Barriers to patient portal access among veterans receiving home‐based primary care: a qualitative study

Abstract

Background

Electronic, or web‐based, patient portals can improve patient satisfaction, engagement and health outcomes and are becoming more prevalent with the advent of meaningful use incentives. However, adoption rates are low, particularly among vulnerable patient populations, such as those patients who are home‐bound with multiple comorbidities. Little is known about how these patients view patient portals or their barriers to using them.

Objective

To identify barriers to and facilitators of using My HealtheVet (MHV), the United States Department of Veterans Affairs (VA) patient portal, among Veterans using home‐based primary care services.

Design

Qualitative study using in‐depth semi‐structured interviews. We conducted a content analysis informed by grounded theory.

Participants

Fourteen Veterans receiving home‐based primary care, surrogates of two of these Veterans, and three home‐based primary care (HBPC) staff members.

Key Results

We identified five themes related to the use of MHV: limited knowledge; satisfaction with current HBPC care; limited computer and Internet access; desire to learn more about MHV and its potential use; and value of surrogates acting as intermediaries between Veterans and MHV.

Conclusions

Despite their limited knowledge of MHV and computer access, home‐bound Veterans are interested in accessing MHV and using it as an additional point of care. Surrogates are also potential users of MHV on behalf of these Veterans and may have different barriers to and benefits from use.

Introduction

Electronic, or web‐based, patient portals have demonstrated utility to improve patient satisfaction, engagement and health outcomes.1 In the United States, the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009, has led to meaningful use incentives, motivating providers to offer their patients personal health records and patient portals. Despite these incentives and increasing evidence that patient portals can improve health‐care service delivery and outcomes,2, 3, 4, 5, 6, 7 only a minority of patients have embraced this technology. Rates of adoption have been reported to be only 25% on average, and 40–60% for even the most comprehensive portals.5, 8 As of 2012, fewer than 30% of all Veterans receiving care through the Veterans Health Administration (VA) system had registered for the VA electronic patient portal, My HealtheVet (MHV), and fewer than 15% has completed registration to gain full access to all MHV features;9 among Veterans using home‐based primary care services, 8% had registered for an MHV account and only 1% had completed registration to gain full access to all MHV features (personal communication, Tracey Martin, RN, New England MHV Coordinator, 1 February 2013).

Vulnerable patients are less likely to use patient portals than the general population.10, 11, 12, 13 Older patients,10, 11 those with lower socioeconomic status,13, 14 residing in rural areas,14 or living with HIV15 or other chronic diseases,2, 16 have been reported to use patient portals at low rates. In contrast, those with multiple chronic diseases may be more likely to adopt patient portals, however.8 Older adults' less frequent use of patient portals is somewhat surprising because these individuals are relatively frequent users of the Internet for other health‐related activities.17 Poor access to computers and the Internet are barriers to using patient portals among socioeconomically disadvantaged individuals.12 Even after accounting for computer and Internet access, low socioeconomic status remains a correlate of low rates of Internet use for health‐related activities.16 Among older adults, receipt of training, cognitive ability and prior use of computers were significant predictors of being able to navigate a complex health website.17, 18 Certain vulnerable populations may stand to benefit from the use of patient portals at least as much as the general population, if not more, given their medical complexity and high‐care needs.

VA's Home Based Primary Care (HBPC) provides health services in the home for qualified Veterans, who are often older, frail and have multiple complex medical problems. HBPC‐enrolled Veterans are also more isolated than the general population due to their home‐bound status. Because of this relative isolation, HBPC patients, as with other vulnerable patient populations, may benefit more than the general population from increased points of access, such as through a patient portal. Despite the high needs and potential benefit of patient portal adoption, HBPC patients continue to have low MHV enrolment. Little is known regarding the barriers to patient portal adoption in this population, and understanding these barriers among Veterans may provide insight into the barriers to adoption of patient portals among home‐bound and otherwise vulnerable patients beyond the VA. Therefore, we sought to characterize the perspectives of Veterans using HBPC to guide strategies for engaging these patients in the use of the VA patient portal.

Methods

We used a qualitative study design through semi‐structured interviews with patients, their surrogates and providers to understand barriers to adoption of MHV in Veterans receiving HBPC.

