Patient Portal Enrollment and Engagement Rounds on Inpatient Units

Citation

Mintor, R., Williams, L., Bourgeois, F., & Reed, M. (2023). Patient portal enrollment and engagement rounds on inpatient units. Online Journal of Nursing Informatics (OJNI), 26(3), https://www.himss.org/resources/online-journal-nursing-informatics

Abstract

Patient portals give patients access to personal health information, laboratory results, and clinical notes. Patient portals also allow patients to send secure messages, request medication refills, schedule appointments, and pay bills. Portal enrollment correlates with improved patient engagement, understanding of medical issues and illness, and increased patient participation in self-management (McAlearney et al., 2019). However, in a national study, more than 50% of participants were not portal users (Turner, 2020). This quality improvement project aimed to determine the feasibility and preliminary effectiveness of dedicating staff to conduct patient portal engagement rounds on inpatient units. During patient portal rounds, staff discussed the portal's benefits and gave direct enrollment support to patients or their parents. Seventy-seven patients/parents participated in portal rounds, and 60 (78%) enrolled in the portal. Forty-two (54%) participants agreed to complete a survey. There was no association between portal adoption and preferred language or patient age. Seventy-one percent of participants reported being 'very confident' with technology. This project has proven that offering portal support in inpatient units is effective and feasible. Increased portal enrollment over time may equate to improved patient-provider communication and increased patient engagement, leading to improved patient outcomes.

Background and Significance

In 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted as part of the American Recovery and Reinvestment Act. This act aimed to create programs intended to improve healthcare quality, safety, and efficiency by promoting health information technology. A significant part of HITECH was the Meaningful Use incentive program. Meaningful Use incentivized healthcare facilities to optimize or implement electronic health records (EHR), including patient portals (Burde, 2011). In 2017, the Merit-based Incentive Payment System (MIPS) replaced Meaningful Use to improve care quality, streamline reimbursement, and reduce administrative burdens for physicians. MIPS required all eligible providers to report performance across three categories: quality, advancing care information, and clinical process improvement activities. A significant part of MIPS is the requirement for easier patient access to health data using patient portals (Office of the National Coordinator for Health Information Technology (ONC), n.d.).

Patient portals give patients access to certain health information from their EHR; they also allow patients to send secure messages, request medication refills, schedule appointments, and pay bills (Goldzweig et al.,2013; Griffin et al., 2016). These federal mandates have led to healthcare organizations' swift implementation of portals. Patient access to online health information has become an essential component of healthcare delivery in the digital age; 90% of healthcare organizations offer patients access to an electronic patient portal (Heath, 2020). However, patients' adoption of patient portals has been slow. In one national cross-sectional survey, more than 50% of survey participants were not portal users (Turner, 2020).
In recent years the effect of patient portals on healthcare outcomes has been widely studied. Studies have shown a significant association between patients' health behaviors and portal use (Dumitrascu et al. 2017; Fiks et al. 2016; Huang et al. 2019). An implementation study evaluating the impact of portal use on pediatric asthma patients confirmed that portal users with uncontrolled asthma had improved medication adherence after using the portal compared to the previous year (Fiks et al. 2016). Other adult studies have reported an association between patient portal use with improved blood pressure, low-density lipoprotein cholesterol, and body mass index (Alturkistani et al., 2020).

Several studies have sought to understand the facilitators of portal enrollment and use; evidence has substantiated that a designated leading facilitator of portal adoption is the first step in the successful registration of patients (Bush et al., 2019; Ratliff-Schaub & Valleru, 2017). Ramsey et al. (2018) conducted a feasibility study in the outpatient setting that provided one-on-one education about the portal and assessed patient satisfaction with the portal during a post-education session. Over 85% of the patients who received education agreed to enroll in the portal. This study concluded that using staff for portal enrollment support was feasible, acceptable, and effective in increasing portal registration. Several interventions conducted in the outpatient setting to improve portal enrollment have shown that direct portal enrollment support and provider encouragement positively impact portal registration and use (Ramsey et al., 2018).

