Implementing practice-linked pre-visit electronic journals in primary care: patient and physician use and satisfaction

Abstract

Electronic health records (EHRs) and EHR-connected patient portals offer patient–provider collaboration tools for visit-based care. During a randomized controlled trial, primary care patients completed pre-visit electronic journals (eJournals) containing EHR-based medication, allergies, and diabetes (study arm 1) or health maintenance, personal history, and family history (study arm 2) topics to share with their provider. Assessment with surveys and usage data showed that among 2027 patients invited to complete an eJournal, 70.3% submitted one and 71.1% of submitters had one opened by their provider. Surveyed patients reported they felt more prepared for the visit (55.9%) and their provider had more accurate information about them (58.0%). More arm 1 versus arm 2 providers reported that eJournals were visit-time neutral (100% vs 53%; p<0.013), helpful to patients in visit preparation (66% vs 20%; p=0.082), and would recommend them to colleagues (78% vs 22%; p=0.0143). eJournal integration into practice warrants further study.

Introduction

Primary care physicians have much to accomplish in the limited time of a patient visit.^1–4 Documented gaps in the quality of care include care guidelines not followed, medications not adjusted, tests without follow-up, family history not obtained, and diminished patient satisfaction with the visit.^5–9 Process change and technology can improve information access, medication prescribing, communication, and chronic care results.^{4 6 10–12} Patient portals are anticipated to improve patient/physician collaboration^13–16 and patient access to care.^17–20

Patient pre-visit questions have been used to improve the accuracy and completeness of patient data, visit efficiency, and documentation, although research findings show mixed benefits in this approach.²¹ EHR-connected personal health records linking patients electronically to information from their doctor's office were developed for the Prepare for Care study—a large, prospective, randomized controlled trial (RCT) in primary care (http://ClinicalTrials.gov NCT00251875) designed to assess the impact of technology on care. The study intervention consisted of a pre-visit electronic journal (eJournal) with patient responses that were submitted to providers before an office visit. Intervention groups offering specific eJournal modules were compared to active controls offered the same personal health record and different modules to measure how eJournal use affected outcomes and the care process. This paper focuses on the patient and provider implementation experience through analysis of eJournal usage and survey data.

Methods

A pre-visit eJournal was developed as a new feature in Patient Gateway (PG), a secure EHR-connected internet patient portal at Partners HealthCare, a large integrated health system in Boston, Massachusetts, USA. Patients used the eJournal to review clinical information and answer questions in preparation for a face-to-face visit with their primary care provider (PCP). See online supplementary figures 1–4 available at http://jamia.bmj.com.

Patient Gateway and Longitudinal Medical Record

The PG is a web-based application used by patients of primary and specialty care ambulatory practices affiliated with the Brigham and Women's Hospital (BWH), Massachusetts General Hospital (MGH), and Dana Farber Cancer Institute in Boston, Massachusetts, USA. During the 2005–2007 study period, PG offered patients the ability to (a) communicate securely with their doctor's office; (b) view medical chart extracts (eg, medications, allergies, selected laboratory results, demographic information); (c) make requests (prescription, appointment, referral authorization, and ask-a-question); and (d) search for health reference information. All transactions were stored permanently in the Partners HealthCare's clinical information systems. PG is connected to the Longitudinal Medical Record (LMR)—an ambulatory electronic medical record system used by approximately 5000 physicians as of December 2006, which includes problems, medications, allergies, notes, and advanced clinical decision support. Interfaces between PG and LMR facilitate workflow and linking of patient messages to chart information. Both web-based systems are implemented using the Caché programming platform (Intersystems) linked to redundant Microsoft Internet Information Servers utilizing HTML and Javascript-based page rendering.

