[Show abstract][Hide abstract] ABSTRACT: Background: Patient portals have the potential to support self-management for chronic diseases and improve health outcomes. With the rapid rise in adoption of patient portals spurred by meaningful use incentives among safety net health systems (a health system or hospital providing a significant level of care to low-income, uninsured, and vulnerable populations), it is important to understand the readiness and willingness of patients and caregivers in safety net settings to access their personal health records online. Objective: To explore patient and caregiver perspectives on online patient portal use before its implementation at San Francisco General Hospital, a safety net hospital. Methods: We conducted 16 in-depth interviews with chronic disease patients and caregivers who expressed interest in using the Internet to manage their health. Discussions focused on health care experiences, technology use, and interest in using an online portal to manage health tasks. We used open coding to categorize all the barriers and facilitators to portal use, followed by a second round of coding that compared the categories to previously published findings. In secondary analyses, we also examined specific barriers among 2 subgroups: those with limited health literacy and caregivers. Results: We interviewed 11 patients and 5 caregivers. Patients were predominantly male (82%, 9/11) and African American (45%, 5/11). All patients had been diagnosed with diabetes and the majority had limited health literacy (73%, 8/11). The majority of caregivers were female (80%, 4/5), African American (60%, 3/5), caregivers of individuals with diabetes (60%, 3/5), and had adequate health literacy (60%, 3/5). A total of 88% (14/16) of participants reported interest in using the portal after viewing a prototype. Major perceived barriers included security concerns, lack of technical skills/interest, and preference for in-person communication. Facilitators to portal use included convenience, health monitoring, and improvements in patient-provider communication. Participants with limited health literacy discussed more fundamental barriers to portal use, including challenges with reading and typing, personal experience with online security breaches/viruses, and distrust of potential security measures. Caregivers expressed high interest in portal use to support their roles in interpreting health information, advocating for quality care, and managing health behaviors and medical care. Conclusions: Despite concerns about security, difficulty understanding medical information, and satisfaction with current communication processes, respondents generally expressed enthusiasm about portal use. Our findings suggest a strong need for training and support to assist vulnerable patients with portal registration and use, particularly those with limited health literacy. Efforts to encourage portal use among vulnerable patients should directly address health literacy and security/privacy issues and support access for caregivers.
No preview · Article · Dec 2015 · Journal of Medical Internet Research
[Show abstract][Hide abstract] ABSTRACT: Background:
Text messaging is an affordable, ubiquitous, and expanding mobile communication technology. However, safety net health systems in the United States that provide more care to uninsured and low-income patients may face additional financial and infrastructural challenges in utilizing this technology. Formative evaluations of texting implementation experiences are limited. We interviewed safety net health systems piloting texting initiatives to study facilitators and barriers to real-world implementation.
We conducted telephone interviews with various stakeholders who volunteered from each of the eight California-based safety net systems that received external funding to pilot a texting-based program of their choosing to serve a primary care need. We developed a semi-structured interview guide based partly on the Consolidated Framework for Implementation Research (CFIR), which encompasses several domains: the intervention, individuals involved, contextual factors, and implementation process. We inductively and deductively (using CFIR) coded transcripts, and categorized themes into facilitators and barriers.
We performed eight interviews (one interview per pilot site). Five sites had no prior texting experience. Sites applied texting for programs related to medication adherence and monitoring, appointment reminders, care coordination, and health education and promotion. No site texted patient-identifying health information, and most sites manually obtained informed consent from each participating patient. Facilitators of implementation included perceived enthusiasm from patients, staff and management belief that texting is patient-centered, and the early identification of potential barriers through peer collaboration among grantees. Navigating government regulations that protect patient privacy and guide the handling of protected health information emerged as a crucial barrier. A related technical challenge in five sites was the labor-intensive tracking and documenting of texting communications due to an inability to integrate texting platforms with electronic health records.
Despite enthusiasm for the texting programs from the involved individuals and organizations, inadequate data management capabilities and unclear privacy and security regulations for mobile health technology slowed the initial implementation and limited the clinical use of texting in the safety net and scope of pilots. Future implementation work and research should investigate how different texting platform and intervention designs affect efficacy, as well as explore issues that may affect sustainability and the scalability.
No preview · Article · Dec 2015 · BMC Medical Informatics and Decision Making
[Show abstract][Hide abstract] ABSTRACT: Objective:
Online patient portals are being widely implemented; however, no studies have examined whether portals influence health behaviors or outcomes similarly across patient racial/ethnic subgroups. We evaluated longitudinal changes in statin adherence to determine whether racial/ethnic minorities initiating use of the online refill function in patient portals had similar changes over time compared with Whites.
