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Published on 20.02.15 in Vol 17, No 2 (2015): February

This paper is in the following e-collection/theme issue:

    Review

    Patient and Provider Attitudes Toward the Use of Patient Portals for the Management of Chronic Disease: A Systematic Review

    School of Health Administration, College of Health Professions, Texas State University, San Marcos, TX, United States

    *all authors contributed equally

    Corresponding Author:

    Clemens Scott Kruse, MBA, MSIT, MHA, PhD

    School of Health Administration

    College of Health Professions

    Texas State University

    HPB, 2nd Floor

    601 University Dr

    San Marcos, TX, 78666

    United States

    Phone: 1 210 355 4742

    Fax:1 512 245 8712

    Email:


    ABSTRACT

    Background: Patient portals provide patients with the tools to better manage and understand their health status. However, widespread adoption of patient portals faces resistance from patients and providers for a number of reasons, and there is limited evidence evaluating the characteristics of patient portals that received positive remarks from patients and providers.

    Objective: The objectives of this systematic review are to identify the shared characteristics of portals that receive favorable responses from patients and providers and to identify the elements that patients and providers believe need improvement.

    Methods: The authors conducted a systematic search of the CINAHL and PubMed databases to gather data about the use of patient portals in the management of chronic disease. Two reviewers analyzed the articles collected in the search process in order remove irrelevant articles. The authors selected 27 articles to use in the literature review.

    Results: Results of this systematic review conclude that patient portals show significant improvements in patient self-management of chronic disease and improve the quality of care provided by providers. The most prevalent positive attribute was patient-provider communication, which appeared in 10 of 27 articles (37%). This was noted by both patients and providers. The most prevalent negative perceptions are security (concerns) and user-friendliness, both of which occurred in 11 of 27 articles (41%). The user-friendliness quality was a concern for patients and providers who are not familiar with advanced technology and therefore find it difficult to navigate the patient portal. The high cost of installation and maintenance of a portal system, not surprisingly, deters some providers from implementing such technology into their practice, but this was only mentioned in 3 of the 27 articles (11%). It is possible that the incentives for meaningful use assuage the barrier of cost.

    Conclusions: This systematic review revealed mixed attitudes from patients and their providers regarding the use of patient portals to manage their chronic disease. The authors suggest that a standard patient portal design providing patients with the resources to understand and manage their chronic conditions will promote the adoption of patient portals in health care organizations.

    J Med Internet Res 2015;17(2):e40

    doi:10.2196/jmir.3703

    KEYWORDS



    Introduction

    As of 2012, about half of all adults in the United States suffer from one or more chronic diseases [1]. The top 10 chronic conditions are hypertension, coronary heart disease, stroke, diabetes, cancer, arthritis, and hepatitis [1,2]. Chronic conditions affect any individual regardless of age, race, or socioeconomic status, although it was noted that co-morbidity increases with age and prevalence is higher among non-Hispanic white adults [1]. Individuals suffering from more than one chronic disease usually have multiple providers and consume more medical services such as hospitalizations, office visits, and medications, which lead to higher health expenditures [2,3].

    The concept of a patient portal has asserted its presence in literature for the last several years. The US government provides a rather clear definition of a patient portal: “a secure online website that gives patients convenient 24-hour access to personal health information from anywhere with an Internet connection” [4]. The patient portal differs from a personal health record (PHR), however, in terms of ownership. The data in a patient portal are owned and managed by the health care organization along with the electronic health record (EHR) [4]. The advantage of a portal over a PHR is that the data are updated whenever there are updates on the EHR, while the data in a PHR are only updated when the patient updates them. Patient portals offer many features, and health care organizations can choose different features of even the same vendor solution. The basic portal enables a patient to access his/her information such as recent office visits, discharge summaries, medications, immunizations, allergies, and lab results, and the more advanced portals enable a patient to request prescription refills, schedule non-urgent appointments, and exchange secure messaging with his/her provider [4].

    Features enabled by patient portals are intended to improve quality and access to health care by engaging patients to be more active in managing and monitoring their health [3-6]. Many health care systems have piloted or implemented patient portals with emphasis on secure communication to assist patients with the management of their own health and to improve the coordination of care across multiple providers [3,7,8]. Patients may communicate electronically with their provider, access personal health records (PHR), receive lab results, request for medication refills, schedule appointments, and learn more about their health [7,9,10]. Some portals allow patients to monitor their own health by entering their daily blood sugar levels or weight loss progress, which give patients a greater sense of empowerment in the management of their conditions [10-12].

    In 2009, less than 5% of hospitals utilized a Web-based patient portal [13]. Since Congress passed the Health Information Technology for Economic and Clinical Health Act (HITECH) in 2009, patient portal adoption has gained greater attention as it enables a secure means of continuous patient-centered care [3,8,10,11]. Innovations in health information technologies (HIT) allow providers to implement electronic PHRs to deliver targeted patient education for disease management and to support provider decision-making [14-16]. Patient health coaching has emerged as an effective service to educate patients on their chronic conditions, provide eVisits, and strengthen the patient and provider relationship [17-19].