The Prepare for Care study

The eJournal was developed as part of the Prepare for Care study, a RCT offered to all PG users of 11 primary care practices at the BWH and MGH between 2005 and 2007. Eligible patients having a PG account and an assigned PCP from a study practice were invited to participate via a PG message with a link to an electronic consent form. Consented patients were prompted 3 weeks before a scheduled visit to review and submit an eJournal containing up to three topics depending on study arm. Primary care practices matched for similar characteristics (eg, women's health, urban setting) were randomized into arm 1 (offering medication, allergies, and diabetes modules) or arm 2 (offering health maintenance, family history, and personal history modules). Each intervention group also served as an active control group for the other arm since eJournal modules found in one arm were not in the other.

eJournal modules

Each module asked the patient to review selected data from the LMR, update it if necessary, and answer specific related questions in preparation for the upcoming visit. Skipping an item was permitted. Medication and allergy items included questions such as: ‘are you still taking this medication as shown?’ and ‘are you having any trouble at all with this medication?’. eJournals for patients with type 2 diabetes displayed recent results (HbA1c, low-density lipoprotein cholesterol, blood pressure) and questions such as: ‘how satisfied are you with your blood sugar control?’. Health maintenance items (last cholesterol date, mammogram date, vaccination dates, etc) were identified in the eJournal as ‘due’ or ‘up-to-date’, with prompts to the patient asking how they would like to handle due items (eg, ‘Get it taken care of’, ‘I already had this done’, ‘I'm unsure’, etc). Structured personal history and family history LMR items were displayed, whereas unstructured items were not. Specific module design features and some clinical outcomes have been reported elsewhere,^22–25 including reduced clinical inertia as measured by more frequent medication changes by physicians for patients with type 2 diabetes who had used the diabetes eJournal.²⁴

eJournal flow

The scheduling system was used to trigger an arm 1 eJournal invitation 3 weeks before an ‘annual’ (40 minute, more comprehensive) or ‘follow-up’ (20 minute, problem-focused) visit type since medication/allergies/diabetes topics are an important focus at both. Arm 2 eJournal invitations were triggered for an annual visit type only, when family history and health maintenance topics are more typically reviewed. Each eJournal invitation and weekly reminder triggered an external email message to notify the patient. An eJournal contained current LMR data items when it was first opened by the patient, who controlled whether or not to submit it to the primary care provider, print a summary, ‘recall’ a submission (if unread by a provider), or start over with newly copied LMR data. Submission of the eJournal was only permitted if at least one question was answered, the triggering visit was not canceled or moved, and the visit date had not passed. Patients received no specific training in use of the eJournal, but two rounds of user testing with prototypes helped to refine the eJournal design.

Alerts appeared on the provider's schedule page and LMR patient chart pages to notify providers of submitted eJournal information. PCPs used buttons such as ‘add medication’ to copy a new patient-entered medication or ‘add patient entry’ near eJournal health maintenance items (eg, ‘mammogram was done on 5/12/2006 at another facility’). A practice-wide ‘eJournal tracker’ tool in LMR identified eJournals pending review, and those automatically ‘closed’ in the system due to a visit cancellation or no show, or 21 days after the scheduled visit. Providers received brief training that identified the eJournal icon on the schedule and patient chart pages, the eJournal tracker tool, and the ‘add’ buttons. Physicians determined whether eJournal information was accepted and incorporated into LMR ‘as is’, edited, or ignored.

Analysis

Descriptive statistics are presented as proportions or means with SDs as appropriate. Comparisons between arm 1 and arm 2 subjects were performed using Student t test for continuous variables and fisher's exact test for dichotomous outcomes except for comparisons of survey results between patients in the two study arms, which were performed using general estimating equations to adjust for clustering of patients within PCPs.

Observations

Study patients and physicians

Among 11 primary care study practices with 121 046 active patients, 21 533 (17.8%) patients with a PG account received an electronic invitation to enroll in the study, and 3979 (3.3%) patients consented to participate (table 1 online supplementary data available at http://jamia.bmj.com).

Small differences in age (48.9 vs 46.7 years; p<0.0001), gender (60.2% vs 64.7% female; p<0.0001), and median income ($54 617 vs $52 012; p<0.0001) were found between study enrollees and non-participants, respectively, with larger differences in race (87.1% vs 69.8% white; p<0.0001), insurance (84.7% vs 74.7% privately insured; p<0.0001), and baseline non-PCP visits (4.2 vs 3.0 in the prior year; p<0.0001). Comparisons of patients in arm 1 versus arm 2 showed differences in age (51.2 vs 47.0 years; p<0.0001), gender (54.8% vs 64.5% female; p<0.0001), median income ($55 385 vs $54 024; p<0.0001), and insurance.

