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iPads, portals and patient engagement

How interested are patients in their own clinical information?

October 2015
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Published in the October 2015 issue of Today’s Hospitalist

HOW CAN YOU GET PATIENTS more engaged in their care while they’re in the hospital? That’s a question very much on the mind of Kevin J. O’Leary, MD, chief of hospital medicine at the Northwestern University Feinberg School of Medicine in Chicago.

“We put patients in a totally passive position in the hospital, bringing them food and deciding when they get out of bed,” Dr. O’Leary points out. “Then in the span of five minutes, they’re discharged and they have to go home and figure everything out themselves.”

To try to boost inpatients’ engagement, Dr. O’Leary and a team of researchers borrowed a tool that’s gained a lot more traction in the outpatient world: a patient portal. Hospital patients were given iPads loaded with an app connecting them to their portal, which contained the pictures and names of their providers, as well as a list of scheduled tests, procedures and active medications.

“The way to drive use and engagement with the patient portal may be to integrate it with gaming.”

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~ Kevin J. O’Leary, MD
Northwestern University Feinberg School of Medicine

Researchers assessed how often patients checked their portal and how well-versed they were in portal information compared to patients who didn’t receive portal access.

The good news, according to results published online in June by the Journal of the American Medical Informatics Association, was that 57% of patients in the intervention arm used the portal app more than once a day. The not-so-good news was that 20% of them hadn’t accessed it at all by day 2 or 3 of their hospitalization, when they were interviewed by researchers.

As for how much more informed patients with iPads were about their care, a significantly larger group of them could name one or more of their hospital physicians and identify those physicians’ roles. But patients with portal access did not have any better grasp of planned tests or procedures, new medications or discontinued prescriptions.

Those somewhat discouraging results, however, haven’t deterred Dr. O’Leary, who is convinced that all hospital EHRs within five years will have patient portals, many of which will be integrated with patients’ outpatient records. The trick going forward, he explains, is figuring out the right content and functionality.

He spoke with Today’s Hospitalist.

Why do you think patients with portal access did better recognizing their physicians, but not much else?
Learning a physician’s name is not that complicated, particularly when patients hear it during rounds. It may be much more complex to remember the name of a new medication when patients aren’t even sure what the indication is.

Another explanation is that patients know their treatment is rapidly changing, so if they might not go home on a certain new medication, why bother learning it? And then cognitively, patients in the hospital are slightly impaired. We did exclude patients who were disoriented, and it’s a relatively young population that we gave the portal to. But even these patients’ cognitive function may not be as sharp because they’re sick and getting medications that may impair their ability to learn and retain information.

Might one solution then be giving patients access to their inpatient portal when they’re out of the hospital?
I think that would be great, and it’s something we’re considering. It also would be outstanding to be able to designate certain family members and health care professionals who could access the portal remotely and find out what’s going on with patients in real time.

We also want to think about integrating the hospital portal into an existing outpatient portal. The ideal situation would be to transition patients’ information as they move from one setting to another.

But the information patients need in those settings is different. In the hospital, making sure patients know team members is important, but it’s less important in the outpatient setting, because patients know who their primary care doctors are and what they look like. And ordered tests are especially important in the hospital, but we need to figure out who would release test results in the hospital and how.

In your study, the portal didn’t contain test results. Would that content drive more patient use?
It may, but that raises other issues. We also did a qualitative study that hasn’t yet been published where we asked patients with the iPads what they found helpful and what they’d like to see.

In our initial study, we didn’t give patients results of labs, CTs, radiology or procedures, and we thought that might be a good next step. But we also asked clinicians about portal use, and they expressed a lot of concerns about releasing results. They pointed out the number of abnormal values we see every day, which might overwhelm patients or generate questions for physicians about information that’s clinically insignificant.

Or releasing CT scan results automatically could be a really impersonal way to deliver bad news. So we need to think through rules around releasing information. Should it be automatic or timed? Should we require doctors to approve that release and annotate results?

What do you think is doable in terms of information release?
I think certain results, like basic chemistries and blood counts, can probably be released to the portal at a specific time “at noon, say “for any results that come back before 7 a.m. That would give doctors time to round and discuss any abnormalities with patients.

Probably the same is true for radiology results: a timed release would allow physicians to discuss potentially sensitive results beforehand. But certain results should never be released automatically, like pathology results or an HIV test or viral load. And I don’t think we should require doctors to approve the release of all information, because I’m sure many of them just wouldn’t get around to it.

You mentioned asking patients what they’d like to see. What responses did you get?

The iPads did contain some games and entertainment options, like Netflix, and we found that patients loved the games. So the way to drive use and engagement with the patient portal may be to integrate it with gaming.

We could, for example, ask patients to review their medication lists and tell us if they’re incorrect, and then we’ll give them access to Candy Crush for 24 hours. Or we could give them additional game points that could earn them an extra dessert or somehow “gamify” the review of the portal.

The dominant theme was that the iPad was being used for entertainment, so perhaps some of the 20% who didn’t access their patient portal used the iPad for other reasons.

What’s the next step?
We are planning to add content and features to the portal and then do usability testing.

Probably the best approach ultimately will be to offer patients multiple ways to access their portal. That could include downloading an app so patients can access it on their own device, as well as giving patients and designated family members remote access after their hospital stay. And if patients don’t have an Internet-capable device with them in the hospital, we’ll give them an iPad to use during their hospital stay.

Phyllis Maguire is Executive Editor of Today’s Hospitalist.