Improving Acceptance of Inpatient Portals: Patients' and Care Team Members' Perspectives

Abstract

Background: Inpatient portals are gaining interest as a means to increase patient-centered care during hospitalization. However, acceptance of a new technology such as the inpatient portal relies on perceptions of both its usefulness and ease of use. These factors have not been studied in the context of inpatient portal implementation.

Methods: We interviewed patients (n = 123) and care team members (n = 447) about their experiences using an inpatient portal that had been implemented across a large, academic medical center. Interviews lasted 5–15 min, were audio-recorded, transcribed verbatim, and then analyzed using a combination of deductive and inductive methods.

Results: Collectively, interviewees reported that the inpatient portal was a useful tool as it improved patients' access to information, enhanced communication, facilitated education, and appeared to promote patients' sense of control while in the hospital. Most interviewees also found the technology easy to use. However, there were concerns that the portal was not easy to use for those less experienced with technology. Interviewees identified the need to emphasize the value of the technology to both patients and care team members and the need to provide additional training to support portal use, as ways to promote acceptance of the tool.

Discussion and Conclusions: Inpatient portals can improve patient-centered care, but such improvements require acceptance of the tool by both patients and care team members. Our findings about the usefulness and ease of use of an inpatient portal can inform future efforts to improve the implementation and acceptance of this new technology.

Introduction

Hospitals are increasingly focused on delivering patient-centered health care where patients are actively involved in their care process.¹ New health information technologies (HIT) such as patient portals can support hospitals' efforts to deliver patient-centered care by providing enhanced access to and management of health information and improving the quality of patient-provider communications.^2,3 Introduced in both outpatient and inpatient settings, portal applications allow patients to interact with both their medical records and care team. Popular features available in these portals include viewing care team information, scheduling medical appointments, requesting prescription refills, secure messaging, and checking patients' medical/laboratory results.^4,5

Inpatient portals are designed to support the day-to-day management and care needs of hospitalized patients. However, acceptance of the inpatient portal as a new HIT tool in the hospital environment is complicated because it requires that both patients and care team members are actively involved. Effective inpatient portal implementation is thus predicated on a joint commitment to accept and use the technology.

Davis' Technology Acceptance Model (TAM⁶) frames acceptance of information systems by an individual as motivated by two influential constructs: perceived usefulness (i.e., how a technology would enhance an individual's task performance) and perceived ease of use (i.e., the effort needed by individuals to use a technology). This model has been used to explain technology acceptance in diverse contexts,^7–9 and in health care, it has been applied to examine the adoption and acceptance of HIT, including patient portals.^10–14 Notably, this model has not yet been used to study inpatient portals, but considering inpatient portal adoption and acceptance using TAM can improve our understanding of the tool and how to promote its use.

The research presented here is part of an ongoing, major study of inpatient portal implementation across a large academic medical center (AMC). A component of that research was to explore both patients' and care team members' perspectives about the inpatient portal application. In this article, we investigate patients' and care team members' perceptions about the usefulness and ease of use of the inpatient portal in the context of hospital care.

Methods

Study Design and Study Setting

We designed an extensive qualitative study of patients' and care team members' experience with the inpatient portal, MyChart^® Bedside (Epic Systems, Verona, WI), implemented across the six hospitals of The Ohio State University Wexner Medical Center (OSUWMC). This AMC introduced the inpatient portal system-wide in 2016 with MyChart Bedside offered to patients as an application on an Android tablet. Features of this inpatient portal include access to health information and health education, the ability to view the day's schedule or names and pictures of care team members, and functions that enable ordering of meals, making service requests, note-taking, and messaging with care team members.¹⁵

Data Collection

We conducted interviews with patients and care team members between Fall 2016 and Fall 2018. Patients were interviewed individually by phone in two phases: 15 days after hospital discharge and 6 months after discharge. Care team member interviews were conducted in person, with individuals or in small groups, and in four phases: immediately post-implementation and then at 6-month intervals for the next 18 months. All interviews were conducted using semistructured interview guides (provided in Appendix A1), audio-recorded, transcribed verbatim by members of Ohio State Univerity's (OSU) Center for the Advancement of Team Science, Analytics, and Systems Thinking, and then de-identified. Patients were asked about their experience with the inpatient portal, while they had been in the hospital; interviews lasted an average of 15 min. Patients participating in phone interviews were mailed $15 gift cards as a token of appreciation for their time. Care team members were asked about both their experience with the inpatient portal and their perceptions about patients' use of the portal; these interviews lasted an average of 10 min. OSU's Institutional Review Board approved this study.

Study Subjects

Patients were randomly selected for interviews from the enrollment list of the parent randomized control trial study based on their discharge date. Using this selection process, those patients interviewed 15 days post-discharge were different from the patients interviewed 6 months post-discharge. Care team members from 53 units across the AMC were invited to participate in interviews by research team members who visited their units. Each unit had an interview team available for one pre-scheduled hour. Care team member interviewees included nurses, nurse managers, nurse assistants, and unit clerks. The numbers of interviewees, by type and time frame, are presented in Table 1.

Table 1.

Interviewees, By Type and Time Frame

INTERVIEWEE TYPE	n
Patients
15 Days post-discharge	63
6 Months post-discharge	60
Total patients	123
Care team members
Immediately post-implementation	109
6 Months post-implementation	112
12 Months post-implementation	116
18 Months post-implementation	110
Total care team members	447

Data Analysis

All interviews were analyzed both deductively and inductively, consistent with rigorous qualitative methods.^16,17 We first developed a preliminary coding dictionary, defining codes based on the interview questions. These initial codes included “perceived usefulness” and “perceived ease of use,” in accordance with the TAM framework, as well as “suggestions for promoting portal acceptance.” Next, four members of the research team coded the same four transcripts and met to discuss coding decisions and make suggestions about emergent codes as they refined the preliminary coding dictionary. These emergent codes became the basis of the themes we report in our Results section (e.g., usefulness—improved access to patient information). This refined coding dictionary was then used by two members of the research team who coded the remaining transcripts, meeting frequently throughout the process.

