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Engaging patients in the delivery of health care has the potential to improve health outcomes and patient satisfaction. Patient portals may enhance patient engagement by enabling patients to access their electronic medical records (EMRs) and facilitating secure patient-provider communication.
The aim of this study was to review literature describing patient portals tethered to an EMR in inpatient settings, their role in patient engagement, and their impact on health care delivery in order to identify factors and best practices for successful implementation of this technology and areas that require further research.
A systematic search for articles in the PubMed, CINAHL, and Embase databases was conducted using keywords associated with patient engagement, electronic health records, and patient portals and their respective subject headings in each database. Articles for inclusion were evaluated for quality using A Measurement Tool to Assess Systematic Reviews (AMSTAR) for systematic review articles and the Quality Assessment Tool for Studies with Diverse Designs for empirical studies. Included studies were categorized by their focus on input factors (eg, portal design), process factors (eg, portal use), and output factors (eg, benefits) and by the valence of their findings regarding patient portals (ie, positive, negative, or mixed).
The systematic search identified 58 articles for inclusion. The inputs category was addressed by 40 articles, while the processes and outputs categories were addressed by 36 and 46 articles, respectively: 47 articles addressed multiple themes across the three categories, and 11 addressed only a single theme. Nineteen articles had high- to very high-quality, 21 had medium quality, and 18 had low- to very low-quality. Findings in the inputs category showed wide-ranging portal designs; patients’ privacy concerns and lack of encouragement from providers were among portal adoption barriers while information access and patient-provider communication were among facilitators. Several methods were used to train portal users with varying success. In the processes category, sociodemographic characteristics and medical conditions of patients were predictors of portal use; some patients wanted unlimited access to their EMRs, personalized health education, and nonclinical information; and patients were keen to use portals for communicating with their health care teams. In the outputs category, some but not all studies found patient portals improved patient engagement; patients perceived some portal functions as inadequate but others as useful; patients and staff thought portals may improve patient care but could cause anxiety in some patients; and portals improved patient safety, adherence to medications, and patient-provider communication but had no impact on objective health outcomes.
While the evidence is currently immature, patient portals have demonstrated benefit by enabling the discovery of medical errors, improving adherence to medications, and providing patient-provider communication, etc. High-quality studies are needed to fully understand, improve, and evaluate their impact.
The increasing adoption of electronic medical records (EMRs) by hospitals presents an opportunity for patients to access their clinical data and actively participate in their care via the EMR. Hospitals and other health care organizations can facilitate patient access to their EMR information through patient portals. Patient portals can provide secure, online access to personal health information [
The increase in patient portal implementation is, in part, due to some preliminary evidence that they may improve patient engagement [
Promoting patient involvement in health care delivery may lead to improved quality and safety of care [
The aim of this study was to review literature describing patient portals tethered to an EMR in inpatient settings, their role in patient engagement, and their impact on health care delivery in order to identify factors and best practices for successful implementation of this technology and areas that require further research. Our review aims to inform researchers, health care organizations, and policymakers.
The PubMed, CINAHL, and Embase databases were searched for articles published between 2005 and 2017 using keywords related to patient engagement, electronic health records, patient portals, and their associated subject headings in each database: the full search terms for each database are provided in
The included articles were assessed for quality. Two authors independently scored each article’s quality using the most recent version of A Measurement Tool to Assess Systematic Reviews (AMSTAR 2) [
We analyzed the information extracted from the included articles by categorizing the themes related to the implementation of patient portals into inputs, processes, and outputs. The inputs are the material (eg, hardware and software) and nonmaterial (eg, leadership) components that facilitate or impair the establishment or use of the portal. Processes include the interactions of the users with the portal. Outputs comprise the results of the implementation or the use of the portal. Through the analysis, we identified 14 themes within these three categories, shown in
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart of the search and selection process.
