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A Portal Adoption Program to Enhance Patient Engagement in Primary Care

Paper Type: Free Essay Subject: Information Systems
Wordcount: 4999 words Published: 8th Feb 2020

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Abstract

Patient engagement technologies have become a focal point for defining quality in government and medical practice arenas. Patient portals are recognized as a promising mechanism to foster patient engagement, and as such, have become embedded in major healthcare reform initiatives. Despite sweeping implementation endeavors, portal adoption rates among patients remain low and create a significant gap in quality-based reimbursement. The purpose of this research was to evaluate a 12-week portal adoption program in the primary care setting featuring customized tablets with a patient-centric design for targeted point-of-contact portal registration. This project focused on three objectives: (1) achieve a 75% metric for portal adoption to align with highest tier adopters, 2) evaluate patient satisfaction for measuring perceived ease-of-use and usefulness of system, and (3) assess cost-effectiveness in determining sustainability and potential to replicate the initiative throughout other primary care settings.An outcome evaluation of the program revealed a 90% portal utilization rate, 94% new patient portal adoption rate, and 79% existing patient portal adoption rate during the data collection period. Chi-square analysis revealed a statistically significant difference in patient satisfaction scoring relative to efficiency, quality of care, and safety of information based on gender and insurance carrier demographics.

Keywords: patient engagement; portal adoption; patient satisfaction

A Portal Adoption Program to Enhance Patient Engagement in Primary Care

Patient portals are recognized as a promising mechanism to help patients become more actively involved in their own healthcare experience. Research shows that when patients are engaged in the healthcare process, it can lead to measurable improvements in quality, safety, and cost.1 Questions prevail as to the most effective way clinicians can encourage portal use among patients and what factors contribute to sustained utilization. Few studies bridge the gap between effective information technology (IT) strategies for increasing portal adoption and patient satisfaction with these systems.2 The majority of published studies related to portal adoption focus on general use statistics of patient portals such as patient demographics and overall patient satisfaction with clinical portals.3 Evidence-based research is needed in the area of cost-effective IT strategies for accelerating portal use and patient satisfaction with these modes of operation to assist primary care practices in meeting goals for quality in a new merit-based healthcare market.

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In the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2010, the federal government allocated $30 billion toward achieving electronic health record (EHR) adoption based on potential for economic and clinical transformation.4 The fundamental premise for the creation of the HITECH Act was that it was necessary to demonstrate ’meaningful use’ of EHRs before their use could demonstrate improvements in patient care.5 With the introduction of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, ‘meaningful use’ was transitioned to become one of the four components of a new merit-based incentive payment program.

The Centers for Medicare and Medicaid Services (CMS) implements a quality payment incentive program which rewards value and outcomes in one of two ways: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). Under this payment system, providers no longer face the threat of double digit cuts each year, as they did under the now-repealed Sustainable Growth Rate formula, and there will be greater certainty in annual payment updates.6 Performance within these systems is measured through certified EHR technology with a focus on high-quality, coordinated, and cost-efficient care.7 By increasing portal adoption rates and measuring patient satisfaction with portal adoption systems, quality measures within the ‘patient engagement’ domain can be satisfied resulting in a positive impact on insurance reimbursement.

PURPOSE OF THE PROJECT

The purpose of the quality improvement project described here was to determine the effectiveness of a 12-week portal adoption program featuring computerized tablets configured with a personalized logo, a technical and nontechnical benefits page, a portal privacy information page, and an easy-to-use portal registration template featuring fewer steps than the existing system. Participants were targeted based on inactive portal registration status and offered point-of-contact registration at multiple points of care on the day of visit. This project focused on three objectives: (1) achieve a 75% metric for portal adoption to align with highest tier adoption across primary care practices, (2) evaluate patient satisfaction by using the Health IT Patient Satisfaction Survey instrument for measuring perceived ease-of-use and usefulness of system, and (3) evaluate cost effectiveness in determining sustainability and potential to replicate the initiative throughout other primary care settings.

LITERATURE REVIEW

A review of the literature related to patient engagement IT strategies for increasing clinical portal uptake in the primary care setting and the effect of these strategies on patient satisfaction scoring was performed. Few research studies identified specific IT strategies for increasing portal uptake and general use statistics were primarily used for assessing patient satisfaction with portal use.

