Patient health portals are one example of how technology platforms can be used to support care coordination practices within the healthcare system. Otte-Trojel and colleagues1 describe a patient portal as:
A secure Web site for patients, typically maintained by provider practices, that offers access to a variety of functions linked to a physician’s electronic health record (EHR) including secure messaging (SM), protected health information (eg, laboratory results, medication lists, and immunizations), appointment scheduling, and tethered personal health records.1(p751)
Bumpus and colleagues2 agree that the absence of resilient care coordination practices could lead to premature discharge, lack of prompt access to cardiology follow-up, insufficient and ambiguous patient health education, and increased noncompliance to medical therapy. As healthcare systems move toward a high-quality, high-value care delivery model, strategies, such as health portals, can be used to target specific patient and organizational outcomes. Consequently, low portal utilization is associated with adverse outcomes such as patients’ knowledge about health condition, medical therapy compliance, and communication between providers.3 Engaging patients in their care through portal utilization can improve these outcomes.4
Increasing utilization of the health portal also fulfills the requirements for meaningful use, a Centers for Medicaid & Medicare Services (CMS) program that provides financial incentives for the meaningful use of certified EHR technology to improve patient care. To receive such incentives, providers have to demonstrate that they are meaningfully using their EHRs by meeting certain metrics for a number of objectives.5 Attaining these incentives persuades health organizations to invest in value-added resources that contribute to the ongoing improvement of patient’s outcomes.
Our health system implemented a patient health portal. Although all eligible patients were invited to the portal, most did not access the portal. In the fourth quarter of 2014, account activation and utilization of the health portal by cardiac patients were modest. Portal utilization in this patient group failed to overachieve the 5% goal for view, download, and data transmission of information (10%) and was underperforming for the 5% goal to transmit secure message data between patients and providers (2%). Cardiac patients experienced miscommunication that often resulted in missed appointments, poor adherence to medication regimen, and inconsistent educational information related to their medical diagnosis and procedures.
KNOWLEDGE AND LITERATURE
Promoting the use of health portals requires patient-based adaptations, which includes ease of use and reassurance that access and interpersonal relationships will not be jeopardized.6 Patients must be made aware of what a health portal is and how it can directly benefit them.7 Motivation, usability and functionality, and portal engagement were three themes identified in the evidence to support the intervention and the impact it can have on health portal utilization.
Motivation is a key factor in utilization of patient health portals. Nurses’, physicians’, and patients’ negative attitudes were perceived as barriers to learning and using technology. The literature described negative attitudes as being “tired” and “unwilling” by nurses and physicians and “too busy” or “forgetful” by patients.7,8 Patients displayed positive attitudes about features that increased convenience, such as appointment scheduling, receiving test results, and refilling prescriptions, whereas they were least positive about features that interfered with communication and responsiveness by providers.6,9,10 This body of evidence addressed the importance of understanding what motivates patients’ behaviors to access health technology for increasing portal utilization.
Usability and Functionality
Consistent functionality and usability can also be major facilitators to successful implementation and sustainability of patient portals. The majority of patient users across two studies indicated that portal systems were easy to follow and that success in getting patients to use the portal required an interactive, hands-on experience.11,12 Two prospective studies7,8 found that obstacles related to technology (ie, Internet access and operational complexities) occurred but were infrequently reported as contributing factors to portal usage. However, these same studies collectively highlighted that a lack of sufficient technical equipment created significant barriers to successful implementation and utilization of patient portals. Readiness assessment of implementing technology, financial planning, and ongoing policy development and improvement efforts were key to sustained implementation.13,14 This body of evidence supported the idea of identifying barriers early on and strategically planning prior to educating patients about portal enrollment and access.
Evidence supports that using intentional tactics (ie, physician notes, health education) that appeal to patients increased portal activation, as well as improved outcomes, increased understanding of medical conditions and sense of control, and better prepared patients for future visits.15–17 Patients and healthcare clinicians’ level of engagement in using portals can influence the success of patient health portal utilization. To improve effective patient education and portal enrollment, three studies strongly supported that health portals should be introduced at admission or during hospitalization.7,18,19 While collaborative workflow designs and direct human interaction are key to an effective patient portal utilization plan,4,20 portal usage must be made clear to the patients and how it can benefit them directly.7 Nonphysician healthcare members were more interested in the portal than the actual physician in one prospective study.21 This supported that an entire team of health professionals influences portal utilization opposed to one single person or designated role.
