15% moderate and 5% severe for emotional distress; 25% moderate and 12% severe for fatigue; and 22% moderate and 8% severe for impaired physical function. Table 1 presents score means and standard deviations by demographic subgroup. Conclusions. SPPADE symptoms are common in patients with breast cancer. These observations warrant routine implementation of symptom surveillance and management in breast oncology. Funding acknowledgement: The Improving the Management of symPtoms during And following Cancer Treatment (IMPACT) Consortium is a Cancer Moonshot Research Initiative under the authorization of the 2016 United States 21st Century Cures Act. This research was supported by the National Cancer Institute of the NIH, UM1CA233033 (Mayo Clinic, Rochester, MN). Insomnia, Pain, Anxiety, Distress, Fatigue, and Functional Impairment in Patients with Breast Cancer Citation Format: Kathryn Ruddy, Veronica Grzegorczyk, Deirdre Pachman, Sandra Mitchell, Bolun Liu, Deanne Smith, Ciara O'Sullivan, Shawna Ehlers, Jeph Herrin, Parvez Rahman, Andrea Cheville. Insomnia, Pain, Anxiety, Distress, Fatigue, and Functional Impairment in Patients with Breast Cancer [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 PO2-12-09.

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< 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< 0.001 for NHB and OR=15.0, 95% CI=8.8-27.1, p< 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< 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< 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.

Association of Patient Portal Messaging with Survival Among Radiation Oncology Patients

The shift to electronic health records has led to both patient portal messaging and large amounts of digital, real-world data for research. The objective of this study was to examine the association between portal messaging and survival among radiation oncology patients, using real-world data. This retrospective cohort study included patients at least 21 years old and seen by radiation oncology providers between January 14, 2014, and April 23, 2023, at the University of California, San Francisco. We developed Cox proportional hazards models for the outcome of death and examined factors associated with portal messaging using logistic regression models. Among 25,367 patients, the median age was 64 (interquartile range [IR], 54-72), 13,175 (52%) were White, and 14,389 (57%) were male. Overall, as the first message in a thread, 8986 (35%) patients sent messages to radiation oncology providers, and 4218 (17%) patients were sent messages from radiation oncology providers. Patients with head and neck or genitourinary malignancies were more likely than those with other diagnoses to send portal messages to and be sent portal messages from radiation oncology providers. Both sending portal messages to radiation oncology providers (hazard ratio [HR], 0.90; 95% confidence interval [CI], 0.84-0.96; P = .001) and being sent messages from radiation oncology providers (HR, 0.77; CI, 0.70-0.84; P < .001) as the first message in a thread were associated with patient survival after adjusting for socioeconomic, disease, and treatment characteristics. There were disparities among patients sending portal messages to radiation oncology providers, including for Black versus White patients (odds ratio [OR], 0.60; CI, 0.51-0.69; P < .001) and for Medicaid versus Medicare patients (OR, 0.70; CI, 0.62-0.79; P < .001). There were also disparities among patients being sent portal messages by radiation oncology providers, including for Black versus White patients (OR, 0.77; CI, 0.64-0.91; P = .003), for Medicaid versus Medicare patients (OR, 0.76; CI, 0.65-0.89; P < .001), and for patients with female versus male providers (OR, 1.47; CI 1.34-1.62; P < .001). Sending portal messages to and being sent portal messages from radiation oncology providers were associated with better survival. Future studies should elucidate how best to support patient and provider engagement.

Use of Electronic Patient Messaging by Pregnant Patients Receiving Prenatal Care at an Academic Health System: Retrospective Cohort Study.