The current driver of patient portal enrollment is CMS’s Quality Payment Program (QPP). While CMS criteria outline requirements of adoption rates, they do not delineate the steps required for patient engagement in a relevant and sustainable way.8 In order for healthcare institutions to track the success of patient portals as it relates to patient engagement, a definition of portal adoption should include motivating factors for initiation, usability of system, and provider promotion. A definition of this kind would inform a set of universal quality and efficiency reporting measures beyond the minimal ‘meaningful use’ criteria to include more relevant patient engagement data.

Before a patient portal can serve as a tool for patients to become more engaged and involved in their own care, patients must first adopt it. Several studies examining portal adoption have shown that ethnic minorities and patients who are younger than 35, healthier, and less educated were less likely to adopt patient portals; however, results are mixed regarding gender differences.9 People with disabilities and chronic conditions, frequent users of healthcare services, and caregivers of elderly parents or children tend to have the most interest in patient portals. Other important factors of patient portal adoption include provider acceptance and promotion, and usability of the patient portal interface including ease of registration, navigation, and perceived privacy and security.10

In a state of the science review by Irizarry, Dabbs, and Curran,8  four studies directly addressed the impact of health literacy of intended users on successful portal adoption. Results showed that patients responded better when medical jargon and abbreviations were translated into “patient friendly” language.Monkman & Kushniruk11 suggest that including health literacy assessments in usability testing of consumer health information systems, such as patient portals, would inform the design of systems for better navigation, data input, and conceptual understanding of health information included throughout the patient portal.

Early usability testing, and its role in portal design, is important because it directly impacts whether or not a patient can easily adopt a patient portal. It also impacts the ability of the user to successfully navigate portal functions, accurately input information, and comprehend the information presented, ultimately contributing to its usefulness as a tool for patient engagement.8 Much of the literature surrounding usability confirms that adoption and sustained use of technology are directly related to ease of navigation and the perceived usefulness of the available information. The top two patient portal qualities that were deemed most utilitarian for patients were personalization and collaborative communication between patient and providers.12 While numerous descriptive and qualitative studies confirm the desire for personalized patient portal functionality, there is little research about what kind of IT personalization would lead to greater patient engagement.

Clain13 joined with other colleagues to focus on portal adoption as part of the Athenahealth Peak Performance Initiative, this program combined big-data analytic consultation with leading providers, and best-practice research to help provider groups improve various aspects of their practices.For this patient portal study, more than 1,100 provider groups were analyzed to determine exactly what distinguishes provider groups with very high portal adoption rates from average programs. This research uncovered four key insights: (1) all groups use patient portals, (2) practice size neither hinders nor helps portal adoption, (3) top-performing groups are getting better, and (3) in-office registration works best. Across Athenahealth practices, those in the highest adoption tier with a clinical portal tenure of 36 months maintain an average adoption rate of 75% and managerial resolve is described as the catalyst for driving these high portal adoption rates.13

METHODS

Design

Institutional review board approval was obtained for this quality improvement study featuring an outcome evaluation of a 12-week portal adoption program in a primary care setting. Participants were consented when they checked in for their appointments. The intervention group included any new or existing patient presenting for acute or chronic care with inactive portal registration status. Each participant was asked to utilize a custom designed tablet for portal registration and complete an end-user patient satisfaction survey instrument. Participants were not randomized as all eligible patients were asked to participate in the study.

Sample and Setting

The setting for the study was an internal medicine clinic in the Mid-Atlantic region. The practice provides primary healthcare services to adult patients of different races and a variety of socioeconomic backgrounds. Three full-time physicians, two full-time nurse practitioners, and two part-time nurse practitioners provide services for acute and chronic healthcare needs of the population. On average, providers see approximately 1000 patients per month. For the purpose of this study, the population included eligible patients scheduled with all providers attending the clinic during the data collection phase of the study. Minors, subjects who were unable to read and write English, and those who were cognitively impaired were excluded from the study.

Intervention

The intervention group was selected based on inactive portal registration status as delineated in a nonclinical window within the office-based EHR. Any new or existing patient presenting for acute or chronic care who was unregistered was asked to participate in the study. Each participant was offered a custom designed tablet for point-of-contact portal registration. Participants were encouraged to register for portal use at check-in, during the examination period, and at check-out. Each participant was asked to complete an end-user survey instrument on the day of visit.