Regular meetings between the coders and the lead investigator helped to ensure uniformity in application of codes and agreement about emergent codes. Saturation of the data was achieved, as revealed by the consistency of responses across patients and care team members surrounding our identified themes. This iterative and comprehensive approach to analysis thus strengthen the trustworthiness of our methods and our findings with respect to their credibility, transferability, dependability, and confirmability.¹⁸ The ATLAS.ti^® qualitative data analysis software (version 6.0; Scientific Software Development GmbH, Berlin, Germany) was used to support our coding and analysis process.

Results

Both patients and care team members commented about the usefulness and ease of use of the inpatient portal and had suggestions about how portal acceptance could be promoted, as we present below. Interestingly, patient and care team member responses to interview questions did not change considerably over time between interview phases. As such, we do not distinguish among interview phases in the reporting of our results.

Perceptions About Usefulness of the Inpatient Portal

Patients who had used the inpatient portal during their hospital stay were largely positive about the tool and noted several ways in which they perceived the portal to be useful: (1) improves patient access to information; (2) enhances communication; (3) provides ability to educate; and (4) promotes patient sense of control. Below, we describe these constructs in further detail with additional quotes presented in Table 2.

Table 2.

Perceptions About Usefulness of the Inpatient Portal

THEME	VERBATIM COMMENTS FROM PATIENTS	VERBATIM COMMENTS FROM CARE TEAM MEMBERS
Improves patient access to information	“I liked to see just like my past vital signs and the medications that were on my list, available. I thought those features were helpful. I did like to know what my previous vital signs were, I liked knowing what medicine was available, if I needed any.”	“I think patients that want to know really extensively what their labs are in the morning. They can just pull it up which is nice because they don't have to rely on us to bring our files into the room and read them off to them. Or like with their pain meds and stuff they can keep up when their pain meds are due next.”
	“The fact that I can get my test results from my labs and everything right as soon as they come available. And also to keep track of medications, when they were given last and when they're due next.”	“It helps them so they can see when they are going for this test, stuff like that. They kind of inform themselves by using it.”
Enhances communication	“The ability to see trends and the ability to review them before you get the doctors rounding, that's I think is pretty critical to folks. It also allows you to educate family and friends in ways that are concrete than trying to remember what all your scores were on a certain panel test.”	“They can question things, ‘Hey I didn't say that this was okay,’ ‘I saw that this changed, why did it change?’ I think it…it can help with communication.”
	“I kind of told her she has to sign up for it because it will be an easy way to communicate and she's on that. So very useful as well.”	“Communication between the patient and the staff members I feel like…I mean they can order their food so that's really a plus and they know what's happening at all times of their care which has helped them.”
Provides ability to educate	“I just was able to look up some kind of basic information on some of the diagnoses that they were tossing around so I was able to have more questions you know, informed questions, and I also was able to look at some of the side effects and whatever of different medications that they were playing around with that's how I used it most as an instructional tool for myself.”	“I love that feature because the patient's sitting there for hours and days on end, not knowing maybe what to do with their time and they could be reading and scrolling through videos and documents and all those things to educate themselves on their disease process, or why they're here in the hospital and then when they check off on that.”
	“You know if I had needed an explanation or anything of exactly what they were telling me I didn't always have to bother them with the questions. I could just go on MyChart® and see what it was.”	“I'll give them an education booklet but also have…follow up on the tablet and talk about how they need more education on it or they can mark off that they understand it completely and that it kind of communicates with the chart and communicates with us on how they are learning, so we have the patients use those often.”
Promotes patient sense of control	“…instead of doctors coming in and using big terms that you don't understand so you're sitting there puzzled, you can actually look it up on your MyChart. It breaks it down and forms, definitions, milligrams of what you're taking, your day/night shifts and everything like that with your nurses. So, I think it's very beneficial.”	“I just feel like it takes, it gives it a little more control…. It gives all the information right there so they don't feel overwhelmed when you hand them, here's all your meds here's a packet of 20 papers.”
	“I think any questions I had were answered by the [patient portal]. We had several doctors and instead of having to hunt them down, everything was on MyChart Bedside.”	“I think just being able to have control over kind of being able to see what's up and coming so they can anticipate their care. Being able to kind of look and order their food without having to wait for somebody to come around and do it. And be able to see things, I think is helpful, you know. And again, people who know what their lab work means, being able to look at that and see what their lab work is. I think it helps them be more autonomous.”

First, both patients and care team members emphasized that the portal improved patients' access to information. For instance, one patient explained, “Just knowing…when your medicines were coming, and when you were due for things, like you can order your food on there so you knew basically every time anything was coming to you, so that was quite nice.” Similarly, a care team member explained, “A lot of them utilize, they're looking up their labs and their medication schedule. So that's really helpful for most of our patients. I've found benefit in that.”

Interviewees also described the portal as useful because it enhanced their ability to communicate. One patient noted, “Just having them [results] on hand before the doctor came in and knowing…what to expect and then being able to discuss it with the doctor or nurse.” A provider similarly reflected, “I know they look up the lab results for sure. And then they will ask about the levels, if too high, they will be asking why, and then if anything needs to be done.”

Third, patients and care team members commented about the benefits of using the portal for education. One patient explained, “With MyChart you can go and look it up and get the educational material on it and have a more thorough understanding.” Care team members also noted this was useful: “Educating the patient. I like that function…Here's some videos or whatever…That to me is a positive.”

Interviewees also noted that portals were useful in promoting patients' sense of control. A patient reflected, “I liked being able to see what my bloodwork was without having to wait on the doctors, see my test results.” Another patient explained, “You don't have to sit there and keep calling the nurse's button.” Similarly, a provider commented, “I think they feel more informed, like they have more control over what's going on with their care.”

Perspectives About Ease of use the Inpatient Portal

With respect to ease of use, we found both positive and negative subthemes. The two positive subthemes were as follows: (1) the technology was straightforward and (2) the portal was convenient to use. The two negative subthemes involving ease of use were as follows: (1) concerns related to comfort with technology and (2) concerns related to patient age associated with technology experience. These subthemes are explained further below, with additional quotes presented in Table 3.

Table 3.

