Table 2.

Non-adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework: contextual factors that influence the implementation of patient portals.

NASSS domain and subdomain and contextual factors (namely, facilitators and barriers)					Acute care hospitals		Mixed health care setting		Older adults (aged >60 years)
1. Condition
	What is the nature of the condition or illness?
		Facilitators
			Greater disease severity	—a		[24]		—
			Chronic disease (and associated well-established case management programs)	—		[21,23]		—
		Barriers
			Severity and circumstances of illness (eg, reduced involvement in decision-making and fewer questions)	[20]		[24]		—
	Relevant sociocultural factors and comorbidities
		Facilitators
			Higher socioeconomic status, female sex, younger age, White ethnicity, and younger senior citizens	—		[23,24]		[18]
			Disease-specific portal	—		[24]		—
		Barriers
			Lower socioeconomic status, male gender, older age, and non-White ethnicity (impacts enrollment and engagement)	[12,20]		[24]		—
			Diversity of older adults (not well understood)	—		—		[19]
			Low health literacy and numeracy (and understanding of health literacy)	—		[23,24]		[19]
			Lack of digital access	—		[23]		[18]
			Insurance status	[12]		—		—
			Comorbidities such as vision and hearing loss, decreased dexterity and mobility, and declining cognitive function	—		—		[18,19]
2. Technology
	Key features
		Facilitators
			Information and identity authentication and protection	—		[23,25]		—
			Usability (eg, set-up, interface design, simple displays, text visibility, buttons, patient-friendly content, ease of navigation, personalized interface, and reminders to view)	[12,17,20]		[21,24,25]		[18]
			Functionality (eg, communication with providers; access to reliable, timely and comprehensive personal medical information; content in minority languages; and inbuilt system alerts)	[17]		[23,24]		[18]
			Accessibility (eg, adding mobile access and providing on-site kiosks)	[12]		[21,23]		—
			Participatory and iterative design approaches	—		[23,24]		—
			Iterative user evaluation (eg, patients and providers)	[12]		—		—
			Definition of minimum data set to plan care and continuously evaluate treatment	—		[25]		—
		Barriers
			Patients’ security and privacy concerns (eg, control over access)	[17,20]		[21-24]		[18]
			Providers’ concerns about sharing patient information	—		[21,25]		—
			Usability (eg, interface design, technical glitches, log-on, navigation, accessibility of information for patients, and printing and using information)	[17]		[21,23,24]		[18,19]
			Establishing a trade-off among security measures, user friendliness, and flexibility	—		[23]		—
			Functionality (eg, differing information needs of patients and providers; differing patient preferences over data content and input; diversity of health data types and formats and portal ability to handle the diversity of health data types and formats; data transparency—what data are released and to whom and how they are released; language used; and level of features [eg, reminders, dictionary, lifestyle advice, print capability, and user voice command])	[17]		[23-25]		[18]
			Accessibility (eg, computer and internet access and secure and stable infrastructures)	—		[21-23]		[18]
	Type of knowledge in play
		Facilitators
			Data set is comprehensive, reliable, complete, understandable, and valid	—		[25]]		—
			Audit trail for revisions to data	—		[23]		—
		Barriers
			Concerns about patients’ ability to interpret test results and deal with sensitive information without professional support or interpretation	[17,20]		[21,23,24]		[18]
			Real-time (release of) information without real-time support	[20]		—		—
			Providers’ concerns about the reliability of patient-generated data (as basis for clinical decisions)	[20]		[23]		—
	Knowledge to use
		Facilitators
			Patient training and technical support (eg, videos, handbooks, hotline, and workshops)	[12]		[23]		[18]
			Training for providers	—		[23]		—
		Barriers
			Quality of patient training	[12]		—		—
			Patients’ level of technology literacy (eg, perceived and actual skill and computer anxiety)	[12]		—		[18]
	Technology supply model
		Facilitators
			Portals that integrate into preexisting systems	[17]		—		—
			Interoperability (eg, information exchange and sharing)	—		[25]		—
		Barriers
