Abstract
Background: Legislation mandates that clinicians make patients' medical information available digitally. This has resulted in hurriedly installing patient portals that do not fully meet the needs of patients or clinicians. This study examined a specific portal, MyPreventiveCare (MPC), a patient-centered portal designed to promote preventive care to consumers, to elicit recommendations from patients and clinicians about how it could be more beneficial by uncovering their uses and gratifications (U&G). Materials and Methods: In-depth interviews with 31 patients and two clinician focus groups were conducted. Multiple methods were utilized, such as grounded theory coding to develop themes and content analysis to classify responses according to the U&G framework. Results: Four main categories emerged that users desire to be included in health portals: integration with technology (27%), coordination of care (27%), incorporation of lifestyle (26%), and increased control (20%). Additional analysis revealed that health portals are mainly utilized to fulfill cognitive and affective needs, with over 80% of recommendations related to the U&G categories of cognitive and affective needs. Cognitive (60%), affective (21%), social integrative (10%), personal integrative (9%), and tension release (0%). Conclusions: Portals will continue to evolve and become important health communication tools if they address the user's perspective and are inclusive of new technological advances. Specifically, portals must become more user centric and incorporate aspects of the patients' lifestyle and integrate health information technology.
Keywords: : e-health, technology, education, medical records
Introduction
The Health Information Technology for Economic and Clinical Health (HITECH) Act was developed to increase adoption of health information technology systems, such as patient portals.1 Consequently, the patient portal market is expected to reach nearly $1 billion by 2017,2 but there is little evidence that portal use improves health outcomes, produces efficiency of care,3 empowers patients, or lowers costs.4
In addition, patients have been slow to embrace the technology. For example, the Mayo Clinic's portal had 240,000 patients initially sign up, but only 5% of registered patients actually used it.5 Low adoption rates may be linked to the way in which they are designed. For instance, most portals are physician oriented and do not consider the way patients prefer functionality.6 However, the ability to positively influence patients' health behavior largely depends on the usability of the portal.7 Research has shown that the patient perspective must be considered and integrated into the design of portals if they are ever going to achieve their full potential.8
The current study focuses on a novel health portal, MyPreventiveCare (MPC), which is used by more than 82,000 patients in 12 primary care practices across Virginia. The website tailors content from Healthfinder.org to internally create personalized educational material for patients, as well as linking to a wide range of resources (e.g., CDC, National Cancer Institute, and American Diabetes Association). Many portals similarly use and link patients to existing resources, making MPC an appropriate test case for this study.
The primary objective of the portal is to inform and encourage patients to undergo preventive screenings, especially since half of all patients are not up to date with recommended screening tests.9 However, the portal is also used to inform patients of laboratory results and provides resources, so patients better understand treatment options. Using MPC as a test portal for this case study, the goal of this study was to determine what additional features and functionality are necessary to advance portals into becoming indispensable healthcare tools.
Theoretical Framework
The uses and gratifications (U&G) framework was utilized because the approach explains the way individuals use communication mediums to satisfy their needs and achieve their goals.10 U&G have been used to describe radio11 and television viewing habits,12 but has evolved to cover computer-mediated communication,13 virtual communities,14 and social media preferences.15
Since multiple media compete for users' attention, individuals choose the medium that meets their needs.16 This is especially true in the current information age, in which people must be selective of their media choices.17 U&G distinguish between five categories as follows18:
(1) Cognitive: Represents the desire for information and knowledge to better understand the environment.
(2) Affective: Emotional experiences connected to individuals' desire for pleasure and entertainment.19
(3) Personal integrative: Related to an individual's value system, in which people strive to appear credible and elevate their self-esteem.
(4) Social integrative: People seek affiliation and want to be part of a community.
(5) Tension release: Also referred to as escapist needs, in which individuals release stress.16
The U&G framework was utilized in this study to ascertain what features patients' desire on health portals using the following research questions:
RQ1: What features do users desire to improve their experience of the health portal?
RQ2: How are patient and clinician needs classified according to the main categories of U&G?