We examined a retrospective cohort of diabetes patients who were existing patient portal users. The primary exposure was initiating online refill use (either exclusively for all statin refills or occasionally for some refills), compared with using the portal for other tasks (eg, exchanging secure messages with providers). The primary outcome was change in statin adherence, measured as the percentage of time a patient was without a supply of statins. Adjusted generalized estimating equation models controlled for race/ethnicity as a primary interaction term.
Fifty-eight percent of patient portal users were white, and all racial/ethnic minority groups had poorer baseline statin adherence compared with Whites. In adjusted difference-in-difference models, statin adherence improved significantly over time among patients who exclusively refilled prescriptions online, even after comparing changes over time with other portal users (4% absolute decrease in percentage of time without medication). This improvement was statistically similar across all racial/ethnic groups.
Patient portals may encourage or improve key health behaviors, such as medication adherence, for engaged patients, but further research will likely be required to reduce underlying racial/ethnic differences in adherence.
In a well-controlled examination of diabetes patients' behavior when using a new online feature for their healthcare management, patient portals were linked to better medication adherence across all racial/ethnic groups.
No preview · Article · Sep 2015 · Journal of the American Medical Informatics Association
[Show abstract][Hide abstract] ABSTRACT: To explore the content of patient-provider e-mails in a safety-net primary care clinic, we conducted a content analysis using inductive and deductive coding of e-mail exchanges (n = 31) collected from January through November 2013. Participants were English-speaking adult patients with a chronic condition (or their caregivers) cared for at a single publicly funded general internal medicine clinic and their primary care providers (attending general internist physicians, clinical fellows, internal medicine residents, and nurse practitioners). All e-mails were nonurgent. Patients included a medical update in 19% of all e-mails. Patients requested action in 77% of e-mails, and the most common requests overall were for action regarding medications or treatment (29%). Requests for information were less common (45% of e-mails). Patient requests (n = 56) were resolved in 84% of e-mail exchanges, resulting in 63 actions. These results show that patients in safety-net clinics are capable of safely and effectively using electronic messaging for between-visit communication with providers. Safety-net systems should implement electronic communications tools as soon as possible to increase health care access and enhance patients' involvement in their care.
No preview · Article · Sep 2015 · Journal of Health Communication
[Show abstract][Hide abstract] ABSTRACT: Non-medical prescription opioid use is a growing public health concern. Social media is an emerging tool to understand health attitudes, beliefs, and behaviors.
We retrieved a sample of publicly available Twitter messages in early 2014, using common opioid medication names and slang search terms. We used content analysis to code messages by user, context of message (personal vs general experiences), and key content themes.
We reviewed 540 messages, of which 375 (69%) messages were related to opioid behaviors. Of these, 316 (84%) originated from individual user accounts; 125 messages expressed personal experience with opioids. The majority of personal messages referenced using opioids to obtain a "high", use for sleep, or other non-intended use (87,70%). General attitudes regarding opioid use included positive sentiment (52, 27%), comments on others peoples opioid use (57, 30%), and messages containing public health information or links (48, 25%).
In a sample of social media messages mentioning opioid medications, the most common theme amongst English users related to various forms of opioid misuse. Social media can provide insights into the types of misuse of opioids that might aid public health efforts to reduce non-medical opioid use.
[Show abstract][Hide abstract] ABSTRACT: With the expansion of Medicaid and low-cost health insurance plans among diverse patient populations, objective measures of medication adherence using pharmacy claims could advance clinical care and translational research for safety net care. However, safety net patients may experience fluctuating prescription drug coverage, affecting the performance of adherence measures. OBJECTIVE: To evaluate the performance of continuous medication gap (CMG) for diverse, low-income managed care members with diabetes.
We conducted this cross-sectional analysis using administrative and clinical data for 680 members eligible for a self-management support trial at a nonprofit, government-sponsored managed care plan. We applied CMG methodology to cardiometabolic medication claims for English- , Cantonese- , or Spanish-speaking members with diabetes. We examined inclusiveness (the proportion with calculable CMG) and selectivity (sociodemographic and medical differences from members without CMG). For validity, we examined unadjusted associations of suboptimal adherence (CMG greater than 20%) with suboptimal cardiometabolic control.
429 members (63%) had calculable CMG. Compared with members without CMG, members with CMG were younger, more likely employed, and had poorer glycemic control but had better blood pressure and lipid control. Suboptimal adherence occurred more frequently among members with poor cardiometabolic control than among members with optimal control (28% vs. 12%, P = 0.02). CONCLUSIONS: CMG demonstrated acceptable inclusiveness and validity in a diverse, low-income safety net population, comparable with its performance in studies among other insured populations. CMG may provide a useful tool to measure adherence among increasingly diverse Medicaid populations, complemented by other strategies to reach those not captured by CMG.
