Electronic Patient Portals: Patient and Provider Perceptions

Citation:

Powell, K. and Myers, C. (Feb, 2018). Electronic patient portals: Patient and provider perceptions. Online Journal of Nursing Informatics (OJNI), 22(1), Available at http://www.himss.org/ojni

Abstract

Background: An electronic patient portal is a potentially powerful tool to facilitate self-management support for patients with multiple chronic conditions; however, patients are not taking advantage of this resource. The purpose of this study was to explore how patients are introduced to and learn about portals and how patients and providers perceive the usefulness of a portal in the context of chronic illness self-management.  

Methods: A qualitative, descriptive design using semi-structured interviews with patients (n=9) and healthcare providers (n=7) was used to understand how patients are introduced to a portal and how they perceived the usefulness of the portal to support self-management of chronic illness. Data were analyzed using conventional content analysis. 

Results: Twelve categories related to four broad themes: 1) how patients are introduced to the portal, 2) perceived benefits of the portal, 3) perceived barriers to using the portal, and 4) perceptions of using the portal for self-management of chronic illness were revealed.

Conclusions: While providers perceived little current value in the use of portals for improving care of patients with multiple chronic conditions, we believe that with improved utilization,  portals have the potential to improve patient engagement in self-care management. This can be achieved in part by providing opportunities to learn about a portal, taking a proactive approach to integrating portals in patient care, and shifting the focus from process to outcomes.

 

Electronic Patient Portals: Patient and Provider Perceptions

Building a sustainable health information technology infrastructure has been a broad goal in the United States in recent years. Seamless flow of information within a digital healthcare environment has the potential to transform the way care is delivered and compensated (Office of the National Coordinator for Health Information Technology, 2015). The Health Information for Economic and Clinical Health (HITECH) Act, enacted in 2010 as part of the American Recovery and Reinvestment Act of 2009, resulted in requirements for health care providers to attest to objectives that demonstrate Meaningful Use (MU) of electronic health records (EHRs) (Senate and House of Representatives of the United States of America in Congress, 2009). Electronic patient portals are web-based platforms that give patients direct access to their electronic health records, potentially creating opportunities for improved engagement in their healthcare (Centers for Medicare and Medicaid Services, 2016a). Effective use of these portals could result in improved access, self-management, care coordination, and reduced costs. These potential benefits are especially critical for meeting the complex needs of patients with multiple chronic conditions. The purpose of this study was to explore how patients are introduced to and learn about the portals and how patients and providers perceive the usefulness of the portals in the context of chronic illness self-management.
Chronic illness is responsible for seven out of of 10 deaths in the U.S. (Centers for Disease Control and Prevention, 2015). Three out of four Americans, aged 65 and over, are living with multiple chronic conditions; that is, two or more conditions that require ongoing medical care (Gerteis et al., 2014).  The resource implications for caring for patients with these conditions are staggering. About two-thirds of all health care spending in the U.S. – 71% -- is associated with caring for people with multiple chronic conditions. Among Medicare fee-for-service beneficiaries, people with multiple chronic conditions account for 93% of total Medicare spending (Centers for Medicare and Medicaid Services, 2012). The management of chronic illness in the U.S. is undergoing a shift from an emphasis on provider-focused care to self-management. This shift comes as the result of both necessity and demand: necessity as the U.S. is burdened with the extensive resources needed to care for this growing populace and demand for more patient-centered care. 

Patient- and family-centered care includes integrating healthcare goals, preferences, and values by forming active partnerships between patients and providers. This requires a culture shift in which patients are no longer subjects of care but rather active participants (Frampton et al., 2017). Many patients do not participate in decisions regarding their care because they do not understand the plan of care, or they are not aware that taking an active role in managing their conditions can positively impact their lives. Self-management support encourages patients with chronic conditions to make daily decisions that foster healthy behaviors and improve clinical outcomes (Institute for Healthcare Improvement, 2009). A growing body of literature provides evidence that self-management support improves clinical outcomes and can reduce costs (Bodenheimer, Lorig, Holman, & Grumbach, 2002).  The electronic patient portal is a potentially powerful tool to facilitate self-management support for patients with chronic illnesses; however, patients are not taking advantage of this resource.