Instruments

 The Health IT Patient Satisfaction Survey was chosen for this study as it was developed by the Health IT Research Center (HITRC) and the Iowa Foundation for Medical Care to aid providers and health IT implementers assess the impact of health IT adoption to inform quality improvement initiatives.14 The results provide an understanding of how patients are responding to EHR use in an office-based setting.

 The Health IT Patient Satisfaction Survey tool is provided by the National Learning Consortium (NLC), a virtual and evolving body of knowledge and tools designed to support health providers and health IT professionals working towards the implementation and adoption of certified HER systems.14 The NLC represents the collective EHR implementation experiences and knowledge gained directly from the Office of the National Coordinator’s (ONC) outreach programs and through the HITRC Communities of Practice (CoPs). This survey tool is used in the healthcare field today and recommended by professionals who have made the commitment to implement or upgrade to certified EHR systems.14

Data Collection Procedure

Eligible patients who were scheduled to see a provider during the data collection phase of the study received a brief explanation of the study at the check-in window. Each patient who agreed to participate was offered a customized tablet for point-of-contact registration during the check-in process. A second point-of-contact for portal registration was offered during the examination period by the provider.  A third and final point-of-contact for portal registration was provided at check-out. Each participant was offered an end-user Health IT Patient Satisfaction

Survey instrument to be completed on day of visit. Demographic information including gender, age group, and insurance carrier information was supplied by the patient and housed within the survey instrument. Personal health records were not accessed as part of this study. The primary investigator audited in-house performance monitoring software filtered for portal adoption and portal utilization. Portal adoption and utilization data were collected at weekly intervals and housed in run chart format to facilitate ongoing performance monitoring. End-user survey data was collected at the end of the 12-week implementation period and entered into an Excel spreadsheet.

Data Analysis Procedure

Internal auditing of performance monitoring software was performed by the researcher to collect portal adoption and utilization data. Data were entered into an Excel spreadsheet. IBM SPSS Statistics Version 24 was utilized to code and measure the data collected from the Health IT survey. Chi-square analysis was used to analyze differences in categorical variables based on gender and insurance carrier. The results of the chi-square analysis allowed the researcher to determine if gender and insurance carrier had any bearing on patient satisfaction with the portal adoption process. The alpha level was set at p < .05 for all analyses.

RESULTS

During the 12-week implementation period, there were a total of 1,076 eligible participants. Of the eligible participants categorized as existing patients, 851 (79%) activated portal accounts on the day of their visit during the data collection period. Of the 2,213 total patients seen during the 12-week implementation period, 90% (1,988) were defined as active portal users during the data collection period. Of the 63 participants categorized as new patients during the study implementation period, 94% (59) registered for portal use on their first visit to the office (Figure 1). 

According to a survey of 184 adults during the data collection period, there was a statistically significant difference in patient satisfaction relative to program efficiency (p=.001, a=.05), quality of care (p=.000, a=.05), and safety of information (p=.000, a=.05) based on insurance carrier. Of the 132 patients with third party insurance carriers surveyed, 80% described the program as efficient, 68% believed the program would ensure quality of care, and 73% believed their personal information was safe in the computer (Figure 2).

Additionally, there was a statistically significant difference in patient satisfaction relative to efficiency (p=.000, a=.05), quality of care (p=.000, a=.05), and information safety (p=.000, a=.05) based on gender. Of the 116 females surveyed during the data collection period, 82% described the program as efficient, 71% felt the program ensured quality of care, and 72% described their personal information as safe (Figure 3).

Conversely, males and Medicare recipients were less satisfied with the portal adoption program. Only 52% of Medicare beneficiaries described the program as efficient, as few as 32% felt the program ensured quality of care, and a mere 27% of believed their personal information was safe. Males had equally low percentages for efficiency, quality of care, and safety of information.