The collection of evidence was sufficient to support the implementation of this evidence-based practice intervention, which involved an educational demo for improving portal utilization in patients who have health portal accounts. Strong recommendations in relation to factors, such as motivation of the portal user (ie, patient or provider), portal functionality, portal behaviors, and outcomes, are essential in shaping educational methods about the portal and improving utilization. Goel and colleagues7 found that 60% of patients who did not attempt to enroll did so because of a lack of motivation and adequate portal information. Patient portal task complexity score of 5.9 (4.01) for patients using the portal was also found, indicating that no one patient was able to complete an entire task when asked to participate in a study examining portal functionality.12 Another study11 that gathered patient perceptions on accessing Web messages via the health portal found that the majority of users considered the portal system easy to use (mean scores ranged from 78 to 85). Human interaction is critical when implementing and engaging patients in new health technology initiatives.20 Finally, assessing and clarifying instructions for both the patient and clinicians on how to access the health portal clearly play a role in improving portal utilization.7
Such evidence supports a process change regarding how patients are introduced to and educated about the use of health portals in the ambulatory clinical setting. This evidence also strongly suggests the need for more clinicians to be engaged with educating patients about access to and use of the health portals. Although some studies lacked strong quality of evidence about portal users who have no Internet access, live in rural geographical locations, or were diagnosed as having specific cardiac health conditions, many behaviors and practices can be applied and used to make process changes within the cardiac population.
Implementing an interactive educational demo to teach patients about the health portal can affect overall utilization rates in the cardiac patient population. Increasing portal utilization will also facilitate coordination of care for patients by actively engaging them in their care. This process change is significant not only to patients and nurses but also to the organization. Engaging patients in their care strengthens the patient-clinician relationship and fosters a consistent path for the nurse to provide quality care. Dickinson and colleagues20 suggest that human interaction is critical when educating patients about the portal and suggested that providing clear instructions for both patients and clinicians is significant to improving portal utilization.7,20 Therefore, based on the collection of evidence, the patient portal utilization intervention is applicable to current practice.
PURPOSE AND AIMS
The purpose of this project was to create and implement an enhanced process to engage patients in using the health portal with the goal to increase overall utilization. The aims of this project were to (1) educate at least 30% of eligible cardiac patients on how to access and use the health portal, (2) increase portal overall utilization by 5% in all the cardiac office patients seen from October 2015 to January 2016, (3) increase utilization of health portal features by 5% in patients who received the intervention (education demo) between October 2015 and January 2016, and (4) ensure that 10% of study participants would view their assigned health education video, in their health portal account, prior to the day of procedure and 30 days after discharge.
The project was reviewed and approved by the healthcare system institutional review board. The Iowa Model for Evidence-Based Practice to Promote Quality of Care was used to guide and implement the intervention in the cardiac nurse navigator ambulatory clinic. A nurse navigator is defined as a professional RN who works with patients and families to overcome health system barriers. He/she often has specific clinical knowledge that helps to individualize patient assistance throughout the healthcare encounter.22 Figure 1 illustrates the Evidence-Based Practice steps taken to identify triggers and evidence to support project implementation.23
According to Locsin,24 “the skilled demonstration of intentional, deliberate, and authentic activities by experienced nurses who practice in an environment requiring technological expertise” describes Locsin’s Technological Competency as Caring in Nursing Theory. This theoretical framework was used to integrate the knowing of the patients in their wholeness24 during teaching sessions and interactions with the health portal during the project. Because technology proficiency levels are diverse among patients, nurses’ knowing to adjust their teaching approaches allows them to fully accept the patient as an individual human being. This further allows for continuous appreciation of the patient person moment to moment despite where he/she is with using the health portal.
Patient health portal utilization and health education video compliance data were collected and entered into REDCap (Vanderbilt University, Nashville, TN). REDCap, which stands for Research Electronic Data Capture, is a secure Web application for building and managing online surveys and databases.25 Open-ended, yes-or-no, and checkbox-option questions were used to gather data. The data collection tool was organized into four major sections labeled demographics, preprocedure visit, day of procedure visit, and 30-day follow-up call visit. To improve consistency, a printed tool was used first, then collected data were entered into the REDCap database. The survey was developed by the project team and used only to collect demographic and patient-reported data.