[Show abstract][Hide abstract] ABSTRACT: The objective was to determine whether automated telephone self-management support (ATSM) for low-income, linguistically diverse health plan members with diabetes affects health care utilization or cost. A government-sponsored managed care plan for low-income patients implemented a demonstration project between 2009 and 2011 that involved a 6-month ATSM intervention for 362 English-, Spanish-, or Cantonese-speaking members with diabetes from 4 publicly funded clinics. Participants were randomized to immediate intervention or a wait-list. Medical and pharmacy claims used in this analysis were obtained from the managed care plan. Medical claims included hospitalizations, ambulance use, emergency department visits, and outpatient visits. In the 6-month period following enrollment, intervention participants generated half as many emergency department visits and hospitalizations (rate ratio 0.52, 95% CI 0.26, 1.04) compared to wait-listed participants, but these differences did not reach statistical significance (P=0.06). With adjustment for prior year cost, intervention participants also had a nonsignificant reduction of $26.78 in total health care costs compared to wait-listed individuals (P=0.93). The observed trends suggest that ATSM could yield potential health service benefits for health plans that provide coverage for chronic disease patients in safety net settings. ATSM should be further scaled up to determine whether it is associated with a greater reduction in health care utilization and costs. (Population Health Management 2015;xx:xxx-xxx).
No preview · Article · Jun 2015 · Population Health Management
[Show abstract][Hide abstract] ABSTRACT: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Care Transitions Measure (CTM-3) scores are patient experience measures used to determine hospital value-based purchasing reimbursement. Interventions to improve 30-day readmissions have met with mixed results, but less is known about their potential to improve the patient experience among older ethnically and linguistically diverse adults receiving care at safety-net hospitals. In this study, we assessed the effect of a nurse-led hospital-based care transition intervention on discharge-related patient experience in an older multilingual population of adults hospitalized at a safety-net hospital.
We randomized 700 inpatients aged 55 and older at an academic urban safety-net hospital. In addition to usual care, intervention participants received inpatient visits by a language-concordant study nurse and post-discharge phone calls from a language-concordant nurse practitioner to reinforce the care plan and to address acute complaints. We measured HCAHPS nursing, medication, and discharge communication domain scores and CTM-3 scores at 30 days after hospital discharge.
Of 685 participants who survived to 30 days, 90 % (n = 616) completed follow-up interviews. The mean age was 66.2 years; over half (54.2 %) of the participants had cognitive impairment, and 33.8 % had moderate to severe depression. The majority (62.1 %) of interviews were conducted in English; 23.3 % were conducted in Chinese and 14.6 % in Spanish. Study nurses spent an average of 157 min with intervention participants. Between intervention and usual care participants, CTM-3 scores (80.5 % vs 78.5 %; p = 0.18) and HCAHPS discharge communication domain scores (74.8 % vs 68.7 %; p = 0.11) did not differ, nor did HCAHPS scores in medication (44.5 % vs 53.1 %; p = 0.13) and nursing domains (67.9 % vs 64.9 %; p = 0.43). When stratified by language, no significant differences were seen.
An inpatient standalone transition-of-care intervention did not improve patient discharge experience. Older multi-lingual and cognitively impaired populations may require higher-intensity interventions post-hospitalization to improve discharge experience outcomes.
No preview · Article · May 2015 · Journal of General Internal Medicine
[Show abstract][Hide abstract] ABSTRACT: Little is known about hospitalization-associated disability (HAD) in older adults who receive care in safety-net hospitals.
To describe HAD and to examine its association with age in adults aged 55 and older hospitalized in a safety-net hospital.
Secondary post hoc analysis of a prospective cohort from a discharge intervention trial, the Support from Hospital to Home for Elders.
Medicine, cardiology, and neurology inpatient services of San Francisco General Hospital, a safety-net hospital.
A total of 583 participants 55 and older who spoke English, Spanish, or Chinese. We determined the incidence of HAD 30 days post-hospitalization and ORs for HAD by age group.
The outcome measure was death or HAD at 30 days after hospital discharge. HAD is defined as a new or additional disability in one or more activities of daily living (ADL) that is present at hospital discharge compared to baseline. Participants' functional status at baseline (2 weeks prior to admission) and 30 days post-discharge was ascertained by self-report of ADL function.
Many participants (75.3 %) were functionally independent at baseline. By age group, HAD occurred as follows: 27.4 % in ages 55-59, 22.2 % in ages 60-64, 17.4 % in ages 65-69, 30.3 % in ages 70-79, and 61.7 % in ages 80 or older. Compared to the youngest group, only the adjusted OR for HAD in adults over 80 was significant, at 2.45 (95 % CI 1.17, 5.15).