DISCUSSION

The study population consisted of 1,076 adult patients at an internal medicine practice in the Mid-Atlantic region during spring 2018. An initial analysis focused on portal adoption and utilization rates with the implementation of patient-centric tablets with simple navigation and point-of-contact portal registration. From February 2018 to May 2018, the practice achieved a 90% portal utilization rate, 94% new patient portal adoption rate, and 79% existing patient portal adoption rate. An audit of portal adoption rates prior to study implementation yielded a calculated score of 60% at 12 months tenure which had remained relatively unchanged over several months. Study results suggest that providing unregistered patients with on-site portal registration technologies which feature an office logo, a portal benefits page, a safety information page, and a simple registration template increases portal adoption and utilization rates in the primary care setting.

Three key areas of focus related to patient satisfaction were extracted from the Health IT Patient Satisfaction Survey based on administrative priorities for assessing the program’s usability, sustainability, and replication throughout other primary care settings.  These three areas of primary examination were perceived efficiency, usefulness, and privacy of the program. Patient satisfaction results revealed a statistically significant difference in patient satisfaction with the portal adoption program based on gender and insurance carrier demographics. Females and private insurance beneficiaries described the newly implemented portal registration process as efficient, secure, and ensured quality of care, whereas, males and Medicare recipients did not share the same view.

In terms of cost effectiveness of the program, direct costs to the organization were minimal. Hardware, software, and technical costs totaled $600.00. There was no increase in administrative or operational costs as all study-related activities aligned with standard operating procedures for the practice. There were no promotional or legal costs to the organization. On the contrary, the pay yield for this type of program is quite substantial. Increasing portal adoption by 20 percent or greater improves pay yields of four to eight percent.15 A registered portal patient is 13 percent more likely to return, and the value of a returning patient is eight to 20 percent higher.15 Practices see an eight percent drop in no-show rates with clinical portal activation and self-pay balances are reduced by 2.6% on average with online payment.15 Practices retain 80 percent of new patients who sign up for a portal account within 30 days of their visit leading to substantial gains in revenue.16

 In a study by Kim, Kagel, Tayal, Bose-Brill, & Lai,5 portal use reduced office visits and telephone encounters by 14 percent and 19 percent per year. The total cost savings over three years was $168,837 compared to total costs for operating the portal at $25,470.5 In the same study, an 11-percentage-point increase in the number of patient portal users allowed a provider to see 26 more patients per year.

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A 2017 Government Accountability Office (GAO) report noted that while 90 percent of providers offer access to a patient portal, less than one-third of patients have integrated the tool into their daily lives.17 Heath states that providers must overcome the barriers that limit portal adoption including low IT literacy, complicated interfaces, and lack of provider promotion.18 The findings from this study support the research done by Health and reveal the measurable benefit of creating a portal adoption program featuring a usable interface and team-based framework for portal registration.18 Furthermore, the results of this study reveal the impact of targeted point-of-contact registration for increasing portal uptake in the primary care setting.

Study findings suggest that an effective patient portal is the centerpiece of any comprehensive patient engagement strategy. Regardless of whether a healthcare organization is looking for ease of operations, productivity gains, cost savings, or a combination of all, a portal will succeed or fail based upon the perceived benefits to the population it serves.

Limitations

There are limitations to this study. First, the researcher did not collect demographic information from participants to better understand differences in participants’ education levels. This information could have served to better understand differences in patient satisfaction scoring with portal use based on education level. Second, the researcher did not collect demographic information from participants to better understand differences in income level. This information could have served to better understand differences in patient satisfaction scoring with portal use based on income level. Third, the researcher collected age group data for patient satisfaction scoring which was too broad and did not satisfy the pretest checklist criterion for chi-square analysis. By narrowing the age group data or studying individual ages, the researcher could have better understood differences in patient satisfaction scoring with portal use related to age. Incorporating individual age, education level, and income status into this study would have provided deeper insight into differences in patient satisfaction scoring with clinical portal use based on a more comprehensive definition of socioeconomic status.

CONCLUSION

Patient portals are increasing in number as healthcare organizations strive to meet patient engagement metrics in a new value-based healthcare economy. Just making a portal available to patients will not ensure its use. This study is a step in determining best practices for implementing a cost-effective IT strategy to increase portal uptake in the primary care setting. The results of this study indicate that patients are more likely to register for portal use when it is supported by providers, features a patient-centric design, and has functionality that supports on-site patient activation in an easy-to-use tablet format. The results of this study also indicate that females and private insurance beneficiaries believe clinical portals are efficient, ensure quality of care, and maintain privacy of information. On the contrary, males and Medicare recipients are far less satisfied. This study suggests a need to further explore the specific needs of males and Medicare beneficiaries to dispel security fears, increase comfort level, and ensure quality of care with clinical portal use to continue to improve portal adoption rates.