Materials and Methods
Sample and Design
Purposeful sampling20 was utilized to recruit patients aged 18–79 who used the portal at least once in the past year. Interviews were conducted in two medical offices in the Northern Virginia area to represent a diverse cross-section of patients. Interviews were semistructured, which is as a guided, yet focused and open-ended discussion of cocreated events by the researcher and interviewee.21 In addition, two focus groups with clinicians were conducted in one Northern Virginia medical office inclusive of nurses, emergency medical technicians, and physicians. All groups were asked the same open-ended questions, categorized into the following domains: factors that positively affected usability, factors that negatively affected usability, and recommended modifications.
Analytical Process
Interviews and focus groups were conducted until thematic salience was reached. Salience was measured by recurrence, repetition, and forcefulness22 of responses. Data were transcribed into word processing software and uploaded to the qualitative analysis tool, NVivo.
To categorize the data, multiple methods23 were utilized. First, grounded theory coding occurred to develop themes from the interviews and focus groups, which involved two steps: (1) open coding of the data, assigning codes, followed by (2) focused coding, which used the most frequent open codes to synthesize the rest of the data.23 Next, qualitative content analysis was conducted,24 in which text was classified into one of the U&G categories. During the coding process, responses were sometimes given multiple codes, but repeated analysis allowed for one category to eventually be determined that encapsulated the central meaning of the response. Internal validity and credibility were addressed through member checks.25
Results
Interviews comprised 31 individuals (18 women and 13 men) and focus groups consisted of 13 total clinicians, generating a total of 58 unique recommendations to enhance the portal.
RQ1: What features do users desire to improve their experience of the health portal?
Responses were aggregated into four main categories as follows: (1) integration with other technology, (2) coordination of care, (3) incorporate lifestyle elements, and (4) increase control (summarized in Fig. 1).
Fig. 1.
Desired features.
Integration with Other Technology (27%)
Both patients and clinicians saw the need to integrate the portal with other technological devices, such as smartphones. One patient envisioned how advantageous it would be if the portal could sync with his mobile device: “This (iPhone) could tie into this (portal) … so you have that data and can monitor blood pressure every morning or track your weight.” Another patient imagined how clinicians could use data from biometric wearables, like Nike Plus™, an application that tracks an individual's workouts, and Fitbit™, which measures metrics such as steps walked, sleep cycles, and heart rate. The Fitbit user said, “Every day I sync this with my computer and it tells me how long I've slept, how much food I've eaten … What would be neat is if you could sync this software with this software (portal).”
Clinicians shared the same sentiment with patients and thought that the portal could be more effective if it integrated content from additional sources. While content on the portal comes from Healthfinder.org and other noncommercial federal and organizational websites, clinicians realized that patients still seek out information from sources like WebMD. Although websites like WebMD sometimes include nonevidence-based recommendations, clinicians agreed that providing information in a similar manner as WebMD would contribute to people relying on the portal for health information. As one clinician said, “it would be helpful if we knew exactly what information they are getting.”
Coordinate Care (27%)
It was common for patients to seek care from multiple specialists, but patients and clinicians agreed that the primary care physician should be kept abreast of what occurs while visiting other physicians. One patient said, “This is not the only physician I see. I see a Lyme disease specialist. He prescribes a lot of stuff I don't get through here. That's not going to show up on the portal.” Clinicians felt that care could be improved by incorporating other specialists into the portal. A physician gave an example in which he recommended a patient to see a hematologist, but thought that the patient would be more inclined to get the follow-up care if the referral was also featured on the portal. He suggested a list of recommended doctors that the practice has worked with in the past to be featured on the portal.
In addition to improving multidisciplinary communication, patients and clinicians thought the portal could assist in making office visits more productive. For instance, clinicians could review patient analytics and better understand concerns and potential questions. In addition, by reviewing information before visits, patients would be better prepared to “start a conversation…and develop a wellness agenda,” according to a physician. Similarly, other clinicians thought the portal could assist in time management by setting expectations for appointments. As a physician said, “If a patient knows they're coming in to get a wellness exam, they might schedule a different appointment to go over additional issues.” The portal could outline the objective of the appointment, helping to lessen clinician workload.