The COVID-19 pandemic accelerated telemedicine and mobile app use, potentially changing our historic model of maternity care. MyChart is a widely adopted mobile app used in health care settings specifically for its role in facilitating communication between health care providers and patients with its messaging function in a secure patient portal. However, previous studies analyzing portal use in obstetric populations have demonstrated significant sociodemographic disparities in portal enrollment and messaging, specifically showing that patients who have a low income and are non-Hispanic Black, Hispanic, and uninsured are less likely to use patient portals. The study aimed to estimate changes in patient portal use and intensity in prenatal care before and during the pandemic period and to identify sociodemographic and clinical disparities that continued during the pandemic. This retrospective cohort study used electronic medical record (EMR) and administrative data from our health system's Enterprise Data Warehouse. Records were obtained for the first pregnancy episode of all patients who received antenatal care at 8 academically affiliated practices and delivered at a large urban academic medical center from January 1, 2018, to July 22, 2021, in Chicago, Illinois. All patients were aged 18 years or older and attended ≥3 clinical encounters during pregnancy at the practices that used the EMR portal. Patients were categorized by the number of secure messages sent during pregnancy as nonusers or as infrequent (≤5 messages), moderate (6-14 messages), or frequent (≥15 messages) users. Monthly portal use and intensity rates were computed over 43 months from 2018 to 2021 before, during, and after the COVID-19 pandemic shutdown. A logistic regression model was estimated to identify patient sociodemographic and clinical subgroups with the highest portal nonuse. Among 12,380 patients, 2681 (21.7%) never used the portal, and 2680 (21.6%), 3754 (30.3%), and 3265 (26.4%) were infrequent, moderate, and frequent users, respectively. Portal use and intensity increased significantly over the study period, particularly after the pandemic. The number of nonusing patients decreased between 2018 and 2021, from 996 of 3522 (28.3%) in 2018 to only 227 of 1743 (13%) in the first 7 months of 2021. Conversely, the number of patients with 15 or more messages doubled, from 642 of 3522 (18.2%) in 2018 to 654 of 1743 (37.5%) in 2021. The youngest patients, non-Hispanic Black and Hispanic patients, and, particularly, non-English-speaking patients had significantly higher odds of continued nonuse. Patients with preexisting comorbidities, hypertensive disorders of pregnancy, diabetes, and a history of mental health conditions were all significantly associated with higher portal use and intensity. Reducing disparities in messaging use will require outreach and assistance to low-use patient groups, including education addressing health literacy and encouraging appropriate and effective use of messaging.

Pediatric Clinical Staff Perspectives on Secure Messaging.

Secure messaging (SM) is a communication feature within a patient portal that allows patients and clinical staff to exchange health-related information securely and confidentially. This study aimed to explore how pediatric clinical staff use SM, identify challenges in its implementation, and suggest quality improvements. A descriptive quantitative study was administered using an online survey in a large health care system. The Task, User, Representation, and Function framework guided the research. The survey participants were moderately satisfied with the SM. Opportunities to design this system to be more efficient and maximize patient safety were identified. Improving training and workflow can aid in incorporating SM into clinician's daily routines, focusing on enhancing user satisfaction. Future developments aimed at increasing usage and standardizing message content are crucial for encouraging adoption and ensuring patient safety.

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.

Minors’ and guardian access to and use of a national patient portal: A retrospective comparative case study of Sweden and Finland

BackgroundApproaches to implementing online record access (ORA) via patient portals for minors and guardians vary internationally, as more countries continue to develop patient-accessible electronic health records (PAEHR) systems. Evidence of ORA usage and country-specific practices to allow or block minors’ and guardians’ access to minors’ records during adolescence (i.e. access control practices) may provide a broader understanding of possible approaches and their implications for minors' confidentiality and guardian support. AimTo describe and compare minors’ and guardian proxy users’ PAEHR usage in Sweden and Finland. Furthermore, to investigate the use of country-specific access control practices. MethodsA retrospective, observational case study was conducted. Data were collected from PAEHR administration services in Sweden and Finland and proportional use was calculated based on population statistics. Descriptive statistics were used to analyze the results. ResultsIn both Sweden and Finland, the proportion of adolescents accessing their PAEHR increased from younger to older age-groups reaching the proportion of 59.9 % in Sweden and 84.8 % in Finland in the age-group of 17-year-olds. The PAEHR access gap during early adolescence in Sweden may explain the lower proportion of users among those who enter adulthood. Around half of guardians in Finland accessed their minor children’s records in 2022 (46.1 %), while Swedish guardian use was the highest in 2022 for newborn children (41.8 %), and decreased thereafter. Few, mainly guardians, applied for extended access in Sweden. In Finland, where a case-by-case approach to access control relies on healthcare professionals' (HCPs) consideration of a minor’s maturity, 95.8 % of minors chose to disclose prescription information to their guardians. ConclusionWhile age-based access control practices can hamper ORA for minors and guardians, case-by-case approach requires HCP resources and careful guidance to ensure equality between patients. Guardians primarily access minors’ records during early childhood and adolescents show willingness to share their PAEHR with parents.