    Current research of patient portals has revealed mixed feelings among patients and providers who use Web-based patient portals to monitor their chronic conditions [20]. Despite potential advantages to providing personalized patient-centered care, health care providers are concerned about the increasing workloads to meet patient demands, lost profits, insufficient security, and the high cost of acquiring and maintaining a patient portal system [8,13,16,21].

    The purpose of this research is to conduct a systematic literature review to identify provider/patient attitudes toward the use of patient portals for the management of chronic disease. The review will also identify portal features that received favorable responses from patients and providers, and it identifies the portal services that patients and providers find valuable but believe need improvement.


    Methods

    Overview

    The search and selection process of the articles used for this review are illustrated in Figure 1. The authors conducted a systematic search using PubMed and CINAHL research databases. A conscious decision was mutually made between researchers to omit Google Scholar in the search because it has an extremely primitive filter capability. The number of key search terms, even when incorporating Boolean operators, creates a highly complex query. Qualitative and quantitative studies and reviews published between January 2004 and July 2014 were included to increase the chance of capture of academic articles on the topic. The broad search terms used included “patient portals”, “internet portals”, “web-based communication”, and “chronic disease”. These terms were chosen from MeSH. Quotation marks for exact phrases and Boolean search operators were included. Because PubMed queries MEDLINE, we excluded MEDLINE from the CINAHL search. The initial search yielded 394 results.

    Figure 1. Literature review process.
    View this figure

    Exclusion Criteria

    Filters were applied to exclude articles outside the period of study (2004-2014) and those not published in academic, peer-reviewed journals. Because PubMed automatically queries MEDLINE, a filter was used in CINAHL to exclude MEDLINE results. A final filter on CINAHL excluded all studies except those published in English. These filters removed 91 articles.

    The remaining 303 articles were examined by at least one reviewer. A determination was made whether the article was germane to the study. This exclusion process was entirely manual, and it removed 285 articles. Of the articles excluded from the study, some only included patient portals as a small part of a broader topic of technological advances in patient care, while others focused on EHRs in conjunction with patient portals. One of the articles excluded from the literature review was a comparative study of various portal systems, which did not comment on the patient or provider attitudes toward the use and adoption of a portal system. Our screening criteria primarily revolved around our research question concerning the attitudes of patients and providers toward the use of patient portals for the management of chronic disease. Articles not related to the objective of this literature review were excluded. The remaining articles and their references were examined by at least two reviewers. An additional nine articles were added to the study from the references, but only if they fell within the 10-year date range. The final sample was 27. A table was built to summarize the observations from the authors on the 27 articles under study.


    Results

    The wide search criteria enabled a well-rounded evaluation of patient portals across multiple chronic diseases: diabetes, obesity, heart health, cancer, etc. Not surprisingly, there are both positive and negative attitudes presented by patients and providers using a patient portal or a Web-based communication system.

    A total of 27 articles were carefully read for common themes. At least two reviewers made and compared notes on the articles for consensus. A more detailed summary of the individual articles is provided in Table 1.

    An affinity matrix has been used by other research to illustrate frequency of mention or discussion of a particular topic [22]. For this review, an affinity matrix was created to identify the occurrences of both positive and negative aspects in the literature. This matrix can be found in Table 2. Overall, seven positive qualities and eight negative qualities of patient portals were common threads throughout the literature. In all, there were approximately 105 instances of both positive and negative perceptions of the patient portals.

    A total of 11 out of 27 articles (41%) reported an improvement of patient-provider communication as a result of using a patient portal [4,5,7,15,16,18,19,23-26]. Ten of 27 articles (37%) reported a positive association with the secure messaging offered by the patient portal [4,5,7,12,18-20,23-25]. Ten out of 27 articles (37%) mentioned improvements in quality of care as reported by both patient and provider [4,5,7,13,16,18,20,23,25,27]. Ten of 27 articles (37%) reported an increase in disease outcomes as a result of using the patient portal. Nine out of 21 articles (33%) attributed greater self-management of chronic conditions through the presence of educational resources presented through a patient portal [4,7,12,13,16,18,21,23,28]. Seven out of 27 articles (26%) reported from both patients and providers of the ease of navigation and user-friendliness of the portals [4,13,15,21,23,26,28].

    Several positive and negative attributes overlapped within the same study. For instance, while the respondents perceived an element from their patient portal as being beneficial, other respondents had a negative experience with a similar element in their portals. Even though patients and providers view secure messaging capabilities in patient portals as a beneficial attribute, 11 of the 27 articles (41%) stated that there was insufficient security in the portal design [7,8,10,12,15,16,20,24,25,27,29]. Also in 11 of 27 articles, patients did not perceive the patient portal as user-friendly and had difficulty navigating Web applications due to a lack of patient technical support, education, and access to the Internet [6,8-10,16-18,21,28-30].

