MyHealthAtVanderbilt (MHAV) is a patient portal available to patients receiving care at Vanderbilt University Medical Center (VUMC), a large academic medical center in Nashville, Tennessee. Users of MHAV can manage medical bills, view PHI (eg, vital signs, laboratory results, medication lists, and diagnoses) from their electronic health record (EHR), use secure messaging to communicate with providers and manage medical appointments, access VUMC information (eg, maps, provider information, and telephone directory), use health screening tools to assess symptoms or risk for various conditions [24], view opportunities to participate in research studies, and view educational content linked to the International Classification of Diseases, Ninth Revision (ICD-9) codes from their EHR [14,23]. There are 2 levels of MHAV access to protect the confidentiality of PHI: upon registering online, patients receive access to certain MHAV functions, but they cannot view PHI until they provide in-person identification at a VUMC clinic [14].

To both learn about patients’ experiences with using MHAV to manage their health and medication regimens and get their ideas for leveraging this portal to improve medication management and adherence, we recruited English-speaking adults prescribed medications for T2DM who were patients at VUMC primary care clinics. Recruitment included approaching patients in the clinic waiting room, posting flyers advertising the study, and announcing the study on a VUMC listserv. Interested and eligible patients were identified, and completed informed consent procedures to enroll in the study. All enrolled participants consented to having study personnel review their EHR to collect demographic and clinical information (including medication lists), responded to a question about MHAV use, and were invited to attend a focus group and complete a survey. Enrolled participants who did not attend a focus group were invited to an average of 2.9 (SD 0.5) focus group sessions scheduled at different times of the day. Participants who could not attend a focus group were asked to complete a survey by phone or mail. The Institutional Review Board at Vanderbilt University approved all procedures prior to study enrollment.

We conducted 11 focus groups with 2 to 6 participants each, a trained facilitator (authors CYO or LSM), and a trained note taker who recorded verbal and nonverbal communications. All focus group sessions were recorded and transcribed verbatim, using session notes to link participants’ comments to survey data. Focus group questions pertained to patients’ experiences with diabetes medications, experiences with and attitudes toward using MHAV and other technologies to manage diabetes and medication regimens, and ideas for leveraging MHAV and other technologies to improve medication management and adherence. The primary questions of interest were:

We stratified sessions by self-reported frequency of patient portal use at enrollment (described subsequently) to homogenize groups relative to the subject matter and elicit different perspectives [27], facilitate a more comfortable discussion about experiences with technology, and understand similarities and differences across types of users rather than to generate thematic saturation within each user group. We conducted 2 focus groups with nonusers, 5 with low users, and 4 with high users. In focus group sessions with nonusers, we asked if participants were aware of the MHAV patient portal. We then showed a video demonstration of MHAV [28], and asked participants if they thought they would want to use MHAV in the future. If not, they were asked why not; if so, they were asked which of the features showcased in the demonstration video would they use and what other features would they like to see added.

All statistical tests were performed using Stata 12 (StataCorp LP, College Station, TX, USA). Descriptive statistics characterized the sample. Mann–Whitney U tests and Fisher exact tests examined group differences between those who participated in a focus group and/or completed a survey (n=61) and those who were enrolled only (n=14) on demographics, MHAV use, and A1C, and then between patient portal users (n=62) and nonusers (n=13) on all variables. Next, Mann–Whitney U tests and Spearman rho (ρ) correlation coefficients tested the relationships between the frequency of MHAV use and demographics and A1C among MHAV users.

We used NVivo 9 (QSR International, Burlington, MA, USA) to code focus group transcripts. The purpose of our analytic approach was not to reach thematic saturation, but rather to explore participants’ receptiveness to using a patient portal for medication management and adherence, and to generate ideas for how to tailor technologies to meet the needs of patients with T2DM. First, author LSM read transcripts in their entirety, identifying statements pertaining to participants’ opinions about, experiences with, and ideas for using MHAV for medication management and adherence. Units of analysis consisted of statements by single participants and, largely, multiparticipant conversations during which participants built on each other’s ideas, interrupted, offered suggestions, and/or indicated a similar or different experience. Next, authors CYO and LSM iteratively reviewed, integrated, and discussed these data until subthemes emerged.