Researchers have examined portal usage in the outpatient setting more than in the inpatient setting. Only a handful of studies have examined the portal usage of hospitalized patients. McAlearney et al. (2019) explored patient perspectives on how inpatient and outpatient portals are used across care settings. Researchers found that the inpatient portals informed patients when to expect medications, laboratory results, and discharge plans while hospitalized. Patients reported a better understanding of their health trajectory during their acute state and the management plan post-discharge. Other researchers have suggested that inpatient portal use improves patient safety, satisfaction, and engagement (Kelly et al., 2017; McAlearney et al., 2019; Winstanley et al., 2017). However, portal enrollment and engagement of admitted patients are not well understood.

The inpatient setting offers a unique opportunity to enroll hospitalized patients, given that patients and families receive a vast amount of information daily that they may need time to process. Priority initiatives in the federal government and local organizations include goals to increase patient engagement in their care; these goals include strategies such as granting patients access to their EHR across the care continuum. Since April 2021, the federal 21st Century Cures Act has required all information in the EHR including labs, radiology repots and clinical notes to be immediately available to patients through a secure online portal (Health and Human Services Department, 2020). Information may not be blocked, and patients' access to the information entered and stored in their EHR cannot be delayed, including test and study results.

Engaging hospitalized patients with portals can potentially improve the provider-patient relationship, awareness of health status, and adherence to therapy (Carini et al., 2021). In this project, we implemented portal enrollment and engagement (PEE) rounds to determine the feasibility and acceptability of providing portal enrollment support for pediatric patients admitted to an inpatient hospital setting and their families. Portal rounds allow patients and families to discuss the portal and receive assistance with enrollment. Using an optional survey, the characteristics of PEE rounds participants were examined, including demographics and technology proficiency.

Methods

Setting and Participants

This project was conducted at an urban, free-standing 484-bed quaternary care center. Portal rounds were piloted on three units; a combined neurology, neurosurgery and neuro-oncology unit, an oncology unit, and a stem cell transplant unit from November 1, 2021, to February 3, 2022. Parents or guardians, and patients aged 13 years and older deemed eligible to register for a MyChildren's patient portal account were allowed to participate in PEE rounds. Verbal consent was received from parents or guardians and patients 13 years and older to participate in PEE rounds. Patients whose guardianship was held by the Department of Child and Family Services were excluded. In addition, patients who were 13 and older and unable to consent themselves verbally were excluded.

Intervention

A daily census report was developed that identified patients admitted to the three units who did not have an active patient portal account. Portal support staff visited patient rooms and offered patients and families participation in PEE rounds.

Portal rounds were conducted three times a week by dedicated trained staff who met with admitted patients and families to discuss the benefits of the portal, provided a demonstration of the portal using a mobile tablet, assisted with immediate enrollment to the portal, and provided basic training on how to use the portal. Interpreter services were utilized during PEE rounds for non-English preferring patients. Portal rounds' participants completed a questionnaire to assess demographics, portal registration process, internet access, technology proficiency, and anticipation of portal use (the survey used during this project is available from the corresponding author on request).

Ethical Consideration

This project was reviewed by the Nursing Research Council and was approved as a quality improvement (QI) project. It did not require further review by the institutional review board. As an additional safeguard, the Institutional Review Board of Simmons University reviewed the proposal and approved it as a no-engagement research project.

Data Analysis

Patient demographic information collected from the EHR were age, sex, and language preferences. Descriptive analyses were performed to describe demographics and technology use and access. The online survey was administered using SmartSheet™.  SPSS Statistics (version #25) was utilized to analyze data. Frequencies are reported for categorical variables and median and interquartile range (IQR) for continuous variables.

Results

During the implementation period, 82 families were evaluated for eligibility to participate in portal rounds; five (6%) were ineligible. Of the 77 eligible participants, 78% (n=60) registered for the portal. Of the 77 portal rounds participants, 54% (n= 42) completed the optional survey. Portal rounds averaged 12 minutes per patient. Selected demographics for survey participants are found in Table 1.