Incorporate Lifestyle Elements (26%)
No clinician recommendations were classified as incorporating lifestyle elements, but based on patient responses, this category accounted for 26%, making it the most frequent suggestion among patients. In addition to laboratory results and screening procedures, a greater level of personalized and customized advice about how to improve health was required. For instance, a patient stated that he would use the portal every day if it provided detailed instructions about how to quit smoking or lose weight. Currently, the portal provides personalized recommendations for smoking cessation and weight loss, but does not update based on a patient's daily progress. Correspondingly, patients wanted to enter goals and interactively use the system. A patient said, “I would go back into it [portal] and commit to exercise more. If you know you're tracking it, you're more likely to do it.”
Other ways of incorporating patients' lifestyle included consideration of how family members were involved in one's health. A patient said that they would be more inclined to get a colonoscopy if messages emphasized the significance of family history, since the patient's father had colon cancer. Likewise, many patients managed the health of other family members and would like a system that was able to assist in making sure family members were getting proper care. A patient compared it to the “blackboard” functionality that schools utilize and said, “I can click on all of my kids to see what's going on so I don't have to log in, log out.”
Increase Control (20%)
The last category, accounting for 20% of responses, focused on how users desire the ability to manipulate the information received. For instance, patients wanted the portal to function with a “Facebook approach,” in which “everything is right there for you,” like updates on new medications and health information directly imported from other health websites of the patient's choosing. In addition, patients saw the advantage in sharing information with one another. A message forum was suggested, in which patients could pose questions and receive feedback from other patients who may have had similar experiences, all while being monitored by the clinician.
Allowing greater patient control was the most popular response among clinicians. It was advocated that the portal allows for more patient self-service. For instance, a nurse was enthusiastic about a link on the portal to a cholesterol calculator because the patient could take control of their healthcare. Other clinicians endorsed using the portal as a comprehensive hub of all patient records. A physician said, “If we could include mammographies and all of their X-rays. That would be extremely beneficial because patients don't have to wait and they will have copies if they need to go to a surgeon.” Similarly, clinicians commented about how helpful it would be if patients could access immunization records, since they constantly receive requests for those records.
RQ2: How are patient and clinician needs classified according to the main categories of U&G?
Over 80% of recommendations are related to cognitive and affective needs (Table 1). No responses fit into the tension release category, which is understandable since patients voluntarily use the portal to seek health information.
Table 1.
Uses and Gratification Categories
CATEGORY | FREQUENCY | PERCENTAGE |
---|---|---|
Cognitive | 35 | 60 |
Affective | 12 | 21 |
Social integrative | 6 | 10 |
Personal integrative | 5 | 9 |
Tension release | 0 | 0 |
Cognitive (60%)
Patients were mainly interested in acquiring knowledge to assist in making decisions about their health. A patient summarized the desire for cognitive needs by saying, “I think the most important thing about the portal is being able to get results, being able to communicate and interact with your physician, and being able to get answers when you need them.” The portal is primarily designed to address patient's cognitive needs, as evidenced by preventive messages and laboratory result section. Both focus on giving patients helpful information based on their own health records.
The majority of clinician responses were categorized as cognitive needs. The portal was found to be most effective when it delivered facts about a patient's health because it primed patients for their upcoming appointment. In addition, tools on the portal, like the cholesterol calculator, allowed patients to gratify their needs for additional knowledge and better understand how to manage their health.
Affective (21%)
The second highest category revolved around the desire for greater emotional experiences. For instance, one patient wanted the portal to feel more personal; a sentiment echoed by many patients, which could be achieved through gentler language. A patient envisioned seeing the following vernacular: “We noticed your heart rate is elevated. Don't be alarmed, it's normal to fluctuate.” Affective needs were also reflected by another patient who thought the portal would be more effective by including messages that intensify people's emotions. She suggested that smoking cessation messages include the potential effect on people's pets and said, “People are crazy about their pets. I think what would motivate you to stop smoking? The worst thing you could do is just say, ‘you shouldn't smoke.’” Similarly, clinicians acknowledged that balancing the amount of information provided on the portal could affect patients' emotional states. For example, a nurse said, “Sometimes when doctors input information for the patient to read, they give too much information or not enough information. It's hard because everyone is different in how they relay information.”