The intervention took place in a cardiac nurse navigator office located inside a very large and busy cardiology ambulatory clinic, consisting of more than 50 providers. Patients scheduled for an invasive cardiovascular procedure were referred to the nurse navigator. The cardiology office is a specialty service line within a large dynamic healthcare system in southeast region United States. Two RNs staffed the cardiac navigator office. On average, between 40 and 65 patients were referred to the navigators each month.
A convenience sample was taken from patients who were scheduled for a cardiovascular invasive procedure. Inclusion criteria included adult patients between 18 and 75 years old, had Internet access, and spoke English as their primary language.
The intervention consisted of an interactive educational demo used to educate patients about how to sign on, activate, and navigate the health portal. Assigning education videos in the health portal was the key tactic used to influence participants to use the portal. An Interactive Patient Care (IPC) vendor provided the video platform in the health portal. Interactive Patient Care is a delivery model that healthcare systems use to engage patients in their care.26 To ensure health literacy compliance, the hospital’s health education council approved the videos and written materials. The nurse navigator implemented the project during three phases of each participant’s healthcare encounter, preprocedure navigator office, day of procedure visit, and post–hospital discharge 30-day follow-up call.
Nurse Visit (Preprocedure)
The nurse used the educational demo to instruct the participant about the health portal and highlighted three major portal features. The nurse assisted participants with creating a new portal account or accessing their existing account. The nurse also assisted participants with creating new personal e-mail accounts if necessary. Health videos were assigned to the participant’s portal, and written instructions were given to refer to at home. Videos were selected based on the type of procedure scheduled, that is, heart catheterization, stent placement, and angiogram.
Day of Procedure
The nurse visited participants in the hospital and surveyed them about video compliance and use of health portal features. Participants were instructed to log into their health portal at home and view a newly assigned video within the next month.
Post Hospital Discharge
Participants received a follow-up call approximately 30 days after hospital discharge. Participants were surveyed about video compliance and use of health portal features.
Meaningful use guidelines are established by the CMS and not the healthcare system. At the time of project implementation, the guidelines for the outpatient setting required health portal reporting based on the provider and not the individual patient. Meaningful use metrics for health portal utilization assess provider use of the portal to engage with patients and include three components.27 The first, view download transmit (VDT), is defined as a timely invitation to use the portal and should be attained by 50% of patients (goal) who were invited to the health portal by the provider. The second component is to achieve actual use of VDT in 5% of providers (goal) who accessed, downloaded, and or transmitted information to patients. The third component is SM, which is bidirectional communication achieved using the portal for 5% of providers to whom patients were sent and from whom providers received a secure message. A report summary was collected before and after the intervention to identify trends in meaningful use outcomes.
Descriptive statistics were generated and used to evaluate four project outcome measures: frequency of educating participants about the health portal using the education demo (intervention), frequency of health portal utilization by participants in the cardiology office based on meaningful use metrics, frequency of health portal utilization by participants who received the intervention (educational demo) in the navigator office, and frequency of health video compliance before and after the intervention. To preserve confidentiality, providers were identified with numbers. Data analyses were conducted using IBM SPSS Statistics version 23 (IBM, Armonk, NY).
Between October 15, 2015, and January 15, 2016, 130 patients were referred to the nurse navigator office. Of those 130 patients, 19 (15%) were approached about participating in the intervention. Seventy-three percent (n = 14) of the 19 patients received the intervention. Two patients declined, and three patients did not meet criteria because of lack of adequate Internet access. Participant mean age was 60.16 (SD, 13.3) years, with (n = 7 [36%]) male and (n = 12 [63%]) female. Seventy-three percent (n = 14) reported being white, and 15.8% (n = 3) reported being African American. Four of the patients (21%) reported less than 12th grade as their highest education level, whereas 78% (n = 15) reported completing a 12th-grade education or higher. Forty-two percent (n = 8) had Medicare. Of the 28 physician providers, 28% (n = 9) referred patients to the nurse navigator for participation in the project.