While the MU program has resulted in improved adoption (Office of the National Coordinator for Health Information Technology, 2016), patient use of portals is surprisingly low. A two-year study found that only 10% of patient’s in the VA system authenticated a portal account (Shimada et al., 2014). Even among large integrated health systems, portal adoption is typically around 30-40% (Roblin, Houston, Allison, Joski, & Becker, 2009) and even less for older patients and those from disadvantaged populations (Ancker et al., 2011; Goel et al., 2011).

Provider endorsement and engagement with a portal is critical to achieve the intended outcomes of enhanced quality, safety and efficiency. Little is known about how patients are introduced to and learn about a portal and how patients and providers perceive the usefulness of the portal in the context of chronic illness self-management support.  

Methods

A qualitative, descriptive study design (Sandelowski, 2010) using semi-structured interviews with patients and healthcare providers was used to understand how patients are introduced to the electronic patient portal and perceived usefulness of the portal to support self-management of chronic illness. The study protocol was approved by the University of Tennessee Institutional Review Board and signed consent forms were obtained from all participants prior to being interviewed.

Study setting and participants

Participants were recruited from three different primary care offices, all affiliated with the same larger primary care organization. Organizational participation was granted by establishment of a business associate agreement. The different practices were selected based on results from a previous study exploring predictors and patterns of portal use by patient with multiple chronic conditions. Practices size (i.e. number of providers), location (i.e. rural or urban) and variance of portal use were included to identify practices thought to represent maximum variation in perspectives.  Small-rural, medium-urban, and large-rural practices were selected. 

The small-rural practice was located in a suburban area despite the U.S. Census Bureau’s classification of rural (U.S. Census Bureau, 2010). This practice consisted of one primary care physician and one physician’s assistant (PA), who both agreed to participate in this study. The physician had been part of the larger primary organization since 2008 and had a well-established practice. The PA identified herself as a new graduate, having only been practicing for a little more than one year. Three patient participants were recruited from the small-rural practice and all three reported some portal use.

The medium-urban practice was located in an affluent area of a large metropolitan city.  This practice consisted of approximately 10 physicians and five nurse practitioners and PAs.    Two physicians from this practice agreed to participate in the study. The physicians were both male and one was close to retirement (he stated this in the interview). Four patients were recruited from this medium-urban practice. One patient reported frequent portal use and the other three reported little or no portal use. In addition to the providers and patients recruited from this location, one office manager was interviewed.

The third location was classified as a large-rural practice. The office was located within a regional hospital of a rural county. There were over 20 primary care providers made up of physicians, nurse practitioners, and PAs at this location. One physician, one registered nurse, and two patients were recruited from this practice. Among the two patient participants, one reported frequent use of the electronic patient portal and the other reported no use.  

Convenience sampling was used to recruit patient participants who were 45 years of age or older, registered users of the electronic patient portal, diagnosed (according to ICD-9 or 10) with two or more of the following: diabetes, hypertension, heart disease, or coronary artery disease, and an active patient (i.e. seen within the last 12 months) of a primary care provider at one of the three selected practices. Once specific practices for participant recruitment were identified by the primary investigator (PI), the central organization put the PI in contact with the office manager at each location to assist with logistics such as establishing a date for the PI to conduct interviews and arranging a private location for interviews to take place. Office staff screened patients for inclusion criteria and presented them with a flyer inviting them to participate in the study. The flyer instructed interested patients to notify a member of the staff if they were interested in participating. Patients who expressed interest were directed to a private location to meet with the PI immediately following their appointment. Providers employed at one of the three selected practice sites were also invited to participate. Providers were sent an email with details of the study and asked to contact the PI if they were willing to participate. Provider participants were interviewed in the same private location as patients at a time convenient for them. After reviewing the study protocol with the PI, participants were asked to sign an informed consent statement. All interviews were audio recorded to ensure accuracy. The qualitative literature suggests that 12 interviews are needed to achieve saturation of findings; however, the number is ultimately determined by the researcher (Sandelowski, 1995). Saturation, that is, the point in which no new concepts arise from the interviews (Walker, 2012), was reached at 13 interviews; three additional interviews were conducted to ensure no new data emerged.