VA My HealtheVet

My HealtheVet allows patients to access health information and communicate with their health‐care team. The goal of understanding how Veterans might access and use MHV guided our study design. This electronic tool has the potential to improve Veterans' health, especially among those with physical or psychological limitations that impede their ability to travel to a VA site for care. MHV has a tiered access structure, with additional features available at each level. The first level is accessible to the public and includes basic general health information and educational resources. The second level is accessible only to Veterans who register online. At this level, Veterans can input data about their own health and prescriptions, which they can then print out for providers, and they can request prescription refills. The third and highest level requires the Veteran to visit a VA site of care with photographic identification for ‘in‐person authentication’ (IPA) for a premium account. Once IPA is complete, Veterans can view a complete list of their VA medications, download their medical record and asynchronously communicate with providers via a secure messaging system.19

Study setting and participants

We recruited Veteran patients enrolled in the VA HBPC programme. HBPC was instituted to decrease disparities, increase access to care, maximize quality of life and minimize institutional care for a growing population of Veterans with complex conditions for whom clinic‐based care was insufficient to meet their health‐care needs.20 The VA Boston HBPC programme served approximately 200 Veterans in 2012, completing an average of 280 home visits each month. The Veterans served by VA Boston HBPC are men (91.4%), non‐Hispanic White people (79.4%), live with others (57.9%), and range in age from approximately 50 to 100 years. Common diseases among HBPC‐enrolled Veterans are similar to the general VA patient population: vascular disease (19%), heart disease (17%), diabetes (15%) and mental health disorders (14%).

HBPC staff used a script we developed to engage patients in a discussion about the study and to gain their permission to be contacted by research staff. Exclusion criteria included patients unable to make their own medical decisions, unable to communicate verbally in English and unable to participate meaningfully in an interview due to compromised mental state (as determined by HBPC clinicians in their regular interactions). Patients were recruited from October 2011 to March 2012. Approximately 50 patients were approached by HBPC staff and 18 patients agreed to be contacted by study personnel. Fourteen patients completed the consent process and were interviewed. Four patients could not be interviewed because of inability to contact the patient, despite repeated attempts by the interviewer.

We interviewed key HBPC staff to provide context for the study and gain insight into the programme, patient population and how MHV might better meet their patients' needs. Veterans were compensated $50 for their time. Following VA policies, providers were not compensated.

Interview guides

Based on our goal of learning more about patients' barriers to using MHV, we developed a semi‐structured patient interview guide focused on five areas: (i) reasons for HBPC services; (ii) comfort level with and general use of computers and the Internet; (iii) prior knowledge and use of MHV; (iv) impressions of MHV regardless of prior use and (v) other individuals who might use MHV on their behalf (i.e. surrogates). Surrogate questions were tailored to reflect their role. The interview began with a short survey to collect demographics and information regarding familiarity with computers, the Internet and personal health records. At the end of the interview, we described MHV and answered any questions that arose during the course of the interview. Using a separate semi‐structured interview guide, we interviewed staff to gain background information about the HBPC programme, HBPC patients and staff workflow. All interviews were audio‐recorded and transcribed verbatim. This study was approved by the Institutional Review Board of the VA Boston Healthcare System.

Analysis

Our multidisciplinary team composed of clinicians and social scientists used both an a priori content analysis approach and a grounded thematic approach to identify key concepts.21 We generated an a priori coding framework based on the existing literature and our research questions; the topics included comfort with computers and the Internet, prior MHV use, potential future MHV use, MHV recruitment strategies and general impressions of VA and HBPC. We also used a grounded thematic approach to generate new concepts from the interview data. Three of us (DKM, MS and RGM) began by reading two interview transcripts to determine if any concepts were not captured by the established framework. Subsequently, each interview was coded using content analysis, based on both the a priori coding framework and grounded thematic approach, by one or more of the researchers (DKM, MS, RGM, SRS, TM). We did not encounter conflicts in coding between researchers during the process. We used NVivo (Version 10, QSR International, Burlington, MA, USA), a qualitative analysis software package, for all coding.

Following the content coding, group discussions among the whole research team led to identification of key concepts related to the barriers to and facilitators of MHV adoption among HBPC‐enrolled Veterans. In addition, researchers discussed the implications of these concepts for guiding future strategies and projects to engage Veterans in MHV.