Perceptions About Ease of Use of the Inpatient Portal

THEME	VERBATIM COMMENTS FROM PATIENTS	VERBATIM COMMENTS FROM CARE TEAM MEMBERS
Perceptions that inpatient portal was easy to use
Technology was straightforward	“It was pretty straightforward. I feel like since we have an iPad, I was familiar with you know how one works and I wasn't intimidated by exploring to try to figure out things on my own, so I thought the training was fine.”	“I mean it's really easy. There's not much work on our end.”
	“Yeah it was very easy, and I got quick results. I was able to order, you know, food. I was able to check my vitals. I was able to see the doctors that were on my team, you know, working with me.”	“It's pretty easy. It's an easy thing to do.”
	“I like the ease of being able to order my meals and seeing pictures of what they have versus a menu. Actually, being able to see it and not just read it is better for me. I like the visual.”	“As far as using the tablet itself, I think it's fantastic. I mean like I said, I've played with it in the playground…I think it is fairly easy to get around. The whole system is.”
Portal was convenient to use	“It's portable, easy. It's not huge, it's very convenient. Not cumbersome, lightweight. It's touchscreen. It's easy to use, it has multiple functions. User friendly. It's really user friendly, it has instructions. I pretty much you know have instructions on everything you do or it has tutorials. It guides you through what you need to do.”	“It's been pretty smooth. I mean it is one more extra step, but it's really quick and easy once you know what you're doing, you know. It's been pretty smooth. At least for me it has been.”
	“It was just a convenient way to find out information I needed.”	“Yeah we have one UCA [unit clerical associate] and she will do that (provision tablets)…and that is very helpful to the RN [registered nurse] staff. It frees us, you know the nurses, it frees us up to do, you know, really nursing care.”
	“It was nice to, you know, have all my vitals and my labs there. And then I also, it was just really convenient to be able to order my food.”	“The people that know how to use it use it very well.”
Concerns about the ease of use of the inpatient portal
Concerns related to comfort with technology	“I thought the navigation was a little bit difficult so if there were some more tutorials, at least on getting started, that might be helpful.”	“Yeah, I mean the patients that know how to use them, I mean like you know, know everything that a tablet can do, really like them. But the ones that aren't technology-savvy they don't really like use them, like there's some tablets they're like, ‘Yeah I want it,’ and then they realize like, ‘Oh, it's basically a computer…’”
	“Of course, it was different than what you see on computers…I mean even though I'm tech savvy, you know it was good to receive instructions on, you know, how to navigate the website, how to navigate on the tablet to find certain things. I mean that was important.”	“Sometimes the patient actually gets interested and they don't actually get to do the tutorials, they kind of find it difficult. They just keep calling us. We always encourage them, if you need any help with anything, do not hesitate to use the call light. They may call two or three times saying, ‘I can't figure this out’ or, ‘I locked myself out.’”
	“I think that if we could make the dining side of it a little bit easier to navigate through, it would be easier for people to be able to use that. But, overall you know, I think it's pretty easy, you know I, quite honestly, I'm used to like I said, I'm used to using it, and familiar with it being from the hospital setting itself, but I think it would be a little overwhelming for somebody that's not quite tech savvy, if that makes sense.”	“I mean I know it's good for the patients, but sometimes it's like they're more concerned ‘cause they don't understand like how to work it. You know as PCAs [patient care assistants] we don't really have time to like sit down and be like, ‘Okay, this is technology.’ Because you know, some people just, tablets are brand new and you get the ones that are like curious so they want to get it even though they know nothing about it.”
Concerns related to patient age associated with technology experience	“There's a lot of people that are, you know, older that might not be familiar with technology.”	“It's just ‘cause of the age difference, I know a lot of people don't want to deal with the technology yet. Yeah a lot of people don't know how to work them, like, ‘Oh a tablet? I don't know how to work that.’”
	“A lot of the older generation they just don't get involved in technology.”	“It's a huge time-suck. The younger patients I mean, and by younger, I mean about probably 50s and under, they pick it up a lot quicker. But whenever they go down, and they go down quite often, that is something I can't fix. And it's generally…it becomes more of a pain than really a help.”
	“I know that that would be hard for older people to navigate. The ones that aren't internet savvy. You know what I mean, and don't really know how to do that type of thing. That'll be a little difficult and they would probably need help with that.”	“Yeah, some of the people in like their 70s or 80s are like, ‘No, we don't want that.’ A lot of times, if we are getting patient after patient, I honestly do not have time to sit there with the patient and go through the tutorial…”

Notably, a majority of interviewees commented that it was straightforward to use the inpatient portal. As one patient explained, “Basically it was self-explanatory if you know how to work computers.” A nurse similarly noted, “It's simple. It's easy to explain to the patients what they need to do.” Interviewees of both types also mentioned that the inpatient portal was convenient to use. For instance, one patient reflected, “I thought it was convenient. I used it for, you know, the ordering food and keeping on top of everything.” Care team members largely agreed, with one commenting about patients, “They can pick their food, I love it. They don't have to wait…for someone to come and select their meals for them, they can select it by themselves.”

Some interviewees, however, expressed concerns about the ease of portal use, noting that the tool was not necessarily easy to use for those with less experience with technology. One patient explained, “Yes, if I could've had it user-friendly I probably would've played on it a little longer to kind of search things and stuff like that. And I just didn't. I mean I get frustrated…I'm not computer-literate.” Less experience with technology was also noted as a concern for care team members introducing the tool to patients. As one nurse manager commented, “I'm always thinking my nurses' time is very valuable. If you build it into your practice you become comfortable with it. I think MyChart Bedside should only take five minutes to hand out and go over, but I think those who don't have a lot of experience with them [the tablets with the MyChart Bedside application] view it as this daunting task.”

Patient age was also a concern related to ease of use, with some comments equating older age with less comfort with technology. As one patient reflected, “The problem is that there are a lot of patients that aren't necessarily tech savvy. Especially older people…for older folks that aren't necessarily computer savvy, it needs to be very easy.” Further, care team members noted that patients declined portal use for reasons they associated with concern about ease of use. As a nurse explained, “We have a mostly elderly population. They do not like technology and they don't know how to use it so they say no to a tablet.”

Suggestions for Promoting Acceptance of Inpatient Portals

Both patients and care team members provided examples of how the inpatient portal was a valuable tool and we found three important approaches that interviewees suggested could promote portal acceptance: (1) highlight the value of the tool to patients and families; (2) emphasize the value of the tool to care team members; and (3) provide more training to support portal use. These approaches are discussed below with additional quotes presented in Table 4.

Table 4.