Interview Guide

Based on the goal of understanding how patients with multiple chronic conditions learn about and use the portal, an interview guide was developed for patients and providers. The patient interview guide focused on four areas: 1) how the patient learned about the portal, 2) perceived benefits of the portal, 3) barriers to using the portal, and 4) perceptions of using the portal as a tool to manage chronic illnesses.  The provider interview guide focused on four areas: 1) how patients are introduced to the portal, 2) perceived effectiveness of that approach, 3) incorporation of the portal into the clinical workflow, and 4) perceived usefulness of the portal as a tool to help manage chronic conditions. 

Analysis

Conventional content analysis was the data analysis approach used in this study. Conventional content analysis was selected because it is the analysis of choice in qualitative descriptive research when existing theory or research literature on a phenomenon is limited (Sandelowski, 2010). Meaning is developed inductively from the data by allowing categories and names for categories to flow directly from the data (Hsieh & Shannon, 2005). The expected outcome of this analysis is a descriptive summary of the information contained in the data. A variety of methods were used to achieve trustworthiness of findings. Peer debriefing was used as a technique to establish credibility related to formation of codes and categories. Confirmability was established by maintaining an audit trail as codes and categories were identified and refined.

The analysis consisted of immersion in the data beginning with listening to each digital recording within 24 hours of the interview. Digital recordings were transcribed verbatim by a professional transcriptionist. All transcribed recordings were then compared to the digital recording to ensure accuracy. Identifying information (i.e. names of people or places) were removed at the same time the recordings were checked for accuracy. The coding process began by highlighting exact words from the text that appeared to capture key thoughts or concepts.  Next, codes thought to be reflective of more than one key thought were developed. The preliminary codebook was iteratively refined as additional transcripts were analyzed. A sample of four transcripts (two patient and two provider) were independently reviewed by a second researcher and then discussed with the PI until consensus was met. Preliminary codes were sorted into categories by identifying relationships between codes and groupings of codes. Over the course of the analysis, 58 open codes were developed. These were combined into four broad themes and twelve categories (see Figure 1). The results section contains exemplars for each category identified from the data.

Results

Individual interviews ranged in length from approximately five to 30 minutes with a mean time of 14 minutes. In all, nine patients and seven providers were interviewed. Provider participants included four primary care physicians, one PA, one registered nurse, and one office manager. Following the structure of the interview guide, findings are organized along four broad themes: 1) introduction to the portal, 2) perceived benefits, 3) perceived barriers, and 4) perceptions of usefulness related to self-management of chronic illness.

Introduction to the Electronic Patient Portal

Frequency and Timing of Use

Participants reported variance in their overall frequency and timing of use of the electronic patient portal. Six out of nine patients reported logging in to the portal about once per month.  The other three participants reported having never logged on since registering the account.  When asked to describe their frequency of use, several participants commented on variance in use based on their perception of their current health. Patients who perceived themselves as healthy reported fewer logins compared to times when something active was happening:

[The portal] doesn’t come into consideration to remember to check or look at unless there’s an appointment or something active going on. I did it more (logged on) when I was having scans and a lot of lab work a few years ago. Most of the time my lab results are good, and I’m in good health.  I don’t know why I’d be accessing it.

Learning to Use the Portal
This category describes how the portal was first presented to patients and how they learned to use it. Patients reported a variety of sources for their initial exposure to the portal, including the physician, nurses, and office staff (i.e. receptionist or person checking them out upon conclusion of the appointment). Some providers described an active approach to introduce patients to the portal:

The way I usually get a patient charged about it is, of course we have in every exam room, we have a sign on the door and it talks about the portal and ease of access and all that and so if they’re a new patient, I’ll tell them that.  If they’re not a new patient, a lot of times, when we’re talking about getting their lab results, I’ll say “Now, are you on the portal?” and they say “Well, no” or “What’s that?” and I’ll kind of show them the sign and I’ll say…”I recommend it and I think you should do it.

Other providers described taking a more passive approach: “there was an incentive to get so many people signed up so we were trying to talk to everybody initially but not anymore so I kind of leave it up to them if they’re interested in that.”