Results

Sample description

We interviewed 14 HBPC patients and three staff members: a physician, social worker and nurse manager. Veteran interviews took place either by telephone (N = 10), in the Veteran's home (N = 3), or at a VA Boston clinic (N = 1), as determined by the Veteran's preference. Two of 14 patient interviews were primarily conducted with the Veterans' health‐care proxies or surrogates at the Veterans' request. In these cases, the surrogates indicated that they would use MHV on the Veterans' behalf if adopted. The Veterans were all men; most had used a computer and the Internet previously; few had prior knowledge of MHV (see Table 1). The two surrogates were women, used computers and the Internet extensively, and had prior knowledge of MHV (see Table 1).

Table 1.

Participant characteristics

	Veteran (N = 12)	Surrogate (N = 2)
Male	12	0
Used computer previously	10	2
Used Internet previously	9	2
Owns a computer	8	2
Has Internet access	7	2
Had heard of MHV previously	8	2
Had completed MHV IPA process	1	0 (on behalf of Veteran)

Themes

We identified five themes related to adopting MHV. Three themes were barriers to adoption: (i) limited prior knowledge of MHV, (ii) satisfaction with status quo communications with providers and (iii) limited computer and Internet access. Two themes were facilitators of adoption: (iv) a desire to learn more about MHV and (v) surrogates acting as intermediaries between Veterans and their medical care.

Barriers to adoption

Limited prior knowledge

Veterans were generally familiar with using computers and the Internet; however, only one had completed the enrolment process and accessed the full functionality of MHV. Although the majority had heard of MHV previously, almost none knew about MHV's functionality or how to gain access to MHV. Despite having seen mailed flyers or posters at VA clinics, these Veterans were not aware that MHV might be a useful tool for them:

[I've] seen posters…at the VA, and then when [I] get notices about appointments there's a flyer…. I have no idea how [it] works because nobody tells me anything.

When asked how they would like to learn about MHV, Veterans were most enthusiastic about having a provider they knew describe its functionality to them and how it might benefit them personally. Both Veterans and surrogates wanted written information about MHV features and enrolment for future reference.

It was 98% more useful to hear [about MHV] from the social worker [than a flyer] because she spelled it all out.

Veterans and HBPC providers indicated that an HBPC provider could assess the Veterans' ability to use MHV and provide enrolment information.

HBPC providers, however, had limited knowledge of MHV. These staff members noted that they would need training and expressed willingness to learn how to complete the MHV enrolment process to obviate the Veterans' need to visit a VA medical centre in person.

Satisfied with status quo

Participants expressed satisfaction with their current HBPC care, and this contentedness emerged as a reason for not adopting MHV. Most of the Veterans noted that they receive comprehensive, timely care from the home‐based primary care group. Many receive twice‐monthly HBPC visits to refill medications, review treatment plans and generally maintain the connection between the Veteran and the HBPC team.

[HBPC] is certainly wonderful. And the nurses are wonderful. I never have to wonder about my medication refills or anything. [My nurse] keeps me up to date all the time. She's remarkable.

While participants were satisfied with HBPC, they also identified communication problems they encountered in the wider VA system. Multiple Veterans mentioned that they are often unable to reach a given VA clinic or office by telephone, frequently being transferred to extensions that are not answered or that have recorded messages. Even when they leave voice messages, the Veterans report that they often do not receive return calls; these Veterans made a point of stating that they do not have this issue with calls to the HBPC group.

Veterans uniformly did not want to replace the level of service provided by HBPC by enrolling in a patient portal. However, at the end of the interview, when interviewers described how MHV would not replace, but would potentially enhance, the services they already receive, Veterans were once again interested in using MHV.

Computer access issues

Few participants had computer access. Many Veterans described lacking the financial means to purchase new computers, upgrade their existing systems or subscribe to Internet service. Veterans were not comfortable accessing MHV via public computers, such as in a public library, due to privacy concerns. Many inquired as to whether the VA might furnish them with a computer and Internet service to access MHV and with training on how to use MHV.

I do not [own a computer]. [Using a computer] is very frustrating. I don't know the cost of any plan. I can't seem to find out the things that I want to find out.

Some participants also noted special needs when using computers, such as large font for the visually impaired or touch screens for those with limited fine motor skills. Two Veterans noted they had previously received computers through a programme for the visually impaired, and indicated that they had received information about MHV's functionality and registration process through this Veteran organization.