			Interoperability (eg, achieving appropriate data exchange among systems)	—		[21,23]		—
3. Value proposition
	Supply-side value
		Facilitators
			Facilitates the processing of payments by insurance companies	—		[25]		—
			Trial period before purchase (ie, to test usability and estimate financial and organizational impact)	—		[23]		—
			Positive return on investment and impact on charges and costs	—		[21]		—
		Barriers
			Trade-off among the type of architecture, responsiveness to local needs, and implementation time and cost (ie, decentralized and more expensive but more responsive and shorter implementation time)	—		[25]		—
			Establishing sound business case (eg, no standardized evaluation frameworks, no reimbursement structures for electronic services, lack of evidence of cost savings, and lack of financial sustainability)	—		[23,24]		—
	Demand-side value
		Facilitators
			Satisfies patients’ need for information; facilitates knowledge retention, understanding, and engagement in care by patient; sense of empowerment and control; feeling of being better prepared; and perceived usefulness (eg, aids self-management, utility features, and information in one place)	[17,20]		[21,22,24,25]		[18,19]
			Provide communication route with professionals between clinic rounds (eg, patient driven communication)	[17]		[21,24]		[18]
			Assists (verbal) interactions or appointments with professionals and patient-provider communication	[17,20]		[21,22,24,25]		[18]
			Access to information facilitates the development of trust in diagnosis, investigations, treatment, and professionals (eg, relationships)	[20]		[21]		[19]
			Helps inaccuracies in EHRb to be identified (eg, detection of errors and patient safety)	[17,20]		[24]		—
			Contributes to enhanced discussions with patients and aids communication	[17]		[21,24,25]		—
			Prevents misunderstandings and builds trust (ie, careful and clear recording of information)	[20]		[21]		—
			Usefulness and time efficiency (ie, clear recording prevents the need to repeat information and aids interprofessional communication)	—		[21,25]		—
			Helps improve care (eg, planning and continuous evaluation of treatment, adherence, patient satisfaction and engagement, reduced patient anxiety, timely decision-making)	—		[24,25]		—
		Barriers
			Patients perceive extra responsibility for finding errors or poor outcomes	[20]		—		—
			Patients’ concern about threat to face-to-face communication with professionals	[20]		—		[18]
			Patients’ do not see value or usefulness (eg, lack awareness of features)	[12]		[21,23,24]		[19]
			Patient views about “user fee for use”	—		—		[19]
			Professionals’ concern that messaging may adversely impact verbal communication	[17]		—		—
			Professionals do not perceive usefulness	—		[21]		—
4. Adopter system
	Changes in staff roles, practices, and identities
		Facilitators
			Accepting of collaborative versus expert-led care	[20]		—		—
			Professionals’ positive level of engagement, knowledge, and confidence in portal systems	—		[24]		—
		Barriers
			Less accepting of collaborative versus expert-led care and do not wish to cede autonomy to patients	[20]		[23]		—
			Professionals need to support patients to interpret and emotionally deal with the information in portals	[20]		—		—
			How is responsibility for the release of test results managed? (eg, who takes responsibility and editing before release)	[20]		—		—
			Professionals’ level of engagement, knowledge, skills, and confidence in portals	—		[2,21,23]		—
	What is expected of patients?
		Facilitators
			Professionals support and encourage patients’ use of portals (eg, endorsement, reminders, and materials)	—		[22-24]		—
			Patients’ willingness to enter basic information into portals or manage records	—		—		[18,19]
		Barriers
			Patient preferences regarding the entry of data into portals, increased knowledge, and managing records	[20]		[24]		[18,19]
			Professionals or providers do not encourage patients’ use of portals	—		[23]		—
	What is assumed about the network of lay care givers?
		Facilitators
			None identified	—		—		—
		Barriers
			Patients lack help or support to access portals	—		—		[18]
5. Organization
	Organization’s capacity to innovate
		Facilitators
			Leadership involvement in portal design and development of policies for user training and the integration of patient portals into workflows	—		[24]		—