Patients who reported using the portal were asked to describe how they learned to use it.  The majority of patients reported learning to use the portal on their own. They used phrases such as “trial and error”, “hook or crook” or “played around with it” to describe learning to navigate the website. None of the patient participants stated that someone oriented them to the portal or described the functionality to them. 

Perceived Benefits of the EPP

Access to Information
The most frequently reported patient perceived benefit of the portal was having access to their personal health information. This category includes having access to specific health information with the ability to archive data and make comparisons. Almost all of the patient-users mentioned the ability to access their data. Both patients and providers valued the ability to archive and compare trends in data. In addition, patients reported the perceived benefit of greater depth of information when viewing results via the portal versus receiving a call from the provider’s office: “You do all these test results and in the past, you get a call from the doctor and he says, “It’s good. Don’t worry about it. It’s good but some people want to know more.”

Having access to information made patients feel more informed in their health care. One patient described how the portal facilitates active involvement. “It’s really nice to be able to pull up my cholesterol level and see what it was last time around and you know, and do some comparisons.” Several patients mentioned the benefit of being able to access data by proxy, that is, for a family member. One participant described how he is responsible for monitoring the portal for both himself and his wife: “I don’t think she has (logged in). She counts on me to do it.” Another participant gave a similar account: “I like to keep up with my information, and of course, my husband. I do for both of us.”

Providers also mentioned the benefit of the portal in providing opportunities for active participation. Providers reported benefits related to patients being more self-aware and having the ability to formulate questions (related to test results) prior to the face-to-face appointment. 

Technology-Related Benefits

The majority of participants made favorable comments regarding the technological benefits of the electronic patient portal. One patient stated, “I use my computer quite a bit and so I like learning new and different things.” Another patient stated, “One of the biggest things, I like, the technology, I’m interested in that.” The benefit of technology was perceived differently by providers. Providers were quick to point out technological limitation according to the age of the patient. Providers perceived the technology as a benefit only to younger patients:

It really depends on age, patients in their 60s and 70s are not going to use it but the ones in their 20s and 30s really like it…When you get much past the 50s and you get more into the 60s and 70s, it’s not beneficial. Most of those generations don’t know how to use a computer.

Enhanced Efficiency and Accuracy

Both patients and providers described enhanced efficiency as a benefit of the electronic patient portal. Providers were asked about how the portal had been incorporated into the clinical workflow. Providers overwhelmingly reported easy integration and little or no disruption in their clinical workflow: “It’s integrated easily. It’s just part of the normal workday.” Providers perceived using the portal to communicate as more efficient than making a phone call, which often results in leaving a message and awaiting a return call: “it saves us more work on our end cause then we’re not gonna have to chase them (patients) down.” Several patient participants mentioned cutting down on paperwork as an efficiency of the portal. In addition, one patient described the potential benefit of improved accuracy:

One thing that I would like to do obviously is avoid all this paperwork when it comes to the doctor’s office, having to type it in and read. I mean there is incorrect information and simply because people use their hands to write. When you write things down, it’s inevitable that 6 turns into an A, or a 5 turns into a 6 and a 7 or an 8, so there’s incorrect information in there. Ideally, it would be ideal if it could be done electronically.

Specific uses of the portal often came up when patients were describing the efficiency of the portal. Overall, patients perceived benefits such as viewing lab results, requesting medication refills, scheduling appointments, and using the secure messaging feature. Similarly, providers most often mentioned viewing lab results followed by communication capabilities (secure messaging). 

Perceived Barriers of the EPP

Difficulty with Portal Access

Difficulty accessing the portal due to password, computer, or server problems was frequently identified as a barrier by both patients and providers. Problems typical of any website such as forgetting the user’s password and server downtime were reported. Problems with portal access were described by patients who used the portal and those who did not. One patient who reported little, if any, portal use had this response to being asked about barriers to using the EPP,

I’ve got too many passwords. I can’t ever remember and then, lots of times, it just would freeze up and not let me have anything once I would get my new password and go back in and then it was like, there’s nothing there. So it wouldn’t update right or something.