Among 272 physicians in study practices (mean age 41 years, 68% female), 222 (82%) had patients who had completed PG activation, 167 (61%) had patients consented to the study, 89 (33%) had at least one patient invited to complete an eJournal, 84 (31%) had at least one patient who submitted an eJournal, and 80 (29%) opened at least one eJournal (table 2 online supplementary data available at http://jamia.bmj.com).

eJournal activity and content

During the intervention period, of the 3979 consented patients, a total of 2027 (arm 1: 1052; arm 2: 975; 50.9% of consented) were invited to use at least one eJournal (table 3), 1567 patients (77.3% of invited) opened a total of 2200 eJournals (arm 1: 1349; Arm 2: 851), and 1423 patients (70.3% of invited; 6.8% of PG account holders) submitted a total of 1988 eJournals (90.4% of opened). A total of 1012 patients (71.1% of submitters) had 1452 eJournals (73.0% of submitted) opened electronically by their provider, with more providers in arm 1 receiving an eJournal than in arm 2 (mean 10.5 vs 4.9; p<0.03; table 4).

Table 3.

eJournal life cycle and content analysis

Table 4.

Patient post-intervention survey responses

Patients had more eJournals generated (2091 vs 1194), submitted (1223 vs 765), and provider-opened (928 vs 524) in arm 1 versus arm 2 (table 3), which is consistent with having more eligible visit types in arm 1 (annual and follow-up visits) than in arm 2 (annual visits only). Content analysis of the first eJournal submitted by each patient showed that the majority of actionable items were edited by arm 1 patients: 98% of medications (6.6 mean items per eJournal in 743 eJournals), 96% of allergies (1.8 mean items in 743 eJournals), and 84% of diabetes items (8.7 mean items in 48 eJournals). Similarly, arm 2 patients edited 99% of family history (13.4 mean items in 680 eJournals) and 99% of personal history (13.1 mean items in 680 eJournals) items, but only 55% of health maintenance due items (2.5 mean due items in 332 eJournals).

Patient survey

In the post-intervention survey (table 4) completed by 2345 patients (59.3% of consented), 806 (34.4% of respondents) said they had submitted an eJournal to their doctor's office. Survey respondents who reported submitting an ejournal and responded to each specific item agreed or strongly agreed that: their provider had more accurate information about them (58.0%), they felt more prepared for their visit (55.9%), communication with their provider during the visit improved (37.2%; 53.4% neutral), they felt more satisfied with the visit (37.7%; 52.1% neutral), and the quality of care at the visit improved (24.5%; 64.1% neutral). Most patients (75.3%) wanted to complete an eJournal again for another visit, and 66.6% would recommend the eJournal to a friend or relative. After adjusting for clustering of patients within PCPs, more arm 1 than arm 2 respondents said they submitted an eJournal (46.3% vs 25.1%; p<0.0001), discussed it with their provider (59.3% vs 46.3%; p<0.01), and felt more prepared for their visit (59.4% vs 50.9% strongly agree or agree; p<0.02).

Additional patient narrative comments identified strengths of the eJournal—such as ‘it saved time during the visit’, ‘it prompted me to prepare more thoroughly’, and ‘it helped me to remember the questions I wanted answered.’ Other comments identified weaknesses—such as concern that the eJournal would not help communication improve unless a physician knew about it, looked at it, and found useful information in it. Some patients felt the eJournal content ‘should have expanded questions’, ‘should allow access to… earlier answers as I fill out a new one’, and ‘(should) allow me to focus on areas I wanted to.’ Some patients reported usability concerns such as ‘the software was too clumsy’, ‘the navigation was unfriendly’, and ‘data from an earlier visit could not be marked as unchanged.’ Fewer than 4% of survey respondents rated the eJournal as difficult (3.5%) or very difficult (0.4%) to use.