Socioeconomic Disparities in Online Patient Portal Utilization Among Total Knee Arthroplasty Recipients

BackgroundSince 2021, the Centers for Medicare and Medicaid Services have mandated that patients have open access to their medical records. Many institutions use online portals, which allow patients to access their health information and communicate with care teams. Our research aimed to evaluate demographic patterns for online patient portal utilization in patients undergoing total knee arthroplasty (TKA). Further, we assessed if and how portal engagement contributes to perioperative outcomes. MethodsThis study retrospectively reviewed primary and elective TKA from 2017 to 2022 at a single academic institution. Patients were stratified into 2 groups based on their online portal status: activated (A) or not-activated (NA). Baseline characteristics and postoperative outcomes were collected from the electronic medical record and compared. ResultsIn total, 10,995 patients were included: 8,330 (75.8%) were A and 2,625 (24.2%) were NA. The NA group was significantly older (P < .001); more likely to be Black (P < .001), women (P < .001), single/divorced/widowed (P < .001), non-English speaking (P < .001), and Medicare or Medicaid insured (P < .001); from zip codes with median incomes below $50,000 (P < .001), and more likely to be American Society of Anesthesiologists class III or IV (P < .001). Patient-reported outcome measure completion rates were significantly lower in the NA group (15.3 versus 47.7%, P < .001). Lengths of stay (LOS) were significantly higher in the NA group (2.7 versus 2.1 days, P < .001). The NA group was significantly more likely to be discharged to skilled nursing facilities (P < .001). Comparable rates of 90-day emergency department visits, readmissions, as well as 90-day and 2-year revisions, were observed across groups. ConclusionsThere are significant disparities in online portal activation status based on patient demographics. Patients who have A portals had significantly higher Patient-reported outcome measure completion rates, shorter LOS, and higher rates of home discharge. Further research should determine which other factors may affect patient portal utilization and inform interventions to improve portal utilization among minority populations.

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.

Quality of Answers of Generative Large Language Models Versus Peer Users for Interpreting Laboratory Test Results for Lay Patients: Evaluation Study.

Although patients have easy access to their electronic health records and laboratory test result data through patient portals, laboratory test results are often confusing and hard to understand. Many patients turn to web-based forums or question-and-answer (Q&A) sites to seek advice from their peers. The quality of answers from social Q&A sites on health-related questions varies significantly, and not all responses are accurate or reliable. Large language models (LLMs) such as ChatGPT have opened a promising avenue for patients to have their questions answered. We aimed to assess the feasibility of using LLMs to generate relevant, accurate, helpful, and unharmful responses to laboratory test-related questions asked by patients and identify potential issues that can be mitigated using augmentation approaches. We collected laboratory test result-related Q&A data from Yahoo! Answers and selected 53 Q&A pairs for this study. Using the LangChain framework and ChatGPT web portal, we generated responses to the 53 questions from 5 LLMs: GPT-4, GPT-3.5, LLaMA 2, MedAlpaca, and ORCA_mini. We assessed the similarity of their answers using standard Q&A similarity-based evaluation metrics, including Recall-Oriented Understudy for Gisting Evaluation, Bilingual Evaluation Understudy, Metric for Evaluation of Translation With Explicit Ordering, and Bidirectional Encoder Representations from Transformers Score. We used an LLM-based evaluator to judge whether a target model had higher quality in terms of relevance, correctness, helpfulness, and safety than the baseline model. We performed a manual evaluation with medical experts for all the responses to 7 selected questions on the same 4 aspects. Regarding the similarity of the responses from 4 LLMs; the GPT-4 output was used as the reference answer, the responses from GPT-3.5 were the most similar, followed by those from LLaMA 2, ORCA_mini, and MedAlpaca. Human answers from Yahoo data were scored the lowest and, thus, as the least similar to GPT-4-generated answers. The results of the win rate and medical expert evaluation both showed that GPT-4's responses achieved better scores than all the other LLM responses and human responses on all 4 aspects (relevance, correctness, helpfulness, and safety). LLM responses occasionally also suffered from lack of interpretation in one's medical context, incorrect statements, and lack of references. By evaluating LLMs in generating responses to patients' laboratory test result-related questions, we found that, compared to other 4 LLMs and human answers from a Q&A website, GPT-4's responses were more accurate, helpful, relevant, and safer. There were cases in which GPT-4 responses were inaccurate and not individualized. We identified a number of ways to improve the quality of LLM responses, including prompt engineering, prompt augmentation, retrieval-augmented generation, and response evaluation.

