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The American Journal of Managed Care May 2015
Comparison of Provider and Plan-Based Targeting Strategies for Disease Management
Ann M. Annis, MPH, RN; Jodi Summers Holtrop, PhD, MCHES; Min Tao, PhD; Hsiu-Ching Chang, PhD; and Zhehui Luo, PhD
Making Measurement Meaningful
Christine K. Cassel, MD, President and CEO, National Quality Forum
Care Fragmentation, Quality, and Costs Among Chronically Ill Patients
Brigham R. Frandsen, PhD; Karen E. Joynt, MD, MPH; James B. Rebitzer, PhD; and Ashish K. Jha, MD, MPH
Results From a National Survey on Chronic Care Management by Health Plans
Soeren Mattke, MD, DSc; Aparna Higgins, MA; and Robert Brook, MD, ScD
Association Between the Patient-Centered Medical Home and Healthcare Utilization
Rainu Kaushal, MD, MPH; Alison Edwards, MStat; and Lisa M. Kern, MD, MPH
Transforming Oncology Care: Payment and Delivery Reform for Person-Centered Care
Kavita Patel, MD, MS; Andrea Thoumi, MSc; Jeffrey Nadel, BA; John O'Shea, MD, MPA; and Mark McClellan, MD, PhD
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True "Meaningful Use": Technology Meets Both Patient and Provider Needs
Heather Black, PhD; Rodalyn Gonzalez, BA; Chantel Priolo, MPH; Marilyn M. Schapira, MD, MPH; Seema S. Sonnad, PhD; C. William Hanson III, MD; Curtis P. Langlotz, MD, PhD; John T. Howell, MD; and Andrea J. Apter, MD, MSc
Annual Diabetic Eye Examinations in a Managed Care Medicaid Population
Elham Hatef, MD, MPH; Bruce G. Vanderver, MD, MPH; Peter Fagan, PhD; Michael Albert, MD; and Miriam Alexander, MD, MPH
Systematic Review of Benefit Designs With Differential Cost Sharing for Prescription Drugs
Oluwatobi Awele Ogbechie, MD, MBA; and John Hsu, MD, MBA, MSCE
Changing Trends in Type 2 Diabetes Mellitus Treatment Intensification, 2002-2010
Rozalina G. McCoy, MD; Yuanhui Zhang, PhD; Jeph Herrin, PhD; Brian T. Denton, PhD; Jennifer E. Mason, PhD; Victor M. Montori, MD; Steven A. Smith, MD; Nilay D. Shah, PhD
Medicaid-Insured and Uninsured Were More Likely to Have Diabetes Emergency/Urgent Admissions
Monica A. Fisher, PhD, DDS, MPH, MS; and Zhen-qiang Ma, MD, MPH, MS
Roles of Prices, Poverty, and Health in Medicare and Private Spending in Texas
Chapin White, PhD; Suthira Taychakhoonavudh, PhD; Rohan Parikh, MS; and Luisa Franzini, PhD
Measuring Patient-Centered Medical Home Access and Continuity in Clinics With Part-Time Clinicians
Ann-Marie Rosland, MD, MS; Sarah L. Krein, PhD, RN; Hyungjin Myra Kim, ScD; Clinton L. Greenstone, MD; Adam Tremblay, MD; David Ratz, MS; Darcy Saffar, MPH; and Eve A. Kerr, MD, MPH

True "Meaningful Use": Technology Meets Both Patient and Provider Needs

Heather Black, PhD; Rodalyn Gonzalez, BA; Chantel Priolo, MPH; Marilyn M. Schapira, MD, MPH; Seema S. Sonnad, PhD; C. William Hanson III, MD; Curtis P. Langlotz, MD, PhD; John T. Howell, MD; and Andrea J. Apter, MD, MSc
A qualitative study of patient and provider perspectives regarding the after-visit summary and the patient portal features of the electronic health record.

Objectives: Voluntary patient uptake and use of electronic health record (EHR) features have been low. It is unknown whether EHRs fully meet needs of providers or patients with chronic diseases.

Study Design: To explore in-depth user experiences, we conducted 6 focus groups: 3 of patients followed by 3 of providers discussing 2 key EHR components: the after-visit summary (AVS) and the patient portal (PP). Focus groups were audio-recorded, transcribed, and analyzed by 3 independent coders.