Suggestions for Promoting Acceptance of Inpatient Portals

THEME	VERBATIM COMMENTS FROM PATIENTS	VERBATIM COMMENTS FROM CARE TEAM MEMBERS
Highlight value of tool to patients and families	“Yes, I'd recommend it to anyone who uses the [AMC] system at all. It's very handy. In fact, my mom was hospitalized a few, a couple months ago and I told her to ask for one because they hadn't offered it to her and she didn't know she could do that so yeah. I would definitely recommend it.”	“I try to tell them about, oh, you know there are other things you can do. You can order your meals, you can track your…you can do patient education, get on the internet, download apps… So, just trying to like have these selling points to get it out there more.”
	“You know everybody wants to look up information on their health and I feel like they don't always pick the best resources. But, going through the MyChart it kind of has to use the good resources so I feel like that would be beneficial to others.”	“I don't think that people know the importance of it. I had a patient, a stroke patient that didn't have a tablet. I encouraged them to get this tablet and I had them do the tutorial and go through it and that way they could order meals…I provided them with the tablet and that way he can see who's all involved and recent labs and all that.”
	“I think everybody should get one when they go in. I mean it helps them…the nurses they're busy. And I mean they want to help me and want to do stuff, but they can't always be right there. So, you can look it up yourself.”	“Yeah, they're nice to have. I mean it's nice to be able to get on the internet and look up stuff about yourself and like your care. I would say that maybe…yeah maybe it helps people feel more comfortable because they know who is taking care of them and kind of what's going on a little bit more.”
Emphasize value of tool to care team members	N/A	“I think for the buy-in, for like people offering the tablets, it…it's one of those things that's hard because people are already so busy and trying to incorporate it so we're trying to encourage you know if like the PCAs [patient care assistants], like when you do vitals these three need to be offered, can you offer it when you're doing vitals.”
		“I think…explain to them the importance it's not just about you know, it might make your lives a little bit easier, you know it takes away, it gives the patients something to do instead of just thinking about hitting the call light or sitting in front of the TV, they have options to do other things. So just explain to them it's another route for a patient to be educated, they can find out information you know on medications they are taking and stay informed on their care.”
		“It's kind of amazing because some of the patients that really understand how the tablet works get to put in their meals, which they are so interested in. They are often excited, you know, at the right time with the food trays…so I think patient satisfaction and happiness comes. And we don't necessarily get praises from our people.”
Provide more training to support portal use	“I think a little bit more training to walk me through it a few more times. And then finally I did ask for help and she showed me and like oh okay that's easy enough. Yeah, and if I would've got it again I probably would've done better you know I would've done more, absolutely.”	“If we ourselves know how to use it better we would be more…encouraged to teach the patient…I think maybe just maybe we might be able to do that.”
	“I liked it because I wasn't, I wouldn't have known you could do all of that stuff on there. So that little bit of a training was a big help.”	“It was a little confusing at first. Once I did two or three of them, no problem, you know just a matter of getting used to it.”
	“Yes, without the training and being aware of what all that I can do with it…I probably would've just used it for food only.”	“I just don't think our staff is taking the time to be aware. Honestly, I think the hands-on thing I think would help them tremendously.”

First, patients' responses suggested they were strongly in favor of using the inpatient portal during hospital stays and commented on the need to promote the value of the tool. As one patient explained, “I think it's really important…Anything that can be done to encourage people to use it I think would benefit everybody.” A care team member similarly reflected, “I think they're useful, especially if you take the time to explain the tablets to them, because they can order their own food and play games and watch TV. I think they're great.”

Interviewees also suggested that portal acceptance and use could be advanced if the value of the tool was emphasized to the care team members themselves. While patients, understandably, did not comment specifically about this possibility, their reflections about the value of the technology suggested that portal access helped them help themselves, indicating that portal use might result in them bothering the care team members less. As one patient noted, “It probably actually helped them [care team members] because…sometimes I had questions and they weren't available. I could always turn to that and…answer my own questions.” More directly, several nurse managers noted the opportunity to promote the care team's understanding of patients' portal use, including how usage could benefit the care team in their work. One nurse manager explained, “I still think there's a lot of staff out there that don't know 100 percent what the tablet can do for them. The buy-in of how the tablet can help me. We've got nurses out there that are phenomenal with the tablets that are all for the tablets. They make sure every day that their patients have tablets because it helps them.” Similarly, another manager mentioned, “The ones that know it love it…But the ones that are like, ‘Ugh, this is just another thing,’ they don't know the benefit of it.”

Finally, interviewees noted that providing more training to support portal use was an important approach to increasing acceptance of the tool. Patients gave examples of how training to use the tool reinforced the benefits of the portal. One patient explained, “It encouraged me to look at different things that were available through the app. And I was already comfortable with it, but it just gave me encouragement to do more with it.” Care team members specifically suggested that having more opportunities to receive hands-on training might be beneficial. As one care team member commented, “If I'm asked to show them exactly where to find this or that, I'm lost because we only did the computer training. And we need hands-on to really get the experience.”

Discussion

Inpatient portals may provide technological means by which hospitals can transform their health care to become more patient centered and, in turn, improve health outcomes,^19–21 as long as both patients and providers use the new technology. The patients and care team members we interviewed largely perceived inpatient portals to be both useful and easy to use, satisfying the two constructs motivating technology acceptance in Davis' TAM framework. Interviewees noted that the inpatient portal was particularly useful as a means to improve patients' access to information, enhance communication with the care team, provide education, and promote patient independence. At the same time, this tool was also reportedly easy to use by many patients and care team members; however, some interviewees noted that the perceptions about ease of use were likely influenced by users' comfort with technology.

Our findings about the perceived usefulness of the inpatient portal are consistent with the results of prior work that has suggested that inpatient portals contain features that align with Umar and Mundy's framework of empowered patients.²² Using this construct, patients with the right information can make better decisions and can build meaningful relationships with their providers, both of which may lead to higher levels of self-efficacy.^22,23 In addition, both patients' and care team members' perceptions that the inpatient portal was relatively easy to use are aligned with previous research by Lazard et al. who noted ease of use played an influential role in advancing outpatient portal use among patients.¹³ At the same time, concerns about the importance of users' comfort with technology suggest that organizations need to consider opportunities to address this issue.