Unscheduled health care interactions in patients with multiple myeloma receiving T-cell redirection therapies

AbstractOutcomes for patients with relapsed/refractory multiple myeloma (R/RMM) have dramatically improved after the development and now growing utilization of B-cell maturation antigen–targeted chimeric antigen receptor (CAR) T-cell therapy and bispecific antibody (BsAb) therapy. However, health care utilization as a quality-of-life metric in these growing populations has not been thoroughly evaluated. We performed a retrospective cohort study evaluating the frequency and cause of unscheduled health care interactions (UHIs) among patients with R/RMM responding to B-cell maturation antigen–targeted BsAb and CAR T-cell therapies (N = 46). This included the analysis of remote UHIs including calls to physicians’ offices and messages sent through an online patient portal. Our results showed that nearly all patients with R/RMM (89%) receiving these therapies required a UHI during the first 125 days of treatment, with a mean of 3.7 UHIs per patient. Patients with R/RMM responding to BsAbs were significantly more likely to remotely contact their physicians’ offices (1.8-fold increase; P = .038) or visit an urgent care center (more than threefold increase; P = .012) than patients with R/RMM responding to CAR T-cell therapies. This was largely due to increased reports of mild upper respiratory tract infections in BsAb patients. Our results underscore the need to develop preemptive management strategies for commonly reported symptoms that patients with R/RMM experience while receiving CAR T-cell or BsAb therapies. This preemptive management may significantly reduce unnecessary health care utilization in this vulnerable patient population.

The patient portal for dental implant treatments.

The patient portal for dental implant treatments.

Medicare Restriction of Telehealth Speech Services Negatively Impacts Patient Care.

Ample literature shows voice and swallowing therapy, in-person or virtual, to be essential for Otolaryngology and Speech-Language Pathology care. In March 2023, Medicare announced discontinuing teletherapy reimbursement in hospital-based outpatient departments, effective May 2023. This decision was subsequently reversed; however, the uncertain interval period provided the opportunity to study the impact of eliminating teletherapy. Prospective cohort. Tertiary laryngology center. Affected Medicare patients were contacted via mailed letter, phone, and secure patient portal and offered to change appointments to in-person, teletherapy with cash self-payment ($165-282/session) or cancellation. Demographics and responses were collected. Statistical analyses conducted using Student's t test. Fifty-three patients (28 female; mean age 66.8 ± 14.2 years) were impacted. 64% (n = 34) changed to in-person appointment, 28% (n = 15) canceled, 8% (n = 4) did not respond. No patients opted to self-pay. 67% of patients that canceled telehealth care cited distance from in-person care location. The mean distance for canceled versus rescheduled patients was 92.3 ± 93.0 versus 32.8 ± 57.4 miles, P = .034. Mean age, gender, and number of sessions were not different between groups. Mean time to third next available therapy appointment was 96 ± 46 versus 46 ± 12 days before and after rule change, P = .007. Upon Medicare's reversal, this trend rebounded to nearly baseline (mean 77 ± 12 days, P = .12). Medicare's discontinuation of reimbursement for teletherapy services caused nearly 30% of patients to cancel voice and swallowing therapy, primarily due to distance. These cancellations led to decreased access to care for Medicare patients with voice/swallowing diagnoses, which affect function, quality of life, and potentially even mortality risk.

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.

Design and implementation of electronic health record-based tools to support a weight management program in primary care.

This paper reports on a mixed methods formative evaluation to support the design and implementation of information technology (IT) tools for a primary care weight management intervention delivered through the patient portal using primary care staff as coaches. We performed a qualitative needs assessment, designed the IT tools to support the weight management program, and developed implementation tracking metrics. Implementation tracking metrics were designed to use real world electronic health record (EHR) data. The needs assessment revealed IT requirements as well as barriers and facilitators to implementation of EHR-based weight management interventions in primary care. We developed implementation metrics for the IT tools. These metrics were used in weekly project team calls to make sure that project resources were allocated to areas of need. This study identifies the important role of IT in supporting weight management through patient identification, weight and activity tracking in the patient portal, and the use of the EHR as a population management tool. An intensive multi-level implementation approach is required for successful primary care-based weight management interventions including well-designed IT tools, comprehensive involvement of clinic leadership, and implementation tracking metrics to guide the process of workflow integration. This study helps to bridge the gap between informatics and implementation by using socio-technical formative evaluation methods early in order to support the implementation of IT tools. clinicaltrials.gov, NCT04420936. Registered June 9, 2020.