Facilitators of adoption

Desire to learn

Despite limited knowledge of the patient portal, Veterans and their surrogates were eager to reap the potential benefits of using MHV, expressing a desire to learn more about its functionality and how to enrol. Most Veterans were unaware of how to gain access to MHV but were interested in learning how to register and begin using the system.

[If the VA would] teach me a little bit more on the computer, great! I'd want to learn anything I could.

Although most participants did not know about the capabilities of MHV, those who expressed an interest in computers and technology wanted to know details about each function listed by the interviewer. Veterans, surrogates and HBPC staff identified medication refills and the ability to electronically communicate with providers via secure messaging as the functions they felt would be most useful.

The rheumatologist told me I can go in and if I need a refill I don't have to go through all the bologna by talking to six different people… I can email him directly from [MHV] to get refills.

There were also some areas where Veterans expressed interest in expanded functionality – for instance, increased access to viewing their entire medical record and ability to communicate securely with specialists in addition to primary care providers.

Surrogates as intermediaries between veterans and their personal health records

Several HBPC Veterans raised the issue of having a surrogate use MHV on their behalf. One Veteran described how MHV access would be valuable to him and his surrogate.

My step‐daughter is my guardian. She's interacting with the VA all the time. And any problem that comes up, she handles it. There's nothing [I wouldn't want her to access]. I wouldn't have any concerns about her being able to access my health record over the internet. She [already] pays all my bills by computer…and that's definitely alright.

We spoke with two Veterans' family members identified by the Veteran as benefitting from surrogate access. Unlike most Veterans interviewed, both surrogates had a computer, Internet access and experience using these technologies. These surrogates were interested in electronic communication with the VA on the Veterans' behalf. One surrogate mentioned that she intended to use the Veteran's MHV access codes to access the portal on his behalf once she registered him for MHV.

Both surrogates interviewed said that they would want to be able to use the same MHV features as would be available for the Veterans. Surrogates expressed particular interest in the ability to trend laboratory values, request medication refills, track appointments and ensure the accuracy of the prior medical record. The surrogates noted access to the Veteran's MHV record would be valuable given that they are not always present when the Veteran has a medical appointment or home visit and often rely on the Veteran to relay information from these encounters.

Discussion

This qualitative study identified five themes – three that may explain the low rates of patient portal adoption among Veterans enrolled in HBPC and two that could indicate potential facilitators of greater portal use in HBPC Veterans in the future. Veterans in HBPC have unique needs related to electronic patient portals. Although enthusiastic about using MHV, this vulnerable population has historically low enrolment and usage rates. Based on our interviews, this lacklustre adoption stems from multiple areas: inadequate information about the portal, logistical barriers to enrolment, lack of home computers and Internet and the absence of portal knowledge and skills among surrogates.

Veterans identified a variety of approaches that the VA could employ to communicate information regarding MHV benefits and enrolment processes, such as through brochures and one‐on‐one discussions from staff or providers. They were particularly interested in their providers describing to them how MHV could benefit them personally. This notion may stem from the finding that these Veterans were generally very satisfied with the HBPC services they receive and had difficulty imagining how their access to care could be increased even further. Because Veterans' surrogates are not always present at clinic appointments or home visits, getting informational materials into the hands of the surrogates may foster adoption. Both surrogates and Veterans noted the need for both verbal and written information about MHV features and enrolment procedures.

Prior work has shown that patients with good relationships with their health‐care providers are less likely to be interested in using patient portals.22 However, in another study among older patients with diabetes, those reporting good communication with and trust in their provider were more likely to be enrolled in a patient portal than those not reporting good communication or trust.23 Many of our study participants mentioned the fear that they would lose HBPC services if they were to adopt the use of a patient portal. This is a concern that should be addressed explicitly when publicizing MHV to patients using HBPC. This message may need to be generalized to all Veterans, who may harbour concerns that MHV enrolment could limit their access to their providers or other VA services.