Similar problems were reported by other patient participants: “I tried to get on it once and I couldn’t get all the way in for some reason on my computer and I don’t know what happened there. I was busy so I didn’t have time to come back and check again.” 

Providers also described problems related to the first login: “I have a lot of patients tell me they almost never can get on the first time. So a lot of people have signed on, they get frustrated and they say, “You know I tried that and I never could get anything.” 

Unavailable Features

In addition to problems accessing the portal, portal users and providers described instances of the portal not having the capability to do something they perceived as useful.  Correcting errors in the medical record, changing the preferred pharmacy, and making a payment online were some examples of unavailable features. Some features perceived as valuable were either unavailable or the participant did not realize they existed. One patient, who reported using the portal frequently (at least once per month) described wanting access to disease-specific information:

There’s a lot of potential there for instance, if there was some way that something could be set up so, that if I have osteopenia. What if something was offered to me, a link on you know on that to explain it to me and tell me what I could do about it…that would be helpful.

It is important to note that the portal currently includes this feature. A nurse participant offered another incorrect perception of portal functionality pertaining to patient entered data (e.g. the ability of the patient to enter their weight, blood pressure, blood glucose readings, etc.):

They (patients) can’t add data from home. They can request us to add a change in pharmacy or a change in phone number or things like that, but they can’t do anything from home. They can just look at it.

The portal allows patients to enter data directly into the medical record although no patient participants in this study reported having done so. When patients were asked why they did not use this feature, every participant said it was because they did not realize the function was available. Despite not using this specific feature, most patients agreed this would be a feature they would consider using in the future.

Preference for Personal Interaction

Many patients and providers described their preference for interacting with a person rather than via the portal. Patients reported enjoyment in talking to someone and having the ability to ask follow up questions if needed. When describing his preference to communicate by phone rather than via the portal, one patient said:

I always enjoy talking to them when they call.  We have a good conversation and a good thing about them is that they can ask things that usually you don’t have time to ask your doctor about.

The preference for personal interaction was shared by patients and providers across the different practice sites. One provider described this preference, “Patients in my practice, like to talk to a real person. They like that personal interaction and frankly, we do too.”

Provider-Specific Barriers

There were several barriers reported only by providers. These barriers were categorized as provider-specific barriers with three subcategories: lack of time, payment concerns, and regulatory barriers. Concerns over lack of time were frequently discussed by providers. Every provider interviewed mentioned time as a constraint in encouraging or teaching patients to use the portal. One provider described feeling guilty, “People don’t know how to do this (use the portal) and so I feel kind of guilty that I really don’t know how to do it either but frankly I don’t have time to sign them up.” Other providers described lack of time as a barrier to reviewing data entered into the portal by the patient. Providers were concerned about the amount of time it would take to review data entered by the patient. 

Providers were also concerned with integrating the portal into the current payment structure. Multiple providers mentioned the need for payment reform, specifically capitated payments, so that providers could be compensated for their work via the portal. One provider stated,

I think the barrier for us is just staying in business. I mean, if I did everything on portal and people didn’t come see me, then I wouldn’t be able to keep my office open so I mean we don’t, there’s no way get reimbursed for the work you do on the portal.

In describing the need for payment reform, another provider said,

I think what’s gonna happen is we’re gonna start getting paid if they keep going the way it’s gonna be paid on more of a capitated rate, more on patients, so keeping patients healthy is gonna be better so the more we do that, the better we’ll be paid. It won’t be fee for service forever.

Regulatory barriers were raised by several physicians when asked about barriers to using the portal. Several providers mentioned the Centers for Medicare and Medicaid Services’ MU program specifically. One provider who described the portal as “a good tool” described being frustrated by the amount of data required to be monitored for the MU program, as well as by being told how to practice:

I think the reason providers get so frustrated is, if we needed somebody to come in and tell us which tools to use, why did we go to school in the first place? Why do I go get 40 CME as a minimum every two years? Why do I go through a residence program to learn how to use the tools in my toolbox?

Another provider discussed similar regulatory barriers to using the portal:

One of the things I would say with the portal is the government’s pushing it out maybe before it’s ready for prime time and so what I found is a lot of people were excited about it initially but because it didn’t work as well as you would expect it to, then they quit using it and then once you quit using it, it’s like some email address that you signed up for and never go check it anymore.”