Patients' and care team members' comments about the inpatient portal were also notable in that many interviewees suggested that the value of the tool should be emphasized to both patients and care team members as a means to increase adoption. Furthermore, recognition that usability influences portal use, and the identification of usability challenges for some patients and care team members, likely contributed to interviewees' suggestions to provide additional training to support inpatient portal use. Training has been shown to increase portal usability,²⁴ and can be implemented in many ways to suit individual learning styles (e.g., visual, audio, and in person).²⁵ Furthermore, increasing portal usability with training may increase a person's likelihood to accept and adopt portal technology.²⁶ Given the unique features of inpatient portals, however, one must consider the type of training that should be provided to encourage the intended use of the technology.^25,27 Future studies to further understand how training influences patients' use of patient portals, and of care team members' decisions to promote portal use, will be critical to the development of strategies that can promote inpatient portal adoption and acceptance in the future.

Limitations

There are several potential limitations of this study that should be recognized. First, this study was limited to one health care system and one inpatient portal platform, which may restrict the generalizability of our results. However, the diverse opinions collected from the large number of interviewees, coupled with the fact that our study was examining the use of standard portal features common to many platforms, suggest these findings may be extended to other organizations. Second, our study may be biased toward inpatient portal users who agreed to participate in our interviews, skewing opinions to those who are more experienced with portal use. Finally, while perspectives about the inpatient portal could shift based on the length of time that had passed since the portal was first introduced, our results suggest consistency in these perspectives over time; this supports the strength of our findings and the appropriateness of applying these insights to inform future actions designed to promote inpatient portal use.

Conclusions

Inpatient portals can serve to improve patient-centered care by increasing access to health information, enhancing patients' abilities to communicate with care team members, and providing patients with an increased sense of control about their care process while they are in the hospital. Moving forward, inpatient portal acceptance and use may be increased through emphasizing the value of the portal to patients and care team members and providing additional training to ensure ease of use of this technology.

Appendix A1. Semistructured Interview Guides

Patient Interview Guide—15 Days Post-discharge

BACKGROUND

First, let us THANK YOU for agreeing to participate in our research project. I am (NAME) and I am a researcher from The Ohio State University. I am contacting you as part of a project we are doing to study MyChart^® Bedside, a personal health record offered by Ohio State University Wexner Medical Center (OSUWMC) and the hospitals associated with the medical center.

As part of this study, we are interested in collecting information from patients about how they tracked their health conditions during their inpatient stay and later after they were discharged. Ultimately, this will help us in the future to understand the issues involved so that we can improve patient training and technology based on user experiences.

When you were recently in the hospital, you agreed to participate in this study, and I am calling you as a follow-up to see if you would be interested in participating in a brief telephone interview that will take about 20 min. In this interview, we will ask you several general and open-ended questions about your experience with managing your conditions when you were in the hospital, and your perceptions about what might be helpful. As a token of appreciation for your time participating in this interview, we will mail you a $15.00 gift card.

OVERVIEW OF INTERVIEW TOPICS

In this interview, I will ask you a series of open-ended questions to get your perspectives about different topics. As an overview, these topics are as follows:

• Section 1: Patient Information

• Section 2: Managing Your Health

• Section 3: Experience with MyChart Bedside

• Section 4: Communication with Hospital Staff

• Section 5: Experience with the MyChart Bedside Training

INTRODUCTION TO INTERVIEW

Before we begin the interview, I need to take you through an informed consent process. In particular, let me make sure you understand that

• a. Your participation is completely voluntary. If you do choose to talk with us, you may decide to hang up at any time during this interview.

• b. We consider this discussion to be confidential. Your participation is confidential in the sense that your name will not be used in any report or article.

• c. We would also like to record the interview for the purposes of data collection for our research. The recording will not be used to identify you in any way.

• d. Do you have questions about our study or this interview process?

• e. Are you okay being recorded?

I will collect your address at the end of this call to mail you your gift card.

PATIENT/CAREGIVER INTERVIEW QUESTIONS

You may remember someone coming into your room with a white or gray vest and providing some training and demonstrating how to use the tablet and MyChart Bedside. I want to talk with you today about what you thought about that training and about MyChart Bedside.

Section 1: Patient information

• Before your most recent hospital stay, had you used MyChart or any outpatient portal before? [Remind the patient that MyChart is the portal that they can use at home and that it is different from MyChart Bedside, which is the one that they used on the tablet while they were a patient in the hospital.]

• ○ How comfortable are you with MyChart (or a different outpatient portal)?

• When you were in the hospital, were you (or your patient) the primary user of MyChart Bedside?

Section 2: Managing your health

• How do you generally keep track of your health when you are not in the hospital? (i.e., medications, doctor visits, and general health status).

• How does that change when you are in the hospital?

Section 3: Experience with MyChart Bedside

• How often did you use the MyChart Bedside application on the tablet that you were given when you were admitted? [If they do not remember the tablet, tell them it looks like an iPad and you may have ordered your meals using it.]

• Tell me about how you used MyChart Bedside.

• ○ Did you look at your daily schedule?

• ○ Did you view your test results?

• ○ Did you look at information about your care team?

• ○ Did you read educational materials?

• ○ Did you request any service?

• ○ Did you make notes about your care?

• What did you like about using MyChart Bedside?

• ○ Was it easy to use?

• What did you not like about using MyChart Bedside?

• ○ Did you encounter any problems?

• How did using MyChart Bedside influence how you felt about taking care of yourself once you were discharged?

• What concerns did you have about using MyChart Bedside?

• What would you change about MyChart Bedside?

• ○ Are there additional features you think might be useful?

Section 4: Communication with hospital staff

• Have you ever been admitted to any hospital before this admission?

• ○ How did you keep track of your test results or communications with your care team without MyChart Bedside?

• ○ How did having MyChart Bedside during this admission compare to your other experiences?

• Did you know who was on your (his or her) care team?

• ○ How did you know who was on the team?

• ○ What happened when members of the team changed?

• If you had a question about your (his or her) care while you were in the hospital, whom did you ask?

• ○ How did you make your request? (MyChart Bedside message, call button, or call the nurse?)

• ○ Was the response adequate

• ○ Was the response timely?

• In what ways did using MyChart Bedside impact how you communicated with your doctors and nurses?

• ○ How?

• ○ In what way(s)?

Section 5: Experience with MyChart Bedside training

• What kind of training did you receive about using MyChart Bedside while you were in the hospital?

• ○ Did a person talking with you provide the training or did you receive written materials?

