Table 2.

Subtheme definitions for guiding principles for developing and implementing adolescent portal policies.

Themes and subthemes			Representative excerpts
Balancing confidentiality and other care needs
	Provide appropriate transparency while complying with state and federal laws	Compliance with laws and regulations was noted as an essential requirement for any portal policy. The overarching goal of improving transparency was shared by nearly all administrators, but there were differences in how to achieve this transparency in ethically and legally acceptable ways. Administrators described the vagueness of these laws and several instances with state and federal laws are in conflict. As a result, administrators described the importance of developing a productive, collegial working relationship with the institutional compliance office and legal counsel.
	Prioritize adolescent health and safety	Administrators strongly believed that all policies should aim to ensure the health and safety of the adolescent. However, health and safety could sometimes be in conflict. For example, some adolescents might need parental involvement to help them manage complex disease. Other adolescents might be unsafe if their parents see sensitive information, such as drug use, gender identity, or sexual activity.
	Preserve clinician-adolescent relationship	Administrators highlighted the importance of ensuring that portal policies support rather than strain the clinician-adolescent relationship. Clinicians especially needed to honor their promises of confidentiality or they would risk losing the adolescent’s trust.
	Support adolescent’s developing autonomy	Although administrators had disagreements about what level of access is appropriate or mandated for parents, most administrators expressed that adolescents should have access to as much of their own information as possible. Not only do adolescents have a right to learn about their own health, but administrators believe that this access could support the adolescent’s development into adulthood and self-management.
Balancing simplicity and granularity
	Strive for appropriate granularity in the differential sharing of health information	Administrators generally agreed that some granularity in the ability to determine which information is shared with parents versus adolescents is ideal. Some described an ideal in which adolescents could determine each type of information that is shared with their parents. However, technological limitations created barriers for differential sharing, especially at centers with smaller pediatric populations.
	Ensure the end product is useful for families	Administrators urged vendors and institutions to ensure the user interface was user-friendly and provided meaningful information for parents and adolescents. They also described how it was important to make sure information was understandable to families. Simply providing access was not sufficient. Additionally, administrators urged against the view of the portal as a panacea for all communication and information challenges.
Collaborating and advocating
	Engage key stakeholders within the institution	Administrators emphasized the importance of engaging with leadership, informatics workforce, legal or compliance officers, clinicians, frontline staff, parents, and adolescents in developing and implementing access policies. Additionally, they encouraged the ongoing engagement of these parties after implementation to ensure the system continues to meet all parties’ needs.
	Collaborate with colleagues at other institutions	Given the uncertainty and vagueness of state and federal laws, administrators encouraged other administrators to communicate with colleagues at other institutions to understand the variety of approaches to adolescent portal access. This collaboration was especially important to understand how other hospitals in the same state were interpreting the laws.
	Advocate with external parties for adolescent and pediatric issues	Many of the conditions influencing adolescent policies originated outside of the institution, especially state laws, federal policies, and EHRa functionality. It is imperative for health care institutions to advocate with these external parties to support safe and transparent sharing of adolescent medical information through portals.

^aEHR: electronic health record.