Perceptions of the EPP for Self-Management of Chronic Illness

Suggestions for Enhanced Utilization

Patients and providers alike offered suggestions to enhance the utilization and effectiveness of the portal. Patients described how creating a more user-friendly interface could improve the portal and make the tool more beneficial to them. Several patients discussed the need for the portal to be easier to use. As one patient noted, “It just needs to be easy, easier to navigate through.” Patients noted that tabs, especially on the mobile interface, were not labeled clearly and it was not obvious to the patient how the information was organized. Patients expect using the portal to be like using any other app on their smart-phone with clear and simple instructions. 

Provider Modeling

Patients indicated in response to direct questions that they want their providers to make specific recommendations of how using the portal could benefit their health. Patients were asked questions regarding their interest in using features (such as patient entered data) if recommended to do so by their providers. Patient responses included “most definitely” and “I would use that if he (provider) asked me to.” Rather than just encouraging general use, patients described wanting their providers to recommend using the portal in a way that has the potential to benefit their particular situations. Based on the patient’s diagnosis or level of engagement, the provider might encourage the patient to track lab results, enter weight on a regular basis, or enter blood pressure readings.

Improved Care Integration

Provider participants described future opportunities for using the portal in chronic illness management. Providers indicated a need for support through training and exposure to opportunities for use beyond those required by regulations. Multiple providers described their lack of training and familiarity with the portal as an opportunity for improved use. Providers admitted that they had little experience with the portal and some had never even seen it.  Providers made statements like, “I’ve never signed on to the portal and I don’t know what’s involved” and “I personally have never actually gotten on it”. 

Lack of provider experience using the portal leads to mixed perceptions of its potential as a tool to improve self-management in patients with multiple chronic conditions. Some providers had generally favorable opinions of the portal while others took a more defensive position as they perceived the portal was being forced on them. One physician explained, “I haven’t thought much about it. Ah, you know, I got by for 34 years without it.” Several providers recognized value in the portal in the present but even more so in the future. Providers described the portal as “in its infancy” and were hopeful in the future benefits for patients with chronic illness. 

Despite frustration with the regulations set forth in the MU program, providers remained hopeful that the portal would benefit the care of patients with chronic illnesses. One provider summarized, “It’s the rules. We live by it. I hope that some of it has the ah, the intended result of better patient care.” Another provider had positive perceptions of the potential for using the portal in chronic illness management. She described the value specifically for patients with chronic conditions being able to track small improvements:

I really do feel like they (portal users) have more of a grasp on what’s going on and the continuum of their care because a lot of these diseases, you don’t fix overnight and a lot of them get discouraged I think because they’re not making progress, the great leaps and bounds like you can do if you have an upper respiratory tract infection or something, but I think that through communication of the portal and then being able to communicate back with us, and talking about the plan of care, I think that would certainly help in chronic disease management.

Discussion

This qualitative study identified 12 categories describing perceptions of how patients are introduced to the portal and how patients and providers view the tool in the context of chronic illness management. By interviewing patients and providers from practices that varied in both size and location, we were able to capture a broad perspective of perceived usefulness of the portal and identify areas of opportunity for the future. We postulate that with improved utilization, the portal has the potential to improve patient engagement in chronic illness self-management. Findings from this study reveal opportunities for future research, as well as practice and policy implications.

Opportunities for Future Research

Data from this study revealed overall low rates of portal use.  Three of nine (33%) patient participants reported never logging in despite activating their portal accounts. Understanding why patients registered but never used the portal was important to our study; thus, we welcomed the perspective of these registered non-users. In most cases, patients who did not use the portal perceived it to be of limited value. Patients who perceived their health as good, despite having multiple chronic conditions, were not aware of how the portal might be useful to them. Patients were optimistic about using the portal if their providers suggested they do so. This finding is consistent with others who report improved rates of use when providers recommend a specific feature of the portal or explain how it might benefit a particular patient (Black et al., 2015; Mikles & Mielenz, 2014). There is a need for further research, specifically, outcome-focused, interventional studies examining the effects of provider encouraged use of the portal for self-management in chronic illness.

