Keywords
patient portal - discharge summary - communication barriers - inpatient care - discharge
planning
Background and Significance
Background and Significance
The use of electronic health records (EHRs) throughout the United States health care
system has created opportunities for enhancing patient access, engagement, and education.[1] A growing body of evidence suggests that providing patients electronic access to
their full medical records may improve their satisfaction, engagement in care, medication
adherence, and chronic disease management.[2]
[3]
[4]
[5]
[6]
[7] Although data suggest that black and Hispanic patients are just as interested as
Caucasian patients in gaining access to their health information online, they were
much less likely to be offered access, raising concerns that the benefits of shared
electronic records are not reaching all patients equally.[8]
Most research on patients' access to their EHRs has been conducted in the outpatient
ambulatory setting among insured patient populations, although studies are currently
underway to improve inpatient portals to engage hospitalized patients and vulnerable
populations.[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17] A 2015 systematic review highlighted the lack of evidence on inpatient portals,
as it identified 120 studies on patient portals, but noted that none of the studies
included inpatient portals.[13] Some recent studies have explored the use of bedside portals to allow patients access
to their daily laboratory and radiology results with modest benefit, although they
did not explore access to discharge summaries or medication lists.[16] It is important to understand inpatients' access to their EHR information, as hospitalization
is a disruptive and consequential event in patients' lives that may signify disease
progression, lead to diminished functional capacity, or require new treatments and
follow-up. Hospitalization presents an opportunity for education as well as provision
of secondary and tertiary prevention of chronic illness, potentially decreasing morbidity
and improving quality of life, some of which may be addressed or improved through
online record access as seen in results from the outpatient setting.
Unfortunately, after discharge, patients and their families often describe a lack
of understanding about prognoses, resources, and posthospitalization care plans, despite
providers reporting significant efforts toward education and counseling.[18] Providing postdischarge instructions for patients has been identified as a potentially
important educational strategy to prevent hospital readmission.[19]
[20] Providing patients with electronic access to their hospital medical records, including
the discharge summary, and access to secure communication with providers may help
address this comprehension gap after discharge.[21] Access to email is often a requirement for portal access and secure messaging, and
has thus become a critical piece to enable communication outside of the health care
setting.
Objective
The primary objective of this study was to evaluate an intervention that teaches hospitalized
patients at a safety net hospital how to access and use their EHR online portal. Our
secondary objectives were to characterize perceptions and access to patient portals,
as well as to increase online portal use and uptake by hospitalized patients.
Methods
Participants and Setting
Patients were recruited from inpatient internal medicine services at Harborview Medical
Center (HMC), a public county hospital operated by the University of Washington School
of Medicine.[22] HMC is an urban safety net hospital with 413 beds and 17,000 annual admissions serving
vulnerable patient populations[23] in King County, Washington, United States.[24] HMC's diverse patient population includes homeless and incarcerated patients, as
well as many patients with complicated or chronic conditions.[23] Inpatient care at HMC is supported by Cerner Millennium (Kansas City, Missouri,
United States) and includes an online portal, “eCare” that can be used to access discharge
summaries after hospitalization. Invitation to the patient portal is offered to all
patients, via a secure link which is emailed to an email address of their choosing
if they opt in.
Patients hospitalized on the internal medicine services during the study period (September
16–October 30, 2016) were prescreened by a physician author (J.S., J.K., or S.J.)
using clinical notes to exclude ineligible patients. The prescreening process identified
eligible patients who were ≥ 18 years of age, were able to read and speak English,
but did not have diagnoses such as dementia, cognitive impairment, or decompensated
psychiatric disorder that would preclude instruction, or discharge to an institutional
setting (skilled nursing, long-term care facilities, or incarceration). Given the
large number of homeless patients at HMC, “discharge to street” or “discharge to shelter”
was considered a destination of “home” and not an institutional setting. The remaining
potentially eligible hospitalized patients were then randomized in a 2:1 ratio favoring
the intervention. Patients were then personally interviewed by study staff to confirm
eligibility including whether or not the patient had access to email and a telephone.