• What did you think about the training you received for using the MyChart Bedside patient portal?

• ○ Were all of your questions answered?

• ○ Were there topics you wish had been covered?

• ○ Would you recommend this training to other patients?

• ○ What could we do to improve this training?

• How do you think this training influenced how you used MyChart Bedside during your hospital stay?

• Do you intend to use MyChart (the outpatient portal that you can use from home or on your phone) now that you (he or she) have been discharged from the hospital?

• ○ Why or why not?

• Did using MyChart Bedside influence your opinion about MyChart?

INTERVIEW CLOSURE AND FOLLOW-UP

• Is there anything else you would like to tell us about using MyChart Bedside?

• Thank you so much for your time and helpful answers!

Patient Interview Guide—6 Months Post-discharge

BACKGROUND

First, let us THANK YOU for agreeing to participate in our research project. I am (NAME) and I am a researcher from The Ohio State University. I am contacting you as part of a project we are doing to study MyChart Bedside, a patient portal offered by OSUWMC and the hospitals associated with the medical center.

As part of this study, we are interested in collecting information from patients about how they tracked their health conditions during their inpatient stay and later after they were discharged. Ultimately, this will help us in the future to understand the issues involved so that we can improve patient training and technology based on user experiences.

When you were recently in the hospital, you agreed to participate in this study, and I am calling you as a follow-up to see if you would be interested in participating in a brief telephone interview that will take about 20 min. In this interview, we will ask you questions about your experience with managing your conditions while you were in the hospital, including your perceptions about what might be helpful in the future. As a token of appreciation for your time participating in this interview, we will mail you a $15.00 gift card.

OVERVIEW OF INTERVIEW TOPICS

For this interview, I will ask you a series of open-ended questions to get your perspectives about different topics. As an overview, these topics are as follows:

• Section 1: Experience with and Benefits of MyChart Bedside

• Section 2: Experience with and Benefits of MyChart

INTRODUCTION TO THE INTERVIEW

We have scheduled the next 20 min to discuss these topics. Before we begin the discussion, we need to take you through an informed consent process. In particular, let me make sure that you understand that

• a. Your participation is completely voluntary. If you do choose to talk with us, you may decide to hang up at any time during this interview.

• b. We consider this discussion to be confidential. Your participation is confidential in the sense that your name will not be used in any report or article.

• c. We would also like to record the interview for the purposes of data collection for our research. The recording will not be used to identify you in any way.

• d. Do you have questions about our study or this interview process?

• e. Are you okay being recorded?

I will collect your address at the end of this call to mail you your gift card.

PATIENT/CAREGIVER INTERVIEW QUESTIONS

MyChart Bedside is an electronic personal health record that patients can access using a tablet. It allows patients to see who is on their care team, view their schedules each day, ask questions, view test and laboratory results, and make notes. OSUWMC has made MyChart Bedside available to most of their hospitalized patients, and we are interested in learning about patients' experiences with this new technology.

Section 1: Experience with and benefits of MyChart Bedside

• You first joined our study when you were in the hospital about 6 months ago. Have you been a patient in the hospital again since then?

• ○ If yes, did you use MyChart Bedside during that admission (those admissions)?

• ○ If no, when you were in the hospital 6 months ago, did you use MyChart Bedside?

Thinking about any of the times you were in the hospital and used MyChart Bedside, I'd like to know about how you used MyChart Bedside.

• What did you like about using MyChart Bedside?

• ○ Was it easy to use?

• What did you not like about using MyChart Bedside?

• ○ Did you encounter any problems?

• Would you recommend MyChart Bedside to other patients?

• Did you receive any training while you (your patient) were in the hospital on how to use MyChart Bedside?

• ○ If yes, what did you think about the training?

• ○ Did the training help you to understand how to use MyChart Bedside?

• ○ What would you change about the training?

• ○ What would you keep?

• ○ If no, would training have helped you?

• What benefits did you think you got from using MyChart Bedside in the hospital?

• ○ How?

• ○ In what way(s)?

Section 2: Experience with and benefits of MyChart

MyChart is an outpatient portal offered by OSUWMC, which patients can use outside the hospital to track their health conditions, communicate with their doctors, view test and laboratory results, and schedule appointments. This is available to any OSUWMC patient who wishes to create an account, or any patient of an OSUWMC physician.

• Do you use MyChart now?

• ○ If you do use MyChart, how do you use it?

• ○ For how long have you been using MyChart?

• ○ How did using MyChart Bedside in the hospital influence using MyChart outside of the hospital?

• Did you receive any training in how to use MyChart?

• ○ If yes, what did you like about the training?

• ○ Did the training help you to understand how to use MyChart?

• ○ What would you change about the training?

• ○ What would you keep about the training?

• ○ If no, would training have helped you?

• In what ways do you use MyChart outside of the hospital?

• Do you think there are benefits to using MyChart to manage your (your patient's) health conditions?

• ○ How?

• ○ In what way(s)?

• Did you or do you have any concern about using MyChart?

• How does using MyChart compare with other ways you have used to manage your (your patient's) health conditions?

• Would you recommend using MyChart to other patients?

INTERVIEW CLOSURE AND FOLLOW-UP

• Is there anything else you would like to tell us about using MyChart Bedside or MyChart with respect to your experience?

• Thank you so much for your time and helpful answers!

Care Team Member Interview Guide—Within 4 Weeks of Implementation

BACKGROUND

First, let us THANK YOU for agreeing to participate in our research project. We are (NAMEs) and we are researchers from The Ohio State University. We have reached out to you as part of a project we are doing to study how The Ohio State University Wexner Medical Center (OSUWMC) can understand how providers interact with the new MyChart Bedside application in Epic.

As part of this study, we are interested in collecting information from provider users about their experiences and how they use MyChart Bedside in their work. You have been identified as someone who would provide invaluable information about this topic. In this interview, we will ask you several general and open-ended questions about your thoughts using MyChart Bedside to accomplish patient care-related tasks.

OVERVIEW OF INTERVIEW TOPICS

In this interview, I will ask you a series of open-ended questions to get your perspectives about different topics. As an overview, these topics are as follows:

• Section 1: Participant Information

• Section 2: Training

• Section 3: Expectations

• Section 4: Communication

INTRODUCTION TO INTERVIEW

We anticipate that it will take around 10 min or so to discuss these topics with you. Before we begin the discussion, we need to take you through an informed consent process. In particular, let me make sure you understand that

• a. Your participation is completely voluntary. If you do choose to talk with us, you may decide to stop at any time during this interview.