    Secure messaging and time management were both mentioned in five of the 27 articles (19%). The latter was most often mentioned by providers as an expression of frustration that they would not have sufficient time to take care of business that is reimbursable. Surprisingly, only three in 27 articles (11%) identified cost as a concern [7,8,14]. This is a surprise because cost is mentioned consistently in the literature relating to cost of other aspects of health information technology [31]. Three of 27 articles (19%) reported a sharp decrease in patient to provider communication after implementing a patient portal due to patients cancelling office visits [10,19,27]. Although patients value the educational resources provided in their patient portal, in three articles, many patients reported difficulty understanding and navigating interactive resources such as health libraries in their patient portal [9,10,15]. Only two of 27 articles (7%) reported negative medical outcomes as a result of using a patient portal [4,5].

    Table 1. Summarized findings of the literature.a
    View this table
    Table 2. Affinity matrix illustrating the frequency of factors identified in the literature (n=27).
    View this table

    Discussion

    Principal Findings

    In this systematic review, the authors sought to understand the characteristics of patient portals that cause mixed feelings among patients and providers using patient portals. The authors identified the shared characteristics of patient portals that received favorable responses from patients and providers. The authors also identified the elements that patients and providers believe need to be improved or included in the portal design.

    Successful patient portals and Web-based portals are user-friendly and empower patients to take responsibility for managing their health. However, it is evident from the literature reviewed in this study that attitudes toward patient portals differ. There is a lack of clarity regarding the portal design used among respondents; it is unknown whether the portals are designed the same, or whether they differ from one to another. For instance, while one portal may offer immediate access to laboratory results, it may not provide the patient with explanatory material to educate the patient on the meaning of his/her lab results. Another portal may provide an explanation of the lab results but the medical terminology used may cause further confusion for the patient.

    Although this manuscript examines the same overall topic of portals from Ammenwerth et al (2007), our findings differ in many ways [31]. Ammenwerth et al did not find statistically significant effect of the portal on medical outcomes. Our study identified positive disease outcomes across 10 of 27 articles (37%) [4-7,12,15,16,21,23,30]. Ammenwerth et al reviewed only randomized controlled trials, however, and they did not broaden their search to encompass the breadth of this study. A common thread through the Ammenwerth et al study and ours is that security concerns rank very highly in the list of negative perceptions about patient portals. This manuscript did not set out to duplicate the work of Ammenwerth, but their work is raised for comparison purposes.

    Patients are concerned about the safety of secure messaging on an Internet application, the complexity of the portal design, the lack of guidance in how to use the portal, and the inability to understand the information presented in the educational resources. Patients over the age of 65 years are more likely to have trouble using advanced technology than patients who are more technologically inclined. The gap among users who have different levels of expertise in using advanced technology is called the “digital divide”. The authors believe that by providing patients with a tutorial prior to using the patient portal, patients who have little knowledge of technology will better understand how to operate the portal.

    A recurring theme in the literature is the inability of patients to understand medical terminology presented in the patient portal and not being knowledgeable about their own condition. Some patient portals offered a Health Library, which is an interactive educational resource enabling patients to have a bettering understanding of their conditions and how to better manage their health. The resources educate patients on the importance of taking their prescribed medications and changing their behavior in order to improve their health. An advantage of using electronic educational resources is that by providing an electronic version of an information pamphlet covering a patient’s condition, patients will no longer be at risk of losing their information packet.

    Patient portals are an effective way to improve communication between patients and their health care providers. However, the large volume of electronic messages sent to providers from their patients may overwhelm providers who must respond to the messages as well as conduct office visits during their workday. In addition to being very expensive to install and maintain, patient portal systems require training for providers who may or may not be willing to shift from paper records to electronic health records. The ease of learning a new technology for the provider is, no doubt, an important factor in the acceptance and adoption of patient portals in health care organizations.

    Conclusions

    Innovations in health information technologies improve the quality of and access to health care. Web-based portals provide patients with access to their health record, improve the patient-provider communication, and enable patients to take control of their chronic condition(s). In order to enable the acceptance of patient portals among health care organizations, the portals must be redesigned to be both user-friendly and aesthetically appealing. The authors suggest that a standard patient portal design providing patients with the resources to understand and manage their chronic condition(s) will promote the diffusion of this important technology.

    Authors' Contributions

    Authors contributed equally in the preparation of this review. The topic began as a directed research in partial fulfillment of a Masters of Health Administration (MHA) at Texas State University. The manuscript developed further after the conclusion of the class.

    Conflicts of Interest

    None declared.

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    Abbreviations

    EHR: electronic health record
    HIT: health information technology
    HITECH: Health Information Technology for Economic and Clinical Health
    PHR: personal health record


    Edited by J Brixey; submitted 13.07.14; peer-reviewed by T Palen, L Seldon; comments to author 08.08.14; revised version received 17.09.14; accepted 11.11.14; published 20.02.15

    ©Clemens Scott Kruse, Darcy A Argueta, Lynsey Lopez, Anju Nair. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 20.02.2015.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.