Those meeting all eligibility criteria were invited to participate (see [Supplementary Material A], available in the online version). Informed consent was obtained for all participants.
Intervention
The intervention consisted of an in-person introduction to the online patient portal
conducted while participants were still in the hospital. Trained research personnel
brought a laptop or tablet to the patient bedside and: (1) determined whether the
patient had portal login credentials and sent a new registration email link to patients
not yet registered (staff did not assist with actual portal account registration);
(2) demonstrated navigation of the patient portal using a simulated teaching (sham)
patient account as an example; (3) explained the components of a hospital discharge
summary and walked through an example (see [Supplementary Material B], available in the online version); and (4) discussed how reading the hospital discharge
summary might be helpful to a patient in ways such as reviewing the medication list
and sharing the information with a primary care provider or caregiver. Intervention
patients were sent two email reminders (not via the portal) by study staff to read
their hospital discharge summary after discharge.
Control participants did not receive intervention training or reminder emails, but
were invited to use the portal per hospital policy and usual care protocols: nonclinical
staff members approach all hospitalized patients shortly after admission as part of
the registration process for usual care. Staff members do not use a script and they
do not explain details of the patient portal or discharge summaries.
Measures and Data Collection
Patient demographics (e.g., age, sex, race) and comorbidities (e.g., coronary artery
disease, diabetes, hypertension, cancer, human immunodeficiency virus, substance use
disorder) were abstracted from the EHR by a study physician (J.S., J.K., or S.J.).
The baseline survey was conducted in person during the hospitalization. The survey
assessed patients' understanding of their medications and medical problems, a previously
validated single-item health literacy assessment about their confidence in filling
out forms without help[22]
[25] and perceived helpfulness of reading the discharge summary, using a 4-point Likert
scale.
The follow-up survey was administered beginning 2 weeks after hospital discharge.
Patients were sent one email invitation and up to three telephone call reminders to
complete the postdischarge survey. Patients with a nonworking phone number were sent
an additional email from study staff and those with a nonworking email received an
additional phone call. Paper questionnaires were mailed to patients who could not
be reached via email or telephone. Thus, depending on which reminder patients responded
to, the postdischarge survey was completed either via the Web, telephone, or paper.
The postdischarge survey included the same questions as the baseline survey, but also
assessed patients' perceptions and self-reported utilization of the patient portal
after discharge, their trust in their doctors, and satisfaction with their care. Upon
completing the postdischarge survey, participants were given a $25 gift card for participating
in the study.
All survey data were managed using the Research Electronic Data Capture Web application
(Vanderbilt, Nashville, Tennessee, United States), including data originally completed
via telephone or mailed paper survey[26] (see [Supplementary Material C] for the complete questionnaires, available in the online version).
Statistical Analysis
Frequency distributions of demographics, survey, and hospital log data were analyzed
across intervention and control groups. Comparisons were made using Pearson's chi-square
test or Fisher's exact test, where appropriate. Four-point Likert scale items were
dichotomized for analytical purposes. The primary outcome was whether they accessed
the patient portal, as determined by electronic logs that tracked which patients created
a patient portal account. We also tracked whether patients had a working email address
as this was a primary barrier to study participation. All analyses were conducted
using SAS 9.4 (SAS, Cary, North Carolina, United States).
Results
Of 533 hospitalized patients on the internal medicine services during the study period,
192 were deemed ineligible from the prescreening chart review, 85 were not available
for approach by research staff during their hospitalization because they were undergoing
medical testing or procedures, and 27 patients declined to participate before eligibility
could be determined. Of the remaining 229 patients, 114 (50%) were deemed ineligible
during the in-person screening (see the figure in [Supplementary Material A], available in the online version), primarily due to lack of an email address and
8 declined participation. An additional 21 patients who did participate in the study
did not have working email addresses. Thus, among the 202 hospitalized patients who
were deemed mentally competent, spoke English, and had a telephone, only 86 (43%)
had a working email ([Fig. 1]).
Fig. 1 Email use among 202 vulnerable safety net hospital patients who were English speaking,
did not have a diagnosis of a condition that would affect cognition, and were discharged
to home.