• b. We consider this discussion to be confidential. Your participation is confidential in the sense that your name will not be used in any report or article.

• c. We would also like to record the interview for the purposes of data collection for our research. The recording will not be used to identify you in any way.

• d. Do you have questions about our study or this interview process?

• e. Are you okay being recorded?

CARE TEAM MEMBER INTERVIEW QUESTIONS

Section 1: Participant information

To start, we would like to learn a little more about each of you:

• What is your role/position?

• Where do you work in the Medical Center and how long have you worked there?

• How comfortable would you say you are using technology (computers and smartphones) in health care settings?

Section 2: Training

• What did you think about the training you received to use MyChart Bedside?

• What was useful about the training?

• Was the format of the training efficient?

• What else would you include in training?

• How much training did you receive in using MyChart Bedside with your patients?

• ○ Was this training sufficient?

• How well do you think the training prepared you for using MyChart Beside?

• ○ Why?

Section 3: Expectations

• How much do you expect patients to use the different features that are available in MyChart Bedside?

• How much do you think patients will benefit from having access to the different features that are available in MyChart Bedside?

• In what ways do you think the MyChart Bedside application will impact your productivity?

• In what ways do you think the MyChart Bedside application will impact your interactions with patients?

Section 4: Communication

• In what ways do you think the MyChart Bedside application will impact your communication with patients?

• In what ways do you think the MyChart Bedside application will impact your communication with your immediate colleagues?

• In what ways do you think the MyChart Bedside application will impact your communication across the health system?

INTERVIEW CLOSURE AND FOLLOW-UP

• Is there anything else you would like to tell us about the use of MyChart Bedside related to patient care?

• Thank you so much for your time and helpful answers!

Care Team Member Interview Guide—6 Months Post-implementation

BACKGROUND

First, let us THANK YOU for agreeing to participate in our research project. We are (NAMEs) and we are researchers from The Ohio State University. We have reached out to you as part of a project we are doing to study how The Ohio State University Wexner Medical Center (OSUWMC) uses the MyChart Bedside application in Epic.

As part of this study, we are interested in collecting information from provider users about how they see patients using MyChart Bedside and how they might like patients to use MyChart Bedside. You have been identified as someone who would provide invaluable information about these issues. In this interview, we will ask you several general and open-ended questions about your experience with MyChart Bedside and your perceptions about benefits related to its use.

OVERVIEW OF INTERVIEW TOPICS

In this interview, I will ask you a series of open-ended questions to get your perspectives. These questions cover several different areas:

• Section 1: History and Background about MyChart Bedside

• Section 2: Workflow Changes

• Section 3: MyChart Bedside Functions: “Messages” and “To Learn”

• Section 4: Impact on OSUWMC

• Section 5: Interactions with Patients Using MyChart Bedside

• Section 6: Other Features of MyChart Bedside

INTRODUCTION TO INTERVIEW

We have scheduled the next 10 min to discuss these topics with you. Before we begin the discussion, we need to take you through an informed consent process. In particular, let me make sure that you understand that

• a. Your participation is completely voluntary. If you do choose to talk with us, you may decide to stop at any time during this interview.

• b. We consider this discussion to be confidential. Your participation is confidential in the sense that your name will not be used in any report or article.

• c. We would also like to record the interview for the purpose of data collection for our research. The recording will not be used to identify you in any way.

• d. Do you have questions about our study or this interview process?

• e. Are you okay being recorded?

CARE TEAM MEMBER INTERVIEW QUESTIONS

Section 1: History and background about MyChart Bedside

• To start, could you please describe your role in your organization and your involvement with the MyChart Bedside application?

• How long have you been working with MyChart Bedside?

Section 2: Workflow changes

• Since your unit began offering MyChart Bedside, have there been changes required to accommodate its use?

• ○ Can you describe what has changed?

• ○ Have these changes made things easier or more difficult?

• How does your unit decide to make changes to accommodate MyChart Bedside?

• How do you show people to use MyChart Bedside when they bring their own devices?

• ○ Where did you find the information about how to do this?

• ○ Do they use MyChart Bedside or MyChart or both on their own devices?

• How do you receive data or a report about MyChart Bedside compliance for tablet provisioning and activation?

• ○ Does unit management discuss the report with you?

• ○ Does your unit have strategies to meet or exceed goal rates?

Section 3: MyChart Bedside functions: “Messages” and “To Learn”

We are especially interested in these two specific features of MyChart Bedside that patients and nurses might use together.

Secure messaging

• Do you have stories about patients using the “Messages” function? (i.e., send messages to the care team)

• ○ Do families ever use secure messaging?

• How do you respond to IHIS Bedside messages? (e.g., send IHIS Bedside message back to the patient or in-person communication)

• What do you tell patients about using the message feature versus using their call button?

• How do you think patients benefit from using secure messages?

Patient education

• Do you have stories about patients using the “To Learn” feature?

• What do you tell patients about using the “To Learn” feature?

• Have patients asked you about these educational materials?

• How has patient use of “To Learn” impacted your experience providing patient education?

Section 4: Impact on OSUWMC

• How has your process of patient care benefited from the introduction of MyChart Bedside?

• Have there been disadvantages you associate with the introduction of MyChart Bedside?

• Has MyChart Bedside had an impact on patient care?

• ○ What kind of impact?

• Has the MyChart Bedside program had an impact on patient satisfaction?

• ○ What kind of impact?

• What kinds of things do you discuss with your colleagues about MyChart Bedside?

• Has the MyChart Bedside program had an impact on staff or provider morale or satisfaction?

• ○ What kind of impact?

Section 5: Interactions with patients using MyChart Bedside

• Do patients ask you questions about MyChart Bedside?

• ○ What kinds of questions do they ask?

• ▪ Technical or applied?

• Have patients mentioned problems they encountered using MyChart Bedside?

• ○ If yes, what was your impression of the proportion of complaints versus positive comments?

• How do you feel using MyChart Bedside impacts working with your patients?

• ○ Do you see any difference in behaviors between patients who use versus do not use MyChart Bedside?

• ▪ Patient knowledge about the process of care?