In adults at a safety-net hospital, HAD occurred in similar proportions among adults aged 55-59 and those aged 70-79, and was highest in the oldest adults, aged ≥ 80. In safety-net hospitals, interventions to reduce HAD among patients 70 years and older should consider expanding age criteria to adults as young as 55.
No preview · Article · May 2015 · Journal of General Internal Medicine
[Show abstract][Hide abstract] ABSTRACT: In the past few years, the rapid adoption of health information technology (HIT) in the US has been very apparent, largely driven by the more than $25 billion in incentives for “Meaningful Use” of HIT provided to date as a part of healthcare reform in the Health Information Technology for Economic and Clinical Health (HITECH) Act. As we move into Stage 2 of the Meaningful Use program with new metrics for patient engagement, healthcare leaders are now shifting their focus from implementation to understanding patient needs and preferences for health technology use. The article by Levy et al.1 in this issue highlights an important issue in this landscape: the intersection of vulnerable populations and HIT use.At the national level, the Pew Research Center’s Internet and American Life Project estimates that the gaps in technology use (that is, the “digital divide”) are shrinking. In 2014, 87 % of US adults accessed the Internet including 81 % of African Americans, 83 % of Hispanics/Latinos ...
Preview · Article · Jan 2015 · Journal of General Internal Medicine
[Show abstract][Hide abstract] ABSTRACT: Objectives
To determine the prevalence of preadmission functional disability in late-middle-aged and older safety-net inpatients and to identify characteristics associated with functional disability by age.DesignCross-sectional analysis.SettingSafety-net hospital in San Francisco, California.ParticipantsEnglish-, Spanish-, and Chinese-speaking community-dwelling individuals aged 55 and older admitted to a safety-net hospital with anticipated return to the community (N = 699).MeasurementsAt hospital admission, participants reported their need for help performing five activities of daily living (ADLs) and seven instrumental activities of daily living (IADLs) 2 weeks before admission. ADL disability was defined as needing help performing one or more ADLs and IADL disability as needing help performing two or more IADLs. Participant characteristics were assessed, including sociodemographic characteristics, health status, health-related behaviors, and health-seeking behaviors.ResultsOverall, 28.3% of participants reported that they had an ADL disability 2 weeks before admission, and 40.4% reported an IADL disability. The prevalence of preadmission ADL disability was 28.9% of those aged 55 to 59, 20.7% of those aged 60 to 69, and 41.2% of those aged 70 and older (P < .001). The prevalence of IADL disability had a similar distribution. The characteristics associated with functional disability differed according to age; in participants aged 55 to 59, African Americans had a higher odds of ADL and IADL disability, whereas in participants aged 60 to 69 and aged 70 and older, inadequate health literacy was associated with functional disability.Conclusion
Preadmission functional disability is common in individuals aged 55 and older admitted to a safety-net hospital. Late-middle-aged individuals admitted to safety-net hospitals may benefit from models of acute care currently used for older adults that prevent adverse outcomes associated with functional disability.
No preview · Article · Nov 2014 · Journal of the American Geriatrics Society
[Show abstract][Hide abstract] ABSTRACT: Delayed and missed diagnoses lead to significant patient harm. Because physician actions are fundamental to the outpatient diagnostic process, a study was conducted to explore physician perspectives on diagnosis.
As part of a quality improvement initiative, an integrated health system conducted six physician focus groups in 2004 and 2005. The focus groups included questions about the process of diagnosis, specific factors contributing to missed diagnosis, use of guidelines, atypical vs. typical presentations of disease, diagnostic tools, and follow-up, all with regard to delays in the diagnostic process. The interviews were analyzed (1) deductively, with application of the Systems Engineering Initiative for Patient Safety (SEIPS) model, which addresses systems design, quality management, job design, and technology implementations that affect safety-related patient and organizational and/or staff outcomes, and (2) inductively, with identification of novel themes using content analysis.
A total of 25 physicians participated in the six focus groups, which yielded 12 hours of discussion. Providers identified multiple barriers to timely and accurate diagnosis, including organizational culture, information availability, and communication factors.
Multiple themes relating to each of the participants in the diagnostic process-health system, provider, and patient-emerged. Concerns about health system structure and providers' interactions with one another and with patients far exceeded discussion of the cognitive factors that might affect the diagnostic process. The results suggest that, at least in physicians' views, improving the diagnostic process requires attention to the organization of the health system in addition to the cognitive aspects of diagnosis.
Full-text · Article · Oct 2014 · Joint Commission journal on quality and patient safety / Joint Commission Resources