Input themes
Portal design: umbrella term for all design-related aspects of the portal including portal interface, content, features, and functions
Usability: extent to which a patient portal has the property of being able to be used by patients, caregivers, and health care teams to enhance patient engagement with effectiveness, efficiency, and satisfaction
Barriers: factors that hinder widespread adoption or portal use
Facilitators: factors that motivate or enable users to sign up for or actively use a portal
User training: equipping patients and health care team members with the necessary skills and knowledge to effectively use a portal
Organizational factors: culture of a health care organization; decisions and actions it takes when an initial consideration is made to implement a patient portal
Process themes
Adoption: from a patient perspective, adoption is the registration for a portal account; from a health care provider perspective, portal adoption refers to acceptance and promotion of the portal [
Use: active engagement and continued use after signing up for a portal [
Information: all aspects associated with providing patients with clinical and nonclinical information via a portal
Communication: all aspects associated with portal-based patient-provider communication
Output themes
Patient engagement: active involvement of patients in their own health care
User perceptions: thoughts, feelings, and opinions of patients, caregivers, and health care team members about their experiences with a patient portal
Health outcomes: impact of patient portals on clinical indicators
Benefits: value provided by patient portals to the health care delivery process
Details of the 58 articles included in this review are given in
There was a spread of articles addressing themes over the inputs, processes and outputs categories (see
Inputs
Portal design
Portals were designed using an iterative approach [
Integrated infobuttons linked users with reliable sources of medical information [
Artificial intelligence was used to enhance portal designs [
Portals can be designed for specific diseases or medical conditions [
Patients requested electronic games within portals [
Usability
Some participants had difficulties using patient portals mainly because of complex portal interfaces [
Some patients found patient portals easy to use [
Barriers
Lack of appropriate training [
Doubt of the portal’s usefulness [
Lost passwords [
Difficulties in using portals [
Anxiety associated with viewing personal medical information [
Data security and privacy concerns [
Lack of encouragement from providers [
Facilitators
Access to information [
Patient-provider communication [
Record-keeping [
Provider encouragement [
User training
Patients were trained using videos and reading material [
Health care teams were trained using verbal instructions and hands-on sessions [
Organizational factors
Rural hospitals were more likely to report costs and obtaining staff cooperation as barriers to health information technology (HIT; including patient portals) adoption than urban hospitals [
Small hospitals were more likely to report cost-related barriers than large hospitals [
Leaderships had crucial roles in the implementation of patient portals, working closely with developers in system design, developing policies to guide user training, and integrating portals into clinical workflows [
Implementation of patient portals varied across organizations due to different interpretations of government legislations by the health care organizations [
Processes
Adoption
Portal use was higher among white patients than other racial groups, younger patients than older patients, female patients than male patients, and high-income than low-income patients [
Use
Portal use was higher among patients with greater disease severity [
Patients were less inclined to use a portal when they were seriously ill, in intense pain,
or soon after undergoing multiple tests or procedures [
Information
Patients wanted timely and comprehensive access to their medical information [
Some patients preferred to have access to their entire EMR, including doctors’ notes [
Patients wanted personalized information tailored to their conditions and needs [
Patients requested clinical unit maps, meal menus [
Communication
Patients and caregivers expressed interest in using portals to communicate with health care staff [
Patients used portal messaging to request information, communicate needs and concerns, contribute to care coordination, offer feedback [
Some patients wanted an option to send messages to specific staff members and an indication of whether a message had been read and when to expect a response [
Ethnicity, age, and gender were associated with portal-based communication [
Outputs
Patient engagement
Some portals did not significantly improve patient engagement [
Patients in some studies reported that portals enabled better engagement in their own care [
User perceptions
Some patients felt that portals did not adequately fulfill their information needs [
Patients associated unrestricted access to their EMRs with empowerment and a sense of control [
Some patients and health care staff had concerns that unrestricted access to sensitive information may cause anxiety and more questions for health care staff [
Health care teams had preimplementation concerns about disruptions to workflows and potential for large volumes of patient messages, but such concerns did not materialize [
Patients and staff thought that the messaging feature of patient portals was important for patient care [
Patients who used a disease-specific portal were more satisfied than those who used a generic portal [
Patients and health care staff agreed that patient portals helped to improve patient care [
Health outcomes
Significant association between portal use and health outcomes was not observed in some studies [
Patient portals facilitated discovery of EMR errors by patients [
Benefits
Improved adherence to medication [
Improved patient satisfaction [
Enhanced patient-provider communication [
Improved patient safety [
Reduced patient uncertainty and anxiety [
Increased patient engagement [
Forty articles addressed themes in the inputs category. We identified 22 articles that addressed portal design. In an iterative design approach, feedback from patients, including requests for electronic games and other functions, was used to refine designs. Enhancements included links to medical education, artificial intelligence techniques, and disease-specific design.
As shown in
Organizational factors (leadership, staff support, and key decisions, etc) was the least addressed theme. However, the findings summarized in
Thirty-six articles addressed themes categorized as processes. Five articles addressed portal adoption while use was addressed in 18 articles (see
Seventeen articles addressed information and 20 addressed communication. The articles suggested that patients wanted unlimited access to their EMRs, medical education in layman’s terms [
Patient-provider communication, usually in the form of secure messages, is a key feature of inpatient portals [
The outputs category was addressed by 46 articles, and 24 articles addressed patient engagement. Results of patient engagement were mixed: portals in some studies did not cause statistically significant improvement, but patients in other studies reported that portals enabled better engagement in their care.