Although none of the study participants was a regular user of MHV, most expressed considerable interest in using electronic communication for health needs. Moreover, areas of VA care that participants identified as frustrating, such as cumbersome telephone systems, could be circumvented with the use of the patient portal, an observation consistent with surveys that have demonstrated high levels of satisfaction among Veterans using MHV.24 One survey of Veterans in VA primary care showed that half were regular computer users and one‐third preferred electronic to in‐person communication for preventive care reminders, test results and prescription refills.25 Another survey of Veterans with diabetes showed that over 40% were interested in using MHV to track their glucose measurements, although one‐third of those interested did not have home Internet access.10 Of note, VA has recently begun to expand secure messaging to include specialists in addition to primary care.

Previous work has shown that training programmes designed for computer‐inexperienced vulnerable Veterans can increase their use of computers, Internet and MHV.26 These trainings also increase self‐efficacy for the use of technology for health‐related purposes and patient engagement in health care.26 Older adults, who may also have cognitive limitations, may see similar benefits from such training.18 Our finding that Veterans would like personal assistance with enrolling in MHV and training in its use, suggests that this vulnerable population may benefit from similar training.

Compared with the general population of Veterans, HBPC‐enrolled Veterans are less able to physically visit a VA site or move from location to location once at the facility. Enrolling Veterans at their point of care, in this case their homes, would eliminate this barrier to MHV use. The VA is beginning to provide this capability, although it is not yet widely utilized. There are barriers to this remote enrolment, including staff hardware that is cumbersome to use. If HBPC Veterans are to have the same potential access to MHV as non‐HBPC Veterans, these obstacles should be investigated and mitigated.

Study participants described financial barriers to purchasing computers and paying for Internet access, which in turn prevent home access to MHV. Some Veterans also noted the need for specialized computers because of physical limitations. To fully engage this vulnerable population, VA may need to consider these special needs and address them as a barrier to portal access for these Veterans.

Surrogates play a vital role in the decision making process around Veterans' health care. Both Veterans and their surrogates identified the need for surrogates to access MHV. Even with special adaptive equipment, as Veterans age, they may become less able to use computers, at which point, they may want a surrogate to be able to access the features in the portal on the Veteran's behalf. In a prior survey, 80% of patients were interested in sharing aspects of their personal health record with caregivers outside of their health system, including spouses, children and other family members.27 Many patients and their surrogates currently do this in an informal manner, by sharing usernames and passwords, raising a security concern and creating a situation where the content displayed to the Veteran, and the surrogate is identical. While this sharing may be beneficial, particularly if both the Veteran and surrogate are accessing the system, there may be different features that a surrogate would find useful that a Veteran would not, such as information related to support services for caregivers. Moreover, the Veteran may wish to limit the surrogate's access to only certain parts of MHV. These findings suggest that surrogates would benefit from having a unique enrolment process and their own MHV access code that would enable them to view authorized portions of the Veteran's record and complete transactions (e.g. refills, secure messages) on the Veteran's behalf.

There are special needs to consider around the type of information that surrogates seek and concerns about privacy and confidentiality when developing surrogate access to patient portals.28, 29 However, many commercially available patient portal products offer this service already. It would be informative to undertake a more in‐depth analysis of surrogate needs to help shape additional MHV functionality targeted at this group.

This analysis is limited by the small number of Veterans and surrogates receiving services through one VA HBPC programme. However, the participants represent a variety of computer, Internet and MHV experience. Only one Veteran and neither of the surrogates used MHV, so their expressions of interest in specific features may not translate into actual use of those features once they are enrolled. Our sample was also limited to male Veterans and two surrogates and thus may not be generalizable to female Veterans or to a wider group of surrogates.

MHV was developed for use by all Veterans receiving care within the VA health‐care system. This includes Veterans who use clinic‐based services as well as those who utilize the VA's home‐based care services. Surrogates are also accessing MHV on behalf of Veterans. Accommodating the needs of these varied constituents is a complex but critical process if MHV is to be accessible to all Veterans.

HBPC‐enrolled Veterans are a vulnerable population given their limited physical access to the VA and their high utilization of health‐care services. Barriers to accessing the patient portal included lack of information as well as limited computer and Internet access for some. Although these Veterans reported contentedness with the care they receive through the HBPC programme, they expressed enthusiasm for the portal features that could provide them with increased access to health information. With appropriate training, the clinical team may be able to promote adoption of MHV among these at‐risk Veterans and their surrogates, thereby enhancing a patient‐centred care model and more fully engaging home‐bound Veterans in their health care.