• ▪ Different types of discussions?

• Do you have feelings about how the tablet is introduced to the patient?

• Do you have thoughts about how tablet use may differ based on patient characteristics?

• ○ Older, sicker, more family around, used it more frequently/effectively?

Section 6: Other features of MyChart Bedside

MyChart Bedside has a number of specific features. The next set of questions will ask about those specific features.

• Did patients seem to use the “Happening Soon” feature—that provided appointment and procedure schedules?

• ○ How can you tell?

• ▪ Patient mentioned it, patient seemed more educated about the flow of his/her care (upcoming appointments, procedures)?

• ○ Do you have stories about patients using this feature?

• Did patients seem to use the “Taking Care of Me” feature—that provided clinician bio, photo, and role?

• ○ How can you tell?

• ▪ Patients seemed to know faces/names of the care team?

• ○ Do you have stories about patients using this feature?

• Did patients seem to use the “I Would Like” feature?

• ○ Did you receive nonurgent service messages and was there a change in the volume of things requested in person?

• ▪ How could you tell?

• ○ Do you have stories about patients using this feature?

• Did patients use the “My Health” feature?

• ○ How could you tell?

• ▪ Patients mentioned access to laboratory results and medication information?

• ○ Do you have stories about patients using this feature?

INTERVIEW CLOSURE AND FOLLOW-UP

• Is there anything else you would like to tell us about patients using MyChart Bedside?

• Thank you so much for your time and helpful answers!

Care Team Member Interview Guide—12 and 18 Months Post-implementation

BACKGROUND

First, let us THANK YOU for agreeing to participate in our research project. We are (NAMEs) and we are researchers from The Ohio State University. We have reached out to you as part of a project we are doing to study how The Ohio State University Wexner Medical Center (OSUWMC) uses the MyChart Bedside application in Epic.

As part of this study, we are interested in collecting information from providers about how they see patients using MyChart Bedside and how they use MyChart Bedside. You have been identified as someone who would provide invaluable information about these topics. In this interview, we will ask you several general and open-ended questions about your experience with MyChart Bedside and your perceptions about benefits related to its use.

OVERVIEW OF INTERVIEW TOPICS

In this interview, I will ask you a series of open-ended questions to get your perspectives. These questions cover several different areas:

• Section 1: History and Background about MyChart Bedside

• Section 2: Workflow

• Section 3: MyChart Bedside Functions

• Section 4: Impact on Care and Patient Experience

• Section 5: Interactions with Patients Using MyChart Bedside

INTRODUCTION TO INTERVIEW

We have scheduled the next 10 min to discuss these topics with you. Before we begin the discussion, we need to take you through an informed consent process. In particular, let me make sure that you understand that

• a. Your participation is completely voluntary. If you do choose to talk with us, you may decide to stop at any time during this interview.

• b. We consider this discussion to be confidential. Your participation is confidential in the sense that your name will not be used in any report or article.

• c. We would also like to record the interview for the purposes of data collection for our research. The recording will not be used to identify you in any way.

• d. Do you have questions about our study or this interview process?

• e. Are you okay being recorded?

CARE TEAM MEMBER INTERVIEW QUESTIONS

Section 1: History and background about MyChart Bedside

• To start, could you please describe your role in your organization and let us know how long you have been working here?

• How long have you been working with MyChart Bedside?

• ○ If since implementation, what were the changes required to accommodate its use?

Section 2: Workflow

• How does your unit offer MyChart Bedside to patients?

• ○ Who is responsible for provisioning the tablet?

• ○ Who is responsible for showing the patient how to use it?

• ○ How long has this process been in place?

• How does your unit decide to make changes to accommodate MyChart Bedside?

• How do you show people how to use MyChart Bedside when they bring their own devices?

• ○ Where did you find the information about how to do this?

• ○ Do they use MyChart Bedside or MyChart, or both on their own devices?

• How do you receive data or a report about MyChart Bedside compliance for tablet provisioning and activation?

• ○ Does unit management discuss the report with you?

• ○ Does your unit have strategies to meet or exceed goal rates?

Section 3: MyChart Bedside functions

• What features of MyChart Bedside do your patients seem to use the most?

• What features of MyChart Bedside do they use the least?

Secure messaging

• Do you have stories about patients using the “Messages” function? (i.e., send messages to the care team)

• ○ Do families ever use secure messaging?

• How do you respond to IHIS Bedside messages? (e.g., send IHIS Bedside message back to the patient or in-person communication)

• What do you tell patients about using the message feature versus using their call button?

• How do you think patients benefit from using secure messages?

• How has patient use of secure messaging changed over time?

• What kinds of messages do patients send?

Patient education

• Do you have stories about patients using the “To Learn” feature?

• What do you tell patients about using the “To Learn” feature?

• Have patients asked you about these educational materials?

• How has patient use of “To Learn” impacted your experience providing patient education?

Section 4: Impact on care and patient experience

• How does the process of patient care benefit from having MyChart Bedside available?

• Are there disadvantages you associate with the use of MyChart Bedside?

• Has MyChart Bedside had an impact on patient care?

• ○ What kind of impact?

• Has having MyChart Bedside available had an impact on patient satisfaction?

• ○ What kind of impact?

• Does the use of MyChart Bedside have an impact on staff or provider morale or satisfaction?

• ○ What kind of impact?

Section 5: Interactions with patients using MyChart Bedside

• Do patients ask you questions about MyChart Bedside?

• ○ What kinds of questions do they ask?

• ▪ Technical or applied?

• ○ Do families ask questions?

• Have patients mentioned problems they encountered using MyChart Bedside?

• ○ If yes, what was your impression of the proportion of complaints versus positive comments?

• How do you feel using MyChart Bedside impacts working with your patients?

• ○ Do you see differences in behaviors between patients who use versus who do not use MyChart Bedside?

• ▪ Patient knowledge about the process of care?

• ▪ Different types of discussions?

• Do you have feelings about how the tablet is introduced to the patient?

• Do you have thoughts about how tablet use may differ based on patient characteristics?

• ○ Older, sicker, more family around, used it more frequently/effectively?

INTERVIEW CLOSURE AND FOLLOW-UP

• Is there anything else you would like to tell us about patients using MyChart Bedside?

• Thank you so much for your time and helpful answers!

Disclosure Statement

No competing financial interests exist.