Patient participants who reported using the portal on a regular basis reported at most, logging in once per month. The most frequent reason patients cited for not using the portal more often was a lack of knowledge surrounding available features and how to use them. Phelps et al. (2014) conducted a study in the United Kingdom examining factors related to persistent use of a portal by patients with chronic kidney disease. They found providing assistance with the first login was strongly associated with becoming a persistent user even after three years. Similarly, Weisner et al. (2016) reported on a study in which patients were taught portal skills including how to send a secure message, view test results, and access educational materials. Patients who received this instruction had more portal logins and engaged in these tasks more often than those who did not receive the training. Future studies should explore effective teaching strategies aimed at both patients and providers to maximize their use of this tool. Teaching patients how to use the portal requires a different approach to integration than providers in the current study described.

Every provider interviewed in this study reported that the portal was easily integrated into their practice. Patients and providers described enhanced efficiencies in using the portal for administrative tasks such as refilling prescriptions and scheduling appointments, however, most practices were using the portal in addition to, rather than in place of, traditional communication approaches (i.e. phone calls, paper reporting). Providers were concerned that patients would not receive the communication sent via the portal but did not have that same concern regarding a phone call or result sent through the mail. It was not clear if this concern was related to a distrust in technology, lack of confidence on the part of the provider, or some other factor. Future research should explore these factors and others that may influence provider confidence in the portal.

Practice Implications

One concern raised frequently by providers was that older patients would not be interested in using the portal. Multiple providers, including physicians, a PA, and a nurse mentioned age as a barrier to using the portal. Older adults, those age 65 and older, have been the fastest growing group of internet adopters since the year 2000 (Perrin & Duggan, 2015). A 2012 Pew Research survey reported over half of Americans age 65 and older were internet users (Smith, 2014). None of the patients interviewed in this study mentioned internet or computer access as a barrier to using the portal.  In fact, they made positive statements regarding technology in general. Patients made statements such as “I like the technology” and “I like learning new and different things.” The overwhelming reason patients reported not using the portal was that they were unaware of how it might benefit them. While we realize the portal will not be embraced by everyone, those who are interested in using it deserve a more proactive approach to clinical integration.

When asked to describe portal integration, providers spoke of the process of getting patients enrolled but none talked about integration into patient care. Providers had not considered using the portal outside of administrative tasks. When asked to share their thoughts for using the portal to improve care of patients with multiple chronic conditions, responses included statements like, “I haven’t really thought about the portal a whole lot” and “I’ve gotten by for 34 years without it.” It is widely reported in the literature that patients with chronic illness such as heart failure and diabetes, who are actively involved in their care and adhere to treatment plans, are more likely to have improved health and quality of life (He et al., 2017; Lainscak et al., 2011).  The ability to track and enter personal data, monitor symptoms, and communicate with the healthcare team are some of the existing functions within the portal that facilitate self-care management. Findings from this study add to the existing evidence that these features are underutilized and under-evaluated (Otte-Trojel, de Bont, Rundall, & van de Klundert, 2016). Providers must look past the short-term benefits of incentive payments and consider the portal’s value in improving patient care. Provider recommendations are critical as portal developers improve current functionality and create new products that facilitate self-management support.

Policy Implications

Throughout the course of provider interviews, it was clear that integration of the portal was a reactive process. Portal deployment, thus far, has occurred under the auspice of federal regulations. The MU incentive program used a sequential approach that first focused on adoption and later implementation and patient engagement (Centers for Medicare and Medicaid Services, 2016a). As regulations were imposed, portal developers focused their attention to creating systems to meet those requirements. The result was a portal with the technological capability of meeting the MU requirements but with underwhelming attention to patient needs. While the portal design met the provider’s needs for MU attestation, it did little to facilitate other provider needs such as clinical-care integration and improved outcomes. Despite harsh criticisms regarding the lack of flexibility and complexity (Halamka, 2016), the MU program made significant strides in facilitating adoption of EHRs.  Since the first MU reporting period in 2010, office-based physician adoption of any EHR increased by almost 40% and, as of 2015, three out of four office-based physicians had adopted a certified EHR with a portal (Office of the National Coordinator for Health Information Technology, 2016). As providers now transition to the merit-based incentive payment system (MIPS), they will be able to customize a set of measures that best represents how they use EHR technology in their day-to-day practices (Centers for Medicare and Medicaid Services, 2016b). While the MIPS program appears to offer greater flexibility for providers, it continues to incentivize processes rather than outcomes. 