Methods: Participants with moderate-to-severe asthma and prevalent comorbidities were recruited from 4 primary care and 2 asthma clinics serving low-income urban neighborhoods. Participants discussed their expectations and experience using the AVS and PP, and responded to prototype formats of these features. Additionally, one-on-one interviews were conducted with 10 patients without PP experience to assess their ability to use the system.

Results: The 21 patient and 13 provider perspectives differed regarding AVS features and use. Patients wanted a unified view of their medical issues and health management tools, while providers wanted to focus on recommendations from 1 visit at a time. Both groups advocated improving the AVS format and content. Lack of awareness and knowledge about the PP was patients’ largest barrier, and was traced back to providers’ lack of PP training.

Conclusions: Our results underscore the importance of user-centered design when constructing the content and features of the EHR. As technology evolves, an ongoing understanding of patient and provider experiences will be critical to improve uptake, increase use, and ensure engagement, optimizing the potential of EHRs.
Am J Manag Care. 2015;21(5):e329-e337
Take-Away Points
This study provides a concrete example of the importance of user-centered design to enhance the uptake of, engagement with, and meaningful use of electronic health records (EHRs) by patients and providers. We explored the after-visit summary (AVS) and patient portal (PP) through a parallel design to uncover similarities and differences in how patients and providers view and use these features. This paper presents empiric evidence supporting the following modifications to the design and implementation of the EHR:
  • Increase awareness of EHR features among patients and providers.
  • Provide training of patients and providers regarding features of the EHR.
  • Enhance the organization and scope of information provided through the AVS and PP.
Incentivized by the federal Meaningful Use program to provide patients with electronic access to their healthcare information, electronic health records (EHRs) potentially play a key role in patient-physician communication.1,2 Using information technology in the promotion of health communication is a goal of Healthy People 2020,3 yet many health systems have experienced lower than desired uptake and use of portals by patients.4

Two features of EHRs are especially important for improving patient-provider communication and helping patients to self-manage chronic diseases: the after-visit summary (AVS) and the patient portal (PP).5 The AVS is a summary of an outpatient visit printed from the EHR for the patient at the conclusion of an appointment. It includes personalized patient instructions, prescribed medications, and upcoming appointments. The patient portal is an interactive Web-based platform for exchanging clinical information between patient and providers. The PP at the University of Pennsylvania Health System allows patients to view lab/test results, review and make appointments, request refills, and contact providers.

Limited research documents the extent to which the AVS and PP meet provider and patient needs, including those of low-income and low-literacy patients. One study found that patients with low levels of education, but with computer and Internet experience, are enthusiastic about the perceived utility of PPs.6 Another study reported that patients cared for in safety net clinics use e-mail, text messaging, and the Internet to communicate with providers; however, all safety net clinics may not offer PPs or secure messaging.7

This study provides an in-depth exploration of the perceptions and needs of patients and their providers around the AVS and PP. It also details the degree to which these features meet patient and provider needs and their recommendations for improvement.


Study Setting

Patients and providers were recruited from 6 University of Pennsylvania Health System (UPHS) clinics in different locations and with different missions. These clinics included 4 primary care clinics (2 internal medicine and 2 family medicine practices) and 2 specialty practices (allergy-immunology and pulmonary)—all located in the West Philadelphia community that they serve. These clinics have used the EHR with its PP from Epic (Epic Systems Corporation, Verona, Wisconsin) for more than 5 years.

Study Design

Qualitative methods are often chosen for exploratory studies because their main strength is capturing participant experiences in depth and eliciting meanings that participants ascribe to their activities.8 We selected a focus-group approach to allow expression of individual ideas and group synthesis9; while individuals’ responses in focus groups may be influenced by social pressure, moderator techniques limit such pressure. In each group the RIVA Institute-trained moderator ensured that the discussion was not dominated by a few participants or a single point of view.

Three focus groups of patients were followed by 3 of providers. Anonymous responses from the patient groups were used to prompt discussion in the provider groups. All sessions were audiotaped and transcribed. To further explore the extent of patients’ ability to learn to use the PP, 10 patients similar to focus group participants with no PP experience were recruited for one-on-one interactions that introduced them to the PP and evaluated the ease of learning to use it.

The University of Pennsylvania Institutional Review Board approved the protocols. All participants gave informed consent.