Seventy patients (47 intervention and 23 control) completed all components of the
study including the postdischarge survey. For patients randomized to the intervention,
the educational component took an average of approximately 15 minutes to complete
(range: 5–30 minutes).
The study population is described in [Table 1]. The majority of patients were 50 years or older, male, white, and non-Hispanic.
Males represented a greater proportion of the control group than the intervention
group (p = 0.03). At baseline, while most patients reported understanding their medications,
why they were admitted to the hospital, and what to do after they left the hospital,
it is also relevant to note that 19% of combined samples reported not knowing what
medications to take and 11 to 17% did not know what they needed to do after leaving
the hospital. The majority of patients also reported confidence filling out forms
themselves, and thought it was a good idea if patients had access to their own hospital
records. There were no differences in responses to these questions between the intervention
and control groups.
Table 1
Patient characteristics and baseline health knowledge
Patient characteristics
|
Study arm
|
p-Value
|
Intervention, N (%)
|
Control, N (%)
|
47 (67)
|
23 (33)
|
Sex
|
Female
|
21 (45)
|
4 (17)
|
0.025
|
Male
|
26 (55)
|
19 (83)
|
Race
|
White
|
34 (72)
|
19 (83)
|
0.88
|
Black
|
5 (11)
|
2 (9)
|
Asian
|
3 (6)
|
1 (4)
|
Other
|
5 (11)
|
1 (4)
|
Ethnicity
|
Hispanic
|
5 (11)
|
3 (13)
|
> 0.99
|
Not Hispanic
|
42 (89)
|
20 (87)
|
Number of comorbidities[a]
|
0–1
|
10 (21)
|
7 (30)
|
0.70
|
2–3
|
17 (36)
|
7 (30)
|
4+
|
20 (43)
|
9 (39)
|
Most common comorbidities
|
Substance abuse
|
21 (45)
|
7 (30)
|
0.25
|
Hypertension
|
15 (32)
|
10 (43)
|
0.34
|
Diabetes
|
13 (28)
|
5 (22)
|
0.59
|
Pain
|
9 (19)
|
5 (22)
|
>0.99
|
Depression
|
8 (17)
|
6 (26)
|
0.53
|
Age
|
18–49
|
18 (38)
|
9 (39)
|
0.95
|
50+
|
29 (62)
|
14 (61)
|
Baseline survey knowledge[b]
|
Know what medications to take
|
Disagree/Strongly disagree
|
11 (23)
|
2 (9)
|
0.20
|
Agree/Strongly agree
|
36 (77)
|
21 (91)
|
Know what medications do
|
Disagree/Strongly disagree
|
8 (17)
|
3 (13)
|
> 0.99
|
Agree/Strongly agree
|
39 (83)
|
20 (87)
|
Know when to visit physician
|
Disagree/Strongly disagree
|
10 (21)
|
2 (9)
|
0.31
|
Agree/Strongly agree
|
37 (79)
|
21 (91)
|
Understand why admitted to hospital
|
Disagree/Strongly disagree
|
2 (4)
|
0 (0)
|
> 0.99
|
Agree/Strongly agree
|
45 (96)
|
23 (100)
|
Understand what need to do after leaving hospital
|
Disagree/Strongly disagree
|
5 (11)
|
4 (17)
|
0.46
|
Agree/Strongly agree
|
42 (89)
|
19 (83)
|
Good idea if patients could read hospital records
|
Disagree/Strongly disagree
|
3 (6)
|
1 (4)
|
> 0.99
|
Agree/Strongly agree
|
44 (94)
|
22 (96)
|
Confidence in filling out forms
|
Somewhat/A little bit/Not at all
|
11 (23)
|
6 (26)
|
0.81
|
Extremely/Quite a bit
|
36 (77)
|
17 (74)
|
Abbreviation: HIV, human immunodeficiency virus.
a Comorbidities captured include: pain, diabetes, hypertension, coronary artery disease,
chronic obstructive pulmonary disease, chronic kidney disease, heart failure, atrial
fibrillation, substance abuse disorder, depression, anxiety, cirrhosis, stroke, cancer,
end-stage renal disease, deep vein thrombosis/pulmonary embolism, hepatitis C, obstructive
sleep apnea, HIV, and other.
b Baseline survey results.