Almost all respondents (98%, n=41) selected 'cell phone' as a primary device used to access the internet. There was no significant association between preferred language and adoption (p= 0.17). There was also no significant association between age (years) and adoption status (p= .67).When asked if a provider previously discussed the benefits of the portal with them, of the 42 respondents, 17 (40.5%) said 'Yes,' 17 (40.5%) said 'No,' and 8 (19%) said 'I'm not sure' (See Table 2). The majority of respondents (71%, n=30) reported being 'very confident' with technology. One survey respondent stated, "Support came to visit us in my son's room. This was extremely helpful. I started the process but needed approval. This visit made our lives so much easier. We have so much going on. Having access to my son's labs and information is beyond helpful. Thank you so much for the visit. We really appreciate!!!! Thank you!!"

Discussion

The results indicated that PEE rounds were feasible and acceptable for enrolling admitted patients to the patient portal. Portal support staff successfully enrolled 78% of the patients approached. This project supports the literature finding that brief portal demonstration, discussion of portal benefits, and enrollment support can positively influence portal adoption (Antonio et al., 2020; Ramsey et al., 2018. & Ratliff-Schaub & Valleru, 2017). It was feasible to have dedicated staff conduct PEE rounds; each encounter only averaged approximately 12 minutes. Having dedicated staff prevented additional responsibility on unit staff to educate and support the enrollment of admitted patients. Bringing portal support directly to the bedside eliminated the families' need to inquire about portal registration; moreover, if a family is unaware of the portal and its benefit, they may not ask about the registration process. Portal rounds were acceptable to unit workflow, and there were no reported disruptions to units and patient care due to PEE rounds. Although hospitalized patients experience high information intake and stress, PEE rounds participants welcomed the opportunity to enroll in the portal once the benefits were discussed.

The survey data demonstrated that most participants described themselves as being 'very confident with technology,' indicating that technological proficiency was not a barrier to portal adoption. Only 14% of our respondents said they used a home computer or laptop to access the internet; 98% reported primarily accessing the internet via their cell phone. Our findings that patients primarily access the portal using their cell phones contradict previous studies. Chang et al. (2018) examined the relationship between race/ethnicity to patient portal use and devices used to access the portal. They found that across all respondents, 62% of all portal users used a desktop, only 6% used mobile devices, and 32% used both. More studies are needed to assess whether using mobile devices to access patient portals impacts usage after enrollment. 

Over 50% of survey respondents said that the portal was never discussed with them, or they were unsure if it was ever discussed with them. Prior research has identified provider encouragement as a facilitator of portal enrollment (Powell, 2017). Through this project, we have identified an opportunity for our direct care team members to encourage portal enrollment.

Limitations

There are several limitations to this implementation project to consider. One limitation was the COVID-19 pandemic (Martinez-Perez et al., 2020). The average monthly enrollment dropped significantly during the third month of the intervention because of the COVID-19 Omicron variant outbreak that resulted in the suspension of non-essential hospital activities. During this time, PEE rounds were halted. Portal rounds participants were pediatric patients and families of chronically ill children, predominantly with oncological conditions. Other studies have found that portal adoption is higher for patients with chronic conditions (Coughlin et al., 2017; Skinner et al., 2016). Therefore our findings may not be generalizable to other acute care settings. Lastly, this project focused on enrollment; many studies have found that portal use remains low after registration. Future work should focus on understanding how patients use the portal post-enrollment; this would facilitate additional analysis of how patients engage with the portal while admitted and if there is any correlation between patient satisfaction and outcomes with the use of the portal while admitted. 

Conclusion and Implications

This implementation project has proven that offering portal support in inpatient units is feasible and acceptable. We have also determined that educating patients about the portal is a crucial facilitator to portal enrollment. Implementing PEE rounds facilitated patient portal activations in the inpatient setting without impacting workflow and patient care. This project provides insight into the facilitators of portal registration. Given the many initiatives and incentives for healthcare facilities to engage patients in health technology, we must understand the barriers to portal adoption and implement strategies to educate and enroll patients. Future work should explore strategies to decrease the obstacles to patient portal enrollment and request additional personnel resources to help promote portal enrollment in the inpatient and outpatient settings. These efforts will likely result in improved patient engagement, thus improving quality, safety, and care satisfaction.