Although Internet access was a requirement for participation, the breakdown of personal device ownership was as follows: smartphones (n = 12 [63%]), computers (n = 11 [57%]), and tablets (n = 5 [26%]). Note that percentages equate to more than 100 because some participants reported having multiple devices. The proportion using public access only, such as libraries or schools, was 10% (n = 2).
Despite lower than expected participation, all four outcome measures defined for the project were achieved. The first outcome, frequency of educating patients about the health portal using the education demo (intervention), occurred in 14 of the 19 participants (73%). Sixty-four percent (n = 9) of the participants who received the intervention reported having a portal account prior to the intervention. Of the participants who created an account, 21% (n = 3) did so during the nurse preprocedure visit.
The second outcome, frequency of health portal utilization by participants in the cardiology office based on the CMS meaningful use goals, showed that of the nine providers the VDT “timely invitation” outcome before the intervention was 93.8% and was 92.4% after the intervention, which outperformed the CMS meaningful use goal of 50%. The VDT standard outcome at preintervention was 12.6% and was 16.7% at postintervention, showing a 4% increase from baseline (goal 5%). The SM outcome at preintervention was 3.5% and was 2.2% at postintervention, indicating a nominal decline from baseline, but still underperforming the CMS expectations (goal, 5%).
The third outcome, frequency of health portal utilization by participants who received the intervention (educational demo) in the navigator office, was achieved. During the preprocedure nurse navigator visit, 13% (n = 2) reported using the health portal within the past 6 months. During the 30-day discharge call, 36% (n = 4) reported using the health portal since hospital discharge, a 13% increase from preintervention. The fourth outcome, frequency of health video compliance before and after the intervention, was achieved. The results indicated that 16% (n = 2) of the participants reported viewing their assigned video in their health portal prior to procedure day, whereas 18% (n = 2) reported viewing their video in the health portal after hospital discharge. See Table 1 for portal utilization activities and video compliance.
Results from this evidence-based pilot project demonstrated the feasibility of using a patient portal for delivery of preprocedural patient education in an ambulatory cardiac setting. The project demonstrated the value of the nurse navigator role and provided preliminary evidence for opportunities to further develop and expand these roles to better support patients in preprocedural and postprocedural care. Despite lower than expected participation, all four outcome measures defined for the project were achieved. Nursing, patient, and technology environments were identified as major points of discussion.
Understanding the environmental factors and infrastructure that minimized patient participation is imperative. For example, patient referrals to the nurse navigator office were inconsistent, ranging from an average of two patients a day to nine patients on other days. When the nurse navigators were off work, alternate nurses were not well educated on the implementation process. On busy days, nurses were often pressured to expedite the health portal education because of time constraints and patient wait times. Irizarry and colleagues28 studied patient portal engagement and found that to increase patient portal enrollment the health team must consider adjusting current workflows. Nurses in this study reported similar workflow barriers and solutions for implementing the intervention and assisting patients with portal accounts.
Participants who were scheduled for a next-day procedure were less likely to access the portal. They placed more emphasis on procedure preparation activities, rather than accessing their new health portal, because they did not have enough time. This was the same for participants returning to work 1 to 2 days after discharge. Participants expressed difficulty recalling their username and password information. Participants who did not have an existing personal e-mail account at the time of intervention were likely to elect creating their new portal account at home, thus minimizing chances of completing the task. Participants reported being preoccupied with their daily routines and often overlooked accessing their portal. These factors significantly affected health portal access and video use.29
Interoperability of the electronic medical record (EMR) and health portal technology platforms was less robust in the ambulatory care setting. Ambulatory office participants had to manually enter and search their assigned health education videos in the health portal, minimizing the opportunity to review their assigned videos prior to procedure day. The IPC platform in the ambulatory setting was not yet configured like the inpatient setting. Because participants could not be admitted into the IPC platform, this prevented health videos from being automatically assigned to the portal, creating a major drawback to a seamless implementation. Participants admitted that their motivation to search for the videos diminished after finding it challenging to navigate to the video section of the portal and search for specific video titles. There was no robust tracking system in the portal that verified whether the participant actually viewed the video as they reported. When asked about the health portal videos, the data were based only on self-reporting, making it difficult to accurately account for video compliance in the study. See Table 2 for participants’ and nurses’ comments regarding portal utilization.