[Table 2] summarizes the data collected after hospital discharge. The majority of the intervention
patients (89%) felt the training they received to access the patient portal was useful.
Both the intervention and the control patients overwhelmingly preferred hospitals
with online record access (85 and 83%, respectively), feeling that access to medical
records would increase their trust in doctors (85 and 87%, respectively) and their
satisfaction with care (91% for each group). Patients in both the study groups were
interested in the idea of sharing their hospitalization medical records with others,
particularly with their primary care doctor and family member.
Table 2
Posthospital discharge follow-up data on perception and activity related to electronic
patient portals
|
Study arm
|
p-Value[b]
|
Intervention, N (%)
|
Control, N (%)
|
47 (67)
|
23 (33)
|
Perception
|
Training I received about the patient portal was useful
|
Disagree/Strongly disagree
|
5 (11)
|
NA
|
|
Agree/Strongly agree
|
41 (89)
|
NA
|
|
Wish had more information about hospitalization
|
Disagree/Strongly disagree
|
20 (43)
|
7 (33)
|
0.47
|
Agree/Strongly agree
|
27 (57)
|
14 (67)
|
Prefer hospital with online record access
|
No
|
2 (4)
|
1 (4)
|
> 0.99
|
Yes
|
40 (85)
|
19 (83)
|
Don't know
|
5 (11)
|
3 (13)
|
Access to medical records would increase my trust in doctors
|
Disagree/Strongly disagree
|
7 (15)
|
3 (13)
|
> 0.99
|
Agree/Strongly agree
|
40 (85)
|
20 (87)
|
Access to medical records would increase my satisfaction with care
|
Disagree/Strongly disagree
|
4 (9)
|
2 (9)
|
> 0.99
|
Agree/Strongly agree
|
43 (91)
|
21 (91)
|
Would share medical records with[a]
|
Share records with family
|
25 (53)
|
13 (57)
|
0.79
|
Share records with primary care doctor
|
37 (79)
|
22 (96)
|
0.087
|
Share records with caregiver
|
16 (34)
|
9 (39)
|
0.68
|
No one
|
8 (17)
|
0 (0)
|
0.046
|
Activity postdischarge
|
Patient activity on portal (hospital click data)[c]
|
Declined portal registration
|
6 (13)
|
8 (42)
|
0.005
|
Did not register
|
18 (39)
|
9 (47)
|
Registered
|
22 (48)
|
2 (11)
|
Attempted to login to patient portal
|
No
|
19 (40)
|
15 (65)
|
0.051
|
Yes
|
28 (60)
|
8 (35)
|
Reasons given for not logging into the portal[a]
|
Didn't know about it
|
2 (4)
|
5 (22)
|
0.035
|
Technical difficulties
|
5 (11)
|
3 (13)
|
> 0.99
|
Didn't feel well enough
|
6 (13)
|
2 (9)
|
> 0.99
|
Personal or time constraints
|
11 (23)
|
5 (22)
|
0.88
|
Didn't think about it
|
10 (21)
|
6 (26)
|
0.65
|
Forgot password
|
3 (6)
|
3 (13)
|
0.39
|
Other reason
|
12 (26)
|
6 (26)
|
0.96
|
a Categories not mutually exclusive, thus column percents do not add to 100%.
b Comparisons made using chi-square statistic or Fisher's exact tests where appropriate.
c Patients who declined portal registration indicated that they did not want to receive
email information instructing them how to sign up for the portal. Patients who did
not register received the email information describing how to register but did not
complete the registration process online.
Over half of the patients in both the intervention and control study arms reported
wishing they had more information about their recent hospitalization (57 and 67%,
respectively). Patients were also asked in the postdischarge survey about the hard
copy paperwork all patients are given upon discharge from the hospital ([Fig. 2]). As the results were similar between patients in both the study arms, the data
are merged for clarity. A substantial proportion did not remember receiving the papers
or did not read them (44%), did not find them helpful (37%), and did not know where
the paperwork was at the time of the postdischarge survey (20%).