A shift from process to outcomes is critical to maximize the potential of the portal.  Providers in this study did not seem to consider using the portal to improve outcomes, rather they perceived it as a federally mandated tool they were prescribed to use. One plausible explanation for this perception is the current structure of the MU incentive program. The providers interviewed in this study focused on the process of getting patients enrolled into the portal but had little interest in patient’s continued use once enrolled. This is likely the result of early objectives targeted at portal implementation and adoption. As providers prepare to report on new MIPS objectives, we hope to see the focus shift from process to patient engagement and improved outcomes. This shift will require continued support of providers and policy makers. Provider must buy-in to the capability of the portal in improving care of patients with multiple chronic conditions and policy makers must look for ways to directly incentivize improvements in quality, safety and efficiency. 

Limitations
This study has several limitations. First, because participants were recruited from primary care practices located in one geographic area, findings may have limited generalizability. Although the sample was drawn from multiple practices varying in size and located in both rural and urban settings, all practices were located in the same state. Regional differences may account for different perceptions of usefulness and barriers to using the portal. Another limitation is related to not collecting demographic data from participants. A decision was made at the onset of this study not to collect demographic data from participants as these data were thought to add little value to the study. In hindsight, demographic data such as age, gender, and ethnicity would have helped to capture some of the nuance associated with different perspectives and should be collected if possible. 

Conclusion

The purpose of this qualitative descriptive study was to understand how patients are introduced to the electronic patient portal and perceived usefulness of the portal to support self-management of chronic illness. By interviewing patients and providers in both urban and rural settings, we were able to identify 12 categories surrounding how patients are introduced to the portal, perceived benefits and barriers, and perceptions of the portal for self-management of chronic illness.

The main reason patients cited for not using the portal was because they did not perceive it to be useful to them or did not understand what features were available. Patients reported being more likely to use the portal when their providers encouraged them to use specific features.  Providers described barriers including lack of time to teach patients to use the portal, as well as payment concerns and regulatory barriers. Providers also made numerous comments regarding their own lack of training and overall lack of familiarity with portal functionality. 

Patients and providers were optimistic regarding the benefits of the portal in giving them direct access to health-related data, technology related benefits, and opportunities for enhanced efficiency. While providers perceived little current value in the portal for improving care of patients with multiple chronic conditions, we believe that with improved utilization, the portal has the potential to improve patient engagement in self-care management.  This can be achieved in part by providing opportunities to learn about the portal, taking a proactive approach to integrating the portal in patient care, and shifting focus from process to outcomes.

The electronic patient portal is an emerging technology that is in its infancy. While federal policy has certainly hastened development, integration into chronic disease management requires identification of best practices and additional research. Best practices related to the portal are just beginning to emerge. Assisting the patient with the first portal login and provider encouraged use of specific portal functions are some best practices identified in this study that are consistent with those previously reported. Additionally, it is important that assumptions regarding patient use based on age be suppressed, as age alone does not appear to be a deterrent to use. As portal use becomes more widespread, best practices should be implemented to fully realize benefits of portal integration in chronic illness management.

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Author Bios:

Kimberly Powell, PhD, RN, CNE, is an assistant professor at the University of Tennessee College of Nursing. Dr. Powell earned her bachelor’s degree in nursing from Purdue University in 2001 and her master’s degree from Spalding University in 2013. In 2017, Dr. Powell earned her Ph.D. in nursing along with a graduate certificate in health policy from the University of Tennessee. Dr. Powell is a native of Louisville, Ky., and currently resides in Knoxville, Tenn., with her husband and two daughters.

Carole R. Myers, Ph.D., R.N., is an associate professor at the University of Tennessee in the College of Nursing with a joint appointment in the College of Public Health. Dr. Myers received her Ph.D., and master of science in nursing degrees from the University of Tennessee. Her scholarly focus is on health policy.