As portal uptake continues to grow, the administrative burden of providers will equally grow. Future healthcare initiatives are needed to assess effective IT strategies for filtering large streams of clinical data to lessen provider burnout. In a data driven culture, time is at such a premium, and the amount of information so vast, leaders can no longer act in a linear fashion.19 Finding ways to combine interconnectivity, innovation, and communication without sacrificing quality of care and increasing office-based manpower and costs, will define healthcare leaders in the future.

References

1.  Agency for Healthcare Research and Quality. Patient and Family Engagement. Agency for Healthcare Research and Quality Website. https://www.ahrq.gov/topics/patient-and-family-engagement. Updated 2018. Accessed June 1, 2018.

2.  Goel M, Brown T, Williams A, Cooper A, Hasnain-Wynia R, Baker D. Patient reported barriers to enrolling in a patient portal. JAMIA. 2011;18: 8-12.

3.  Emont S. Measuring the Impact of Patient Portals: What the Literature Tells Us.  Comprehensive Health and Education Forum Website. https://www.chef.org. Accessed October 1, 2017.

4.  Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health               records. NEJM. 2010;363(6):501-504.

5.  Kim D, Kagel J, Tayal N, Bose-Brill S, Lai A. The effects of doctor-patient portal use on health care utilization rates and cost savings. SSRN. 2017;2:1-39.

6.  American Medical Association. Understanding Medicare’s Merit-Based Incentive Payment System. American Medical Association Website. https://www.ama-assn.org. Updated 2018. Accessed September 1, 2018.

7.  Centers for Medicare and Medicaid Services. Quality Payment Program. CMS Website. https://www.qpp.cms.gov. Updated 2018. Accessed July 1, 2018.

8.  Irizarry T, Dabbs A, Curran K. Patient portals and patient engagement: A state of the science review. JMIR. 2015;17(6):e148.

9.  Ketterer T, West D, Sanders V, Hossain J, Kondo M, Iman S. Correlates of patient portal enrollment and activation in primary care pediatrics. AAP. 2013;13(3):264-271.

10.  Wald J. Variations in patient portal adoption in four primary care practices. AMIA. 2010; 2010:837-841.

11.  Monkman H, Kushniruk A. Applying usability methods to identify health literacy

issues: An example using a personal health record. Stud Health Technol Inform. 2013;183:179-185.

12.  Abramson E, Patel V, Edwards A, Kaushal R. Consumer perspectives on personal

health records: A 4-community study. AJMC. 2014;20(4):287-296.

13.  Clain D. AthenaResearch study: The current state of patient portal. Athenahealth Website. https://www.athenahealth.com. Updated 2018. Accessed August 7, 2018.

14.  National Learning Consortium. Health IT patient satisfaction survey. Health IT Website. https://www.healthit.gov. Updated 2018. Accessed September 1, 2018.

15.  Geyer S. Patient portals helping increase revenue, decrease costs. Healthcare IT News Website. https://www.healthcarenews.com/news/patient-portals. Updated 2018. Accessed September 1, 2018.

16.  Landi H. The business case for increasing patient portal adoption. Healthcare Informatics Website. https://www.healthcare-informatics.com. Updated 2018. Accessed August 1, 2018.

17.  United States Government Accountability Office. Health information technology:

HHS should assess the effectiveness of its efforts to enhance patient access to and use

of electronic health information. https://www.gao.gov. Updated. 2018. Accessed September 1, 2018.

18. Heath S. What are the top barriers to patient portal adoption, use? Patient Engagement Health IT Website. https://www.patientengagementhit.com. Updated 2018. Accessed July 1, 2018.

19.  Dixon P. Top 3 skills healthcare leaders need now. Healthcare IT News Website. https://www.healthcareitnews.com. Updated 2018. Accessed October 1, 2018.

Figure 1. End of Study Portal Adoption Rates

Figure 2. Portal Satisfaction by Insurance Type

Figure 3. Portal Adoption Satisfaction by Gender

 

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