Fig. 2 Patients' responses to a survey question about hospital discharge paperwork. Results
for patients from the intervention and control arms were similar and are therefore
combined.
Based on electronic logs, patients who received the intervention training in accessing
and navigating the patient portal were significantly more likely to register for the
patient portal (48% vs. 11%, p < 0.01). According to patient self-report, intervention patients were also more likely
to attempt logging into the portal; this reached borderline statistical significance
(60% vs. 35%, p = 0.05). The more frequent reasons given for not accessing the portal by our patients
were personal/time constraints, or not thinking about accessing it, rather than technical
difficulties.
Discussion
This study suggests that vulnerable patient populations are enthusiastic about electronic
patient portals, yet a surprising percentage do not use email. Email is the primary
method of communication used by most health systems for both signing patients up for
portals and encouraging them to read their doctors' notes, and yet only 43% of vulnerable
in-patients in this study had a working email address.[27] This is an important and unexpected finding that almost half of patients approached
for this study did not have working email. During prescreening, we had excluded patients
with cognitive or language barriers, and thus had expected a much higher percentage
of remaining patients to report using email. We consider the inability to reach patients
by email to be critical as many patient portals used by hospitals and clinics nationwide
require email for account access and to prompt patients to read clinic notes.[27] When developing an educational program for patients surrounding portal use, including
information on how to access and use email, offering other methods to access the portal
may be needed, especially if we hope to reach vulnerable patients.[27]
In this study, we also found that patients are more likely to take steps to register
for the patient portal if they are provided with brief training. Most patients indicated
a preference for hospitals that offer access to patient portals and also reported
that they would have increased satisfaction with their health care and trust in their
physicians if they had online access to their hospital records, both relevant findings
in an era of patient satisfaction scores. Given the high percentage of patients who
either did not read (44%) or could not find (20%) the hard copy paperwork given to
them at discharge, online portals may improve patient engagement by allowing discharged
patients to read the hospital paperwork at their convenience a long time after returning
home, while at the same time providing a secure, easy-to-find location for accessing
their records. Our training likely improved awareness of the resource, and may have
enhanced patient activation and comfort with the online tool, all of which may have
contributed to the observed increase in use. Training patients to access their health
information using portals on busy inpatient wards, without the benefit of study staff,
is a challenge. However, this work could be incorporated into transitions of care
processes developed to improve care quality and continuity of information between
in- and outpatient domains.
Our findings among this vulnerable patient population are consistent with prior research
demonstrating that most patients consider accessing their health information via online
portals to be important.[28]
[29] Unfortunately, many patients, especially those from vulnerable populations, do not
use patient portals either because they are not given the opportunity[28] or because they do not have the ability to access them.[30]
[31]
[32] Recent studies are consistent with our findings and suggest that tailored and accessible
training and support to assist such patient populations with portal use was strongly
needed, and beneficial when provided.[12]
[13]
[14]
[33]
[34] U.S. Census data from 2015 shows that the majority of Asian and non-Hispanic white
households reported Internet use at home (88 and 79%, respectively), compared with
lower rates in Hispanic and black households (70 and 64%, respectively).[35] A Pew Research Center report on U.S. smartphone use in 2015 states that 13% of Hispanic
and 12% of black smartphone users are “smartphone dependent” for Internet access due
to lack of broadband Internet at home. The report also notes that 73% of Hispanic
and 67% of black smartphone owners in the United States used their phones to seek
information about a health condition in the prior year, compared with 58% of white
smartphone owners.[36] Among vulnerable populations in particular, finding methods to communicate is challenging
and, as our results suggest, may require the identification and implementation of
novel strategies that do not involve email.
Our study has several limitations. It was notable for the high rate of exclusion due
to diagnoses of dementia, non-English fluency, or lack of email access. The final
small sample size might have limited the randomization, with more men in the control
group, and limited our ability to detect meaningful differences between the randomized
groups. The study was conducted at a single safety net hospital that serves a vulnerable
patient population, thereby potentially limiting the external validity of our findings.