Social Integrative (10%)
The socially integrative category comprised patients' desires to feel as if they were part of a community. Patients wanted the portal to be used as a tool that enabled them to manage their family members' health and communicate with other patients through a message forum. In essence, many patients already conduct this type of behavior by soliciting feedback on other websites. Another socially integrative patient suggestion was the desire to know the types of medical articles clinicians were reading. Several patients wished their physician would upload recent research findings and opinion pieces to the portal about treatment options or conditions.
Personal Integrative (9%)
Few patient responses included issues related to self-esteem, such as using the portal to track health information for the purpose of achieving goals. Most personally integrative suggestions were from clinicians. Physicians acknowledged that patients viewed the portal as an extension of the clinician, making it necessary to provide clear and helpful information. They stated that it was important for information on the portal to be perceived as trustworthy, so that conversations during appointments were more productive.
Discussion
Findings from this study indicated that both patients and clinicians are beginning to embrace health portals, but enhancements are necessary for them to become an important health tool. Understanding why users interact with portals and the way in which they receive gratification can influence the impact of portals on health behavior. For instance, individuals searching for information on the Internet became more self-efficacious, and therefore, they expected to obtain specific outcomes with increased usage.26 The same principle can be true of health portals, because if patients find relevant and helpful information, the portal may become a more integral part of the patient's life. Along with user-centric design, the concept of patient centeredness needs to be considered. In fact, it is recommended that technological improvements be considered in concert with enhancing patient-centered care to improve the state of healthcare.27 This is reinforced by the results of this study, which revealed that the portal was mainly utilized to satisfy cognitive and affective needs.
For portals to continue to evolve, meaningful use criteria should include the experience of patients as a measurement.28 Unfortunately, some providers are hurriedly installing portals to meet the HITECH mandate and are searching for inexpensive options since small practices face considerable up-front implementation costs.29 These factors contribute to physicians selecting systems that do not consider the patient perspective, since patients are rarely involved in the planning and design of portals.30 Considering why users access the portal and how to make it a gratifying experience will help to increase the utility and value of health portals. Similarly, business and clinical objectives should be clearly defined before a portal is selected. Just as industries like retail and the financial sector have built applications that demonstrate trust and usefulness to increase consumer satisfaction and behavioral intentions,31 patient goals must be considered when designing patient portals.
MPC is a good example of a portal that goes beyond the HITECH requirements and also provides worthwhile features to patients, such as personalized health plans and health education. However, additional features are needed, such as online scheduling, prescription refills,32,33 and the ability to track calories, diet, and exercise34 to activate patients instead of simply providing a summary of data. Along with incorporating new technological features, portals must connect other healthcare providers so that specialists can communicate and be better informed with primary care physicians. Other personal health records, such as Get Real Health, offer multilingual capabilities and the ability to collaborate.35 In addition, since 64% of Americans own a smartphone,36 “the use of mobile and wireless devices to improve health outcomes, healthcare services, and health research,”37 otherwise known as m-health, is necessary. This is particularly important because 52% of adults in the United States view health information on their phones.38 In fact, the digital divide, which once obstructed women and minorities from utilizing technology,39 is no longer a significant barrier. For example, Latino and African American women between 18 and 49 frequently gather health information using their phone, and women smartphone owners between 30 and 64 are more likely than other smartphone owners to have signed up for health text alerts.38
This study contained several limitations, such as a small sample size, and although a diverse group of individuals participated, it was not representative of all adults. In addition, only one health information system, MPC, was used. A review of multiple systems may have elicited different responses and reactions. Future research should test if patient use increases once additional features are added and how patient-centric health portals impact health outcomes.
Conclusions
Interviews with patients and focus groups of clinicians helped to uncover ways in which health portals could be improved to better meet users' needs. Results indicated that portals need to become more user centric. Specifically, aspects of patients' lifestyle should be incorporated in recommendations, health information technology should be integrated, and communication between multiple providers should be enabled. Incorporating the user's perspective would alleviate the chore of ensuring that providers meet meaningful use standards by transforming portals into systems that patients view as mandatory use, because they address key concerns and contribute to healthier lifestyles.
Acknowledgments
Sources of funding: National Cancer Institute; grant/award No. R01CA166375-01A1 and the National Center for Advancing Translational Sciences; grant/award No. UL1TR000058.
Disclosure Statement
No competing financial interests exist. Informed consent was obtained from all individual participants included in the study.
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