Physician survey

Altogether, 84 of the 272 study physicians had patients who submitted at least one eJournal. These physicians were invited to complete a survey about their experience and 29 (34%)—9 from arm 1 and 20 from arm 2—responded (table 5).

Table 5.

Provider post-intervention survey responses

Overall visit length was reported by arm 1 respondents to be unchanged (100%), whereas arm 2 respondents reported it was unchanged (53%) or longer (47%; p<0.013). More arm 1 than arm 2 respondents reported that they felt patients found the journals to be helpful (66% vs 20%; p=0.082). All (100%) of arm1 respondents felt patients completing eJournals were more prepared for the visit compared to a minority (43%) of arm 2 physicians (p<0.04). Arm 1 and arm 2 respondents did not differ in whether patients completing eJournals were more interested in their health records (50%), asked more questions about their health (36%), or wanted to learn more about upcoming tests and test results (29%).

More arm 1 (78%) than arm 2 (22%) respondents recommended eJournals to other clinicians (p=0.0143) and expressed overall satisfaction with eJournals (p=0.0143). In addition, respondents agreed or strongly agreed they wanted their patients to continue to have the eJournal feature for medications/allergies (90%), diabetes care (86%), health maintenance (83%), and family history (75%). Additional topics suggested were social history update (79%), information about recent appointments with other providers (59%), reason for visit (34%), office questionnaires (31%), and additional screening questions (24%). They described using eJournal information to facilitate conversations during a visit and to update LMR information directly from the eJournal (59% overall; 89% from arm 1 vs 45% from arm 2; p<0.03).

Discussion

In this implementation of a shared, practice-linked, pre-visit eJournal, patients could review EHR data, respond to tailored and untailored health questions, document goals for the visit, and submit the eJournal to their provider. Providers could discuss eJournal information with their patients and document it in the EHR. Despite limitations in overall patient portal adoption, eJournal invitations to study consenters, and eJournal use by study patients and physicians, valuable experience was gained from patient and physician use of the eJournal.

Many patients reported eJournal use improved visit preparation, communication with providers, and the accuracy of information they gave their provider. Providers reported the eJournal helped patients prepare for the visit, learn more about their health records, and ask more questions. Findings specific to the diabetes eJournal are reported elsewhere.^{24 25} Many but not all patients or providers reported benefits of the eJournal, with more benefits associated with medications, allergies, and diabetes topics.

Greater adoption of the eJournal tool will require increases in PG enrollment, in eJournal topics and visit types triggering an eJournal, and in physician engagement. Vigorous marketing of PG led to enrollment growth within study practices of more than 270% between September 2005 and August 2009. Enhanced scheduling system integration and eJournal topics in primary, specialty, and pediatric care will improve the ability to offer tailored eJournal content based on patient, visit, provider, practice, and EHR characteristics. Reducing physician liability concerns (eg, if the patient submits an eJournal but misses the appointment) requires additional study.

Further work is also needed to improve eJournal integration into practice style, workflow, and documentation, including physician notifications and coordinating the use of electronic and non-electronic tools. Higher provider satisfaction with the medication, allergies, and diabetes eJournal topics may reflect better fit with provider workflow given the relevance of these topics at each visit and the LMR shortcuts to document these patient-entered eJournal items. In contrast, submitted family history eJournal information was not reviewed at every visit, was more tedious to view, and was less easily documented into the LMR. Additional work to determine how eJournal information that already appears in the EHR should be displayed (or suppressed) from physician view will be needed.

Factors that limit the generalizability of this work include the narrow set of eJournal topics and the non-response bias given the small percentage of respondents (patients and physicians). Assessment of the eJournal among low literacy or less-educated patients, more specialized physicians, and a greater variety of practice settings was not done. Accuracy of patient-reported data was not addressed in this study.

Future work should also focus on how eJournals can coexist with other technologies to improve the flow of structured and unstructured data while serving the varied needs of patients, providers, and the health system. While a basic eJournal may be useful as a patient data entry tool, advanced eJournal capabilities—including tailored chart information, instructional reference information, and communication tools—may offer additional benefits for enhanced patient–provider collaboration.