Of all 75 participants who were enrolled in the study, 83% (n=62) were patient portal users and reported using MHAV sometimes to often (mean 3.6, SD 1.0) [31]. Most portal users (72%) reported at least 1 year of use. As shown in Table 1, MHAV users were more likely than nonusers to be Caucasian/white, have higher incomes, and be privately insured. MHAV users also tended to have more education than nonusers (Mann-Whitney U; P=.05) though this relationship was not significant at P<.05. We found no other differences between MHAV users and nonusers. Among MHAV users, frequency of use was unrelated to race or indicators of socioeconomic status (SES; ie, education, income, and insurance status). Although there was no difference in A1C between MHAV users and nonusers, more frequent use of the portal was associated with better A1C (ρ=–0.30, P=.02) among users.

After we showed nonusers the MHAV demonstration video, 4 of 7 nonusers reported they were interested in using the portal, but either had never heard about it, or had heard about it but did not know what its capabilities were. One of these participants said she would certainly use MHAV if she could use a computer:

In general, nonusers who were interested in using MHAV reported wanting to use the secure messaging feature to schedule appointments and wanting to view their PHI, such as their laboratory results and medication list.

Of the 3 participants who were not interested in using MHAV, 2 participants did not know how to use a computer and felt they had good systems in place for managing their health and medications, and the third participant reported her husband used MHAV and managed her medications as her online delegate (see [14,31] for more detail on the delegate function of MHAV).

Themes and subthemes are illustrated with quotations in the text and in Table 2. In focus groups, users described using MHAV to review their medication list and request prescription reauthorizations. Participants who used MHAV to view their medication list shared the information with other providers and/or pharmacists and used this information to ensure they were taking medications correctly:

Frequently, users reported using MHAV’s secure messaging feature to request prescription reauthorizations. The participants who used secure messaging for this purpose consistently and enthusiastically endorsed it for streamlining the reauthorization process:

Participants were averse to receiving dose reminders (ie, reminders to take a dose of medication) from MHAV. In general, participants saw value in dose reminder functionality for children, adolescents, and older patients, but did not like the idea of receiving dose reminders via short message service (SMS) text messages, email, or a phone call. Many participants said they do not use SMS text messaging or email on their mobile phones and thought a phone call reminder would be too intrusive. Those who did use SMS text messaging thought dose reminders would become burdensome and unnecessary:

Others felt email reminders would become annoying and indicated they would just turn off the reminder without taking the medication either because they did not have the medication with them or they would become accustomed to turning off the reminder:

However, participants were enthusiastic about leveraging MHAV to improve medication management and promote adherence through other functionality. We categorized participants’ ideas for improving MHAV’s medication management functionality into 3 categories: (1) electronically linking MHAV with pharmacies, (2) MHAV alerting providers to patients’ fill/refill nonadherence, and (3) using MHAV to help patients understand their medications. Specific ideas are presented under each category.

Patient portals represent a technology with the potential to facilitate better care of patients, but virtually no data exist about the real and potential impact of these portals on medication management and adherence. To our knowledge, this is the first study to investigate ways to leverage an existing portal to help patients better manage their medications and, in turn, become more adherent. Users of the MHAV portal (both high and low users) reported using secure messaging to request prescription reauthorizations, and suggested adding portal features and functionality to facilitate medication management and promote adherence. Specifically, participants would like MHAV to be linked with pharmacies to create functionality that (1) alerts providers when long-term prescriptions need to be reauthorized and alerts patients when they need to be refilled, (2) reduces communication problems between providers’ offices and pharmacies, (3) allows patients to request multiple medication refills at once, and (4) alerts providers to patients’ prescription fill and/or refill nonadherence. Finally, participants would like MHAV to (5) deliver medication information (eg, side effects, other drugs to avoid) in an accessible and user-friendly format. They also emphasized the importance of being able to tailor both how they receive alerts and which pharmacy they want to use to fill or refill prescriptions. Taken together, these suggestions illustrate patients’ readiness for additional portal-related features and functionality to support medication management and adherence.

As health care organizations and providers begin to use portals to educate patients about their medications and support them with adherence, there is an increased need for these efforts to be theoretically driven, evidence-based, and patient centered. Behavioral medicine experts have long advocated for the role theory plays in the design and content of health promotion programs [33,34]. The first and most important reason is that programs grounded in empirically derived theories are more effective than those that are not [35]. Second, programs grounded in the theoretical processes that regulate behavior can specify and test the critical assumptions of a program’s components to detect exactly why it worked or failed under certain conditions or with certain populations and how it should be improved [33,36]. Both benefits are essential to developing self-care support tools and content within portals that will successfully reduce the personal, social, and economic burden of medication nonadherence. The participants in our study also saw value in integrating currently disjointed systems (ie, portals with pharmacies) to streamline the refill/reauthorization process and to have providers monitor refill adherence. Thus, future research efforts should investigate both the willingness of pharmacies to integrate with patient portal systems to streamline refill and reauthorization processes and of providers to monitor patients’ adherence-related activities. Finally, implementing a portal or a medication management module within a portal should go hand in hand with monitoring use and evidence of stakeholder satisfaction, patient adherence, cost-effectiveness, and impact on clinical care and outcomes.