However, it is plausible that patients in other large urban areas would experience
similar benefits and challenges. Portal access was measured by registration for an
account as a surrogate, rather than by tracking who actually opened their discharge
summary, as it was not possible to extract that level of individualized click data.
Lastly, the survey data relied on self-report.
Strengths of this study include that it was conducted in an inpatient setting serving
vulnerable patients and that it assessed the patient perspective on current methods
of communication being used by hospitals (e.g., discharge papers and email). We demonstrated
that increasing access to the patient portal is possible in an urban safety net hospital
and patients were enthusiastic about this new tool, yet lack of email is a critical
issue that needs to be addressed.
Future interventions could emphasize signing patients up for email accounts or could
explore alternative ways to share health information with patients, such as texting
or app-based interfaces. Secure hospital- or clinic-based kiosks could offer a safe
means to access portals after discharge. Access could also be offered to caregivers
or surrogates of patients with dementia or other functional impairments. Future studies
could also explore clinical endpoints to bolster our understanding of the effects
of shared medical records on patient engagement, understanding, satisfaction, and
health outcomes.
Conclusion
Hospitals need to support the transition of care from the hospital back to the community
and this can include education and providing patients access to patient portals and
their electronic discharge summaries. Vulnerable patients show interest in having
this information available to them and efforts should be made to engage them and not
allow the digital divide to grow. As shown by our study in a safety net hospital,
additional efforts to teach patients how to access the portal may increase patient
engagement. However, as email may not be an ideal method for communication with all
patients, hospitals should consider other means of communication or consider adding
the support of patient navigators.
Clinical Relevance Statement
Clinical Relevance Statement
Electronic health records are widely used, and patient portals are rapidly growing
as a means to engage patients in their care outside of a health care setting. We developed
a brief intervention to increase uptake of patient portals, and demonstrated efficacy
in an urban safety net hospital. However, many underserved patients lacked email access,
highlighting a critical barrier to connect with vulnerable patients via portals.
Multiple Choice Questions
Multiple Choice Questions
-
Which of the following statements best describe the attitudes of participants in this
study in regards to online medical record access?
-
Increased trust in physicians.
-
Increased satisfaction with care.
-
Prefer a hospital which offers online record access.
-
All of the above.
Correct Answer: The correct answer is option d. While participants attitudes were similar in both
study arms, as seen in [Table 2], patients endorsed that online record access would increase trust in physicians
(87% control, 85% intervention), increase satisfaction in care (91% both groups),
and voiced a preference for hospitals that offered online medical record access (83%
control, 85% intervention). These results are similar to findings in studies conducted
in the outpatient settings that indicate robust interest and support for patient portals
and online record access.
-
Which of the following most accurately summarizes the findings of the study regarding
communication with patients after a hospital stay?
-
Email is a widely available method of communication with near universal uptake, and
is ideal for patient outreach.
-
The vast majority of patients prefer their communication via hard copy printed instructions.
-
Creative approaches are needed, as email use is not as prevalent as expected, and
hard copy paperwork is often misplaced.
-
Most patients are not particularly interested in communication or information after
hospital discharge.
Correct Answer: The correct answer is option c. As seen in [Fig. 1], only 43% of patients had a functional email address, a surprisingly low figure
that suggests email does not have as wide uptake as expected, and is a limited method
for communication with patients. [Fig. 2] describes attitudes toward hard copy paperwork, and a high proportion (44%) did
not recall receiving them or reading them, did not find them helpful (37%), or no
longer knows where those papers are (20%), suggesting that this is not a preferred
form of communication. Lastly, in [Table 2], over half of patients in both groups desired more information about their hospitalization
(57 and 67%, respectively), and had overwhelming preference for access to medical
records. Thus, as mentioned in the “Discussion” section, answer choice C best describes
the complexity and challenges in communicating with patients, and the need for creative
solutions going forward, such as texting or app-based interfaces.