The presence of family, especially an adult child, during the health portal education was key to persuading participants to use the portal. The adult child commonly served as the caregiver or main support system and assisted with managing the participant’s access information and e-mail accounts. Having interactive hands-on education, such as the tablet demo of the health portal, allowed participants to be more receptive about the health portal as opposed to providing them with written materials alone. The nurse navigator office environment facilitated the intervention. Unlike the inpatient hospital setting, the nurse navigator office was a controlled setting where the patient received individualized care. Creating and implementing the tablet-based educational demo were cost neutral, which improved the chance for future sustainability.
Limitations include unpredictable patient volumes, staff callouts, lack of a seamless ambulatory EMR and health portal integration, and lack of structured time frame to complete the intervention during the daily workflow. The intervention was evaluated over 3 months, and additional time may have yielded results that were more reliable and generalizable to clinical practice. Data were unavailable on the actual time to educate the participants about the portal and assist them with creating a new account. Nurses were faced with daily responsibilities, while implementing the intervention. For example, during an appointment, the nurse navigator had to draw blood, schedule the patient, perform a health history assessment, and provide patient education. This influenced the nurses to rush the portal education, therefore potentially compromising the quality intervention. Patients who did not have Internet access, valid e-mail address, and a health portal account also posed a limitation. Usability challenges limited the participant’s ability to experience the portal features.
The majority of the participants were female (63%) and white (73%), and the average age was 60 years, which suggest that the findings may not be generalized to all patient population settings. Specialty offices, such as cardiology, may yield different outcomes when compared with the outcomes of primary care practice settings. Primary care patients may access their health portals more often because they visit more throughout the year compared with specialty care patients. Therefore, the need to access the health portal may be more substantial in the primary care patient population.
The method for reporting meaningful use data was by physicians rather than the individual patient, which created challenges with identifying the patient’s real-time utilization activities and identifying a concrete baseline. While the meaningful use criteria outline the requirement of basic functionality and targeted adoption rates, it does not detail the steps or features required to engage patients in a more relevant way.26
Successful implementation required consistent communication between key players before, during, and after the intervention. This was especially important in our large healthcare system in which multiple key stakeholders had responsibilities aligned with the project. A physician or provider champion should be selected for projects that are implemented in the clinical setting and have an impact on patients. The champion can gain the buy-in from physician partners and have a unique type of influence on the project outcome. Instead of directing others, the project leader should be immersed in the project implementation phase. As the organizational culture changes and unexpected challenges arise, the leader will have to step in and make adjustments. Finally, to maximize project results, allocating realistic time frames for implementation is critical. It is important to build into the implementation phase anticipated barriers that may impact the quality of the project.
Project outcomes indicated that the majority of patients who were approached to participate received the intervention, and many reported owning personal electronic devices such as smartphones, tablets, and computers. Results reflected both challenges and facilitators for implementing health portal utilization initiatives. Improvements in the number of patients using the health portal features and viewing assigned videos in their portal were also identified in the findings. Although assigning health education videos may be a tactic to motivate patient portal utilization, other innovative approaches should be established to further engage patients with the health portal. To accomplish this, providers and nurses will need to generate opportunities that direct patients to their health portal. In order to patients to remain motivated about using their portal, clinicians should provide them with a reason to use it and provide a more hands-on, one-on-one educational training experience. Innovative health portal intervention practices must be a priority and diffused into the daily workflow of the healthcare team.
Future improvements in interoperability will be key to maximizing the use of health portals, enabling easy access to key features such as health education videos, and enhancing the patient experience through improved patient-provider communication and access to health records. Health portals may also improve long-term clinical outcomes such as medication self-management and early symptom identification and reporting, which have been associated with readmission rates.
The authors thank Gail Woods, BSN, RN-BC, and Cynthia Thomas BSN, RN-BC, cardiac nurse navigators, and Bryan Wilfong, senior information system analyst, Carolinas Healthcare System, Charlotte, North Carolina. They acknowledge the Corporate System and Information Analytical Services, Carolinas Healthcare System; and the Interactive Patient Care, GetWellNetwork, Bethesda, Maryland.
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