User perceptions was the most commonly addressed theme across all categories (35 articles), and
Twenty articles addressed the association between patient portals and health outcomes, such as medical errors, readmissions, and mortality. Results were mixed as some studies did not show positive associations between portal use and health outcomes [
Finally, 7 articles addressed the benefits of patient portals, and
This systematic review examined 58 articles studying inpatient portals. Although there was overlap in the themes reflected in these studies, there was also significant variation in the setting, patient population, software, outcomes assessed, and study methodology, making it hard to come to a definitive conclusion on whether inpatient portals are beneficial. This is further shown by the higher number of included studies that were judged to relay mixed valence than those with positive valence. However, more studies relayed positive than negative valence, showing that patient portals may be beneficial for health care. We discuss below the patient portal input, process and output factors that contribute to this assessment, and the areas of research that need focus in order to improve patient care.
Conceptual framework summarizing the findings and key areas for future research.
When assessing common themes within the inputs category, portal design, usability, and barriers were more widely covered than user training and organizational factors. Many articles showed that good portal design is crucial for usability and adoption by patients. While most studies involved users in the design process, more needs to be done to overcome design-related barriers, particularly for people with low health literacy [
Patients’ concerns regarding privacy and security of their medical information [
The results of user training showed that reliance on a one-size-fits-all approach may not be effective for educating users because of varying preferences. Training could be enhanced by providing information that directly addresses common patient concerns (eg, information security) and health care staff concerns (eg, workflow changes).
Information on the best timing to deliver training material to patients is lacking in the literature. While staff training can be scheduled ahead of deploying a patient portal, patients may only encounter a portal upon hospitalization. Furthermore, the severity of their condition may limit their ability to focus on or understand the training material. Innovation may be needed to inform patients about portal services prior to hospitalization. For example, patients could sign up for outpatient portals which would be similar in design to the inpatient portals to ensure seamless transition between the two portals. Hospitals could also collaborate with medical insurance providers to make training material available to potential patients already signing up for hospital insurance.
Associations between patient sociodemographic characteristics and portal use [
The varying preference among patients for level of access to EMRs [
Health care organizations may view patient requests of nonclinical information and functions such as electronic games [
Portal-based patient-provider communication is potentially beneficial but may also be disruptive [
The literature explored some, but not all, potential outputs of patient portal implementations. Most of the studies assessed implementation of patient portals using interim outcomes such as user perceptions, and few studies addressed important objective outcomes such as length of stay, morbidity, or mortality [
Some studies showed no association between portal use and health outcomes such as readmission, adverse events, or mortality [
Increasing patient engagement is a goal of patient portals, but the engagement of health care staff is also important since they are likely to be approached by the patients with portal-related queries [
Several studies reported that patient portals facilitate patient discovery of errors in EMRs [
Research in the evaluation of patient portals is also currently limited. Standardized evaluation frameworks and measures are needed to enable better comparisons of patient portal implementation and outcomes in the future.
While an extensive search was undertaken, the majority of the included studies were conducted at single locations, used outcome measures that were not comparable to those used in other studies, and had small sample sizes. That means results of those studies may not be generalizable to other population groups. Also, a number of the studies were conducted in controlled settings, such as closed-door observations and interviews, which would not be representative of hospital settings. The absence of standardized evaluation tools means the results could not be compared or synthesized, and we were thus limited to providing a descriptive summary of findings only. Most studies that addressed user perceptions or patient-reported results depended on the opinions of those who completed end-of-study questionnaires or interviews; such results could be biased as they may lack feedback from participants who felt uneasy about giving negative feedback. Finally, our conceptual framework enabled us to group the findings gleaned from the included articles, although there was some overlap in the categories caused by interdependence in some of the themes.
The review results suggest that the available evidence for inpatient portals is currently immature. Standardized outcomes assessment and more high-quality studies with objective outcomes (length of stay, mortality, and morbidity) are required to fully understand the impact of such portals.
Search terms for the PubMed, CINAHL, and Embase databases.
Detailed summary of each article selected for inclusion in the review.
Themes addressed by each article.
A Measurement Tool to Assess Systematic Reviews
electronic medical record
health information technology
Quality Assessment Tool for Studies With Diverse Designs
This study benefited from the support of the Australian Research Council (ARC FT130100942), the National Health and Medical Research Council Translating Research into Practice Fellowship (APP 1151021), and the University of Queensland.
None declared.