We also explored the types of patients who are and who are not using MHAV and, separately, the relationship between the degree of use and glycemic control. We found that the groups who often have suboptimal glycemic control (ie, African Americans/blacks and individuals with lower SES) [37] were also less likely to have ever used the portal. We also found that, among portal users, more frequent use was associated with better glycemic control. A few recent studies have reported disparities in patient portal use [19,38-40], including 2 studies with diabetes patients [19,40]. Although our methodology, sample size, and portal in question differ from those studies, we also found that adults with diabetes who were African American/black [19,40] or who had less education [40] were less likely to have ever used the MHAV portal. Furthermore, we identified income and insurance disparities in ever using MHAV, which contributes new findings to this literature. Shaw and Ferranti [19] also reported better glycemic control among portal users versus nonusers. In our sample, there was no difference in A1C between portal users and nonusers. Most nonusers (62%) had A1C values less than 7.0%, suggesting these participants may be using other tools to manage their medications and diabetes. We did find an association between more frequent use of a portal and better glycemic control among users only. This finding extends our limited knowledge about the impact of portals on diabetes outcomes [18]. Although differences in glycemic control based on portal use versus nonuse may be spurious (ie, due to the effects associated with education, income, access to computers, or another variable), our finding that more frequent portal use was associated with better glycemic control among participants who had accessed a portal suggests there may be benefits of using a portal that are independent of the contributions of other characteristics of portal users. Future research with larger samples should explore the independent relationship between frequency of portal use and clinical outcomes, adjusting for race and SES.

Because we used a mixed-method approach, our quantitative findings are limited by our qualitative sampling procedure. We had limited variability in A1C among nonusers as a whole, and particularly among African American/black nonusers, to be able to tease apart the relationships (or lack thereof) between race, SES, A1C, and portal use versus nonuse. Although portal nonusers appear to be using strategies or tools to achieve optimal glycemic control despite not using a portal, additional research with larger, more diverse samples (ie, in terms of SES and glycemic control) is needed to both replicate this finding and identify what strategies are being used to maintain glycemic control among patients who do not use portals. In addition, we likely oversampled MHAV users by promoting the study over a listserv. All but one of the nonusers were recruited from clinic waiting rooms, whereas MHAV users often contacted us from seeing flyers in clinic waiting rooms or seeing the listserv announcement. Moreover, we found nonusers (most of whom we contacted by phone) were more difficult to reach for scheduling and reminding about focus group sessions than users (most of whom we contacted by email). Second, our cross-sectional design limits our ability to discern causal relationships (eg, we cannot conclude that more MHAV use improves glycemic control). Third, our study presents participants’ perceptions of the frequency of using a patient portal, how they use it, and what added functionality would support medication management and adherence, which may not adequately reflect actual opinions and/or behaviors. Finally, the generalizability of these findings to patient populations with lower SES, other chronic illnesses, and/or those patients using other patient portals is limited. Therefore, we recommend future research explore these issues using different research methodologies with a wide range of patient populations and portal platforms.

Patient portals are increasingly being used to demonstrate meaningful use under the Medicare and Medicaid EHR Incentive Program, which provides financial incentives to providers and hospitals that demonstrate they are implementing EHRs to meaningfully improve patient care [41]. Meaningful use is demonstrated through the achievement of benchmarks including, but not limited to: maintaining an active and correct medication and medication allergy list, identifying patient-specific educational resources and making those resources available to patients, performing medication reconciliation, automatically tracking medications from order to administration using assistive technologies in conjunction with an electronic medication administration record, and providing evidence of patients’ use and engagement with their PHI [41]. As providers and hospitals leverage portals to achieve these benchmarks, it will be important to monitor and learn from portal users and nonusers, understand reasons for nonuse, and identify how to offer medication management and adherence support within portals that meet the needs of patients while also satisfying meaningful use requirements.

We found that patients use portals to manage their health, including their medications (eg, messaging doctors to reauthorize long-term medications), and are enthusiastic about further leveraging these systems to support medication management. Although some portals have included functionality to support medication reconciliation [26], reduce adverse drug events, and improve patient-provider communication regarding medications [20,42], more functionality is needed to maximize medication adherence promotion.