			Communication around technical, interpersonal, and workflow aspects of portals	—		[23]		—
			Organizational interpretation of government legislation related to portals	—		[24]		—
		Barriers
			Constrained financial context (eg, small or rural hospitals)	[20]		[24]		—
			Organizational interpretation of government legislation	—		[24]		—
			Lack of leadership support (fear and hesitancy in implementation)	—		[25]		—
	Is the organization ready for technology-supported change?
		Facilitators
			Policies in place to support portals (eg, universal access policy, security protocols, adherence audits, data availability, and timing)	[12]		[23]		—
		Barriers
			Lack of support for new forms of communication between patients and professionals	—		[24]		—
			Lack of policies on access rights and authorization process (including proxy access and access for minors)	—		[23]		—
	Ease of funding and adoption decision
		Facilitators
			Internal and external exchange of information to improve the quality, safety, and effectiveness of care	—		[25]		—
		Barriers
			Providers’ concerns about diverting resources to the less disadvantaged (ie, those who can read and ask questions)	[20]		—		—
			Integrating patient portal use across care transitions (ie, with other organizations) to improve care	[17]		[25]		—
			Deciding on the balance between IT structure and implementation time and cost			[25]
	Changes needed in team interactions and routines
		Facilitators
			Integrating data release with workflow (ie, to facilitate professionals’ follow-up with patients)	—		[23]		—
			Workload and work routines not adversely impacted or positively impacted (eg, time efficiencies)	—		[21]		—
		Barriers
			How to organize the release of results to patients without professionals’ help with interpretation and support (eg, real-time release or delayed released)	[20]		—		—
			Professionals’ concerns about the impact of increased level of patient questions, patient overuse of messaging, increase in documentation time, and portals on workflow	[17]		[21,23,24]		—
	Work involved in implementation and who will do it
		Facilitators
			Involvement of professionals in workflow engineering and the evaluation of the impact of portal use on workload and processes	[17]		[23]		—
		Barriers
			None identified	—		—		—
6. Wider context
	What is the political, economic, regulatory, professional, and sociocultural context of program rollout?
		Facilitators
		Aspects of culture (doctors from English-speaking countries), including the coverage of portals, PHRsc, and EHRs in medical and nursing school curricula		[20]		[23]		—
		Health professionals’ liability concerns		[20]		—		—
		Health systems with a transactional component		[20]		—		—
		Resource for policy makers, health care specialists, and stakeholders to improve care and the quality of treatment		—		[25]		—
		National and international information exchange (interoperability) and other standards (eg, Health Insurance Portability and Accountability Act, International Health Level 7, regional health information exchanges, and key public infrastructures)		—		[23,25]		—
		Appropriate reimbursement mechanisms		—		[23]		—
	Barriers
		Reimbursement structures for electronic services		—		[23]		—
		Providers’ liability concerns (eg, breached privacy or patients’ harmful behaviors)		—		[23]		—
		Nonstandardized rules for developing and managing health information infrastructures		—		[23]		—
		Relationship between macrolevel and mesolevel (eg, organization) factors was not well explored		—		[22]		—
		Regulations (eg, Health Insurance Portability) do not cover portal developers and hosting organizations		—		[23]		—
7. Embedding and adaptation
	Scope for adapting and coevolving technology and service
		Facilitators
			None identified	—		—		—
		Barriers
			Concern that medical record maintains integrity as a working document that facilitates the transfer of knowledge between health professionals	[20]		—		—
			How portals can be extended beyond a single organization (ie, particularly in fragmented care delivery contexts)?	—		[23]		—
	Organization resilience to critical events
		Facilitators
			None identified	—		—		—
		Barriers
			None identified	—		—		—

^aNot available.

^bEHR: electronic health record.

^cPHR: personal health record.