We studied 21 patients and 13 providers in focus groups and introduced 10 additional patients to the patient portal in one-on-one interviews. A purposive sample of 31 patients from the 6 clinics described was recruited from 2 asthma intervention studies.10,11 Asthma was chosen because it is a common disease, offers a model for self-management also required of other diseases, and is often accompanied by comorbidities including diabetes in adults. Thus, it was intended that our findings could be potentially generalizable to other chronic diseases in adults and to patients who have comorbidities that complicate their communications with their healthcare practices. Participants were 18 years or older with moderate or severe asthma per the National Heart, Lung, and Blood Institute Expert Panel Report 3 guidelines.12

Provider participants were physicians and nurses working in the included clinics. Providers and patients were invited until each focus group was assured of having 5 to 8 participants, and each focus group participant was offered a light meal, free parking or tokens for public transportation, and a $25 stipend. Participants in the one-on-one interviews received $10 for the first session and $20 for the second.


Focus groups. Participants were shown a typical AVS. Its features included the patient’s vital signs, health goals, current medications, allergies, new medication and other orders, upcoming appointments, diagnoses, individualized instructions, and recommended timing of any follow-up visits. Participants were asked to comment on content, design, and features, and on how they personally used the AVS. Next, patients were polled about computer/Internet access; familiarity with the

PP, including procedures for enrollment and use; and attitudes about using the PP. The PP was described and “screen shots” of pages were displayed to prompt discussion of content, design, and features. Descriptions of the PP’s functions included logging in, viewing scheduled appointments, viewing lab results, requesting or canceling appointments, requesting prescription renewals, and viewing past AVS forms.

Provider groups followed a similar structure, including discussions of their views on the AVS and how they use it, as well as their experiences with the PP. Providers were also prompted with examples of an AVS and “screen shots” of the PP, and finally, providers were asked to comment on patients’ use of and requirements for the AVS and PP.

One-on-one interviews introducing the PP. In one-on-one interviews, 10 participants were shown a brief introductory video of the PP and they were offered assistance in setting up an e-mail account, if necessary. They were then shown how to activate a PP account and how to complete 7 simulated tasks (Table 1). One week later, participants were tested on their ability to complete these tasks and interviewed about their ease in navigating the PP.


Data collection was iterative, as it is common in qualitative research to continue uncovering nuances in the data. Depending on participant responses, prompts and refinements were added to subsequent groups.13 The 3 focus groups each of patients and providers provided feedback saturation.

Using a Grounded Theory approach,14 3 coders independently identified content codes in transcripts and notes related to perspectives on the content, design, use, and facilitators of, and barriers to, the AVS and PP. From these codes, themes emerged; they were agreed on by consensus of the 3 coders and 2 additional researchers, then summarized and interpreted.


The study included 31 patients who were diverse in sociodemographic characteristics (Table 2). Almost all patients reported access to a computer inside or outside the home, and most had e-mail accounts. Some had used the Internet to obtain medical information. Almost half reported either limited typing skills or low confidence using the computer. Of the 10 patients introduced to the PP, 5 had Internet access in the home, and 4 had an e-mail account. Six had used the Internet to obtain medical information. Five reported limited typing skills. The study included 13 clinician participants, most female and from primary care practices (61%) (Table 2).

Below are the themes that emerged from the focus group analysis. Illustrative quotations for each theme appear in Table 3.


Patient awareness, use, scope, and content of the AVS. All patients were familiar with the AVS; however, they varied in how they used the AVS following the appointment. Three discarded it after each visit, 8 retained it for a limited variable time, and 8 kept every AVS. Patients who retained the AVS described its value as an information source (Table 4).

Patients discussed health management information that would be useful to include in the AVS. They desired a comprehensive record of their health condition and treatment course, including information from multiple practices participating in their care. Patients also desired more information on device use and medication side effects. They objected to medical terminology and most could not locate instructions. Some noted that AVS medication information was inconsistent with medication bottle labels.

Provider perspectives on the use, scope, and content of the AVS. Providers viewed the AVS as supplemental to information discussed in the clinic encounter or as a receipt of the clinical “transaction.” Providers were aware that patients used the AVS as a medication list but not of other uses such as a medical record for use during emergencies.

Most providers expressed frustration with their inability to tailor the AVS format. They found it cumbersome, and disliked that it encompassed administrative data not pertinent to patients, such as diagnostic codes. They felt the excess information increased the literacy and time demands of reviewing the AVS with patients. Some noted errors in the medication lists.

Providers suggested specific format improvements for the AVS including: 1) moving instructions to the first page, 2) changing font sizes or color, 3) highlighting important information, and 4) providing pictures of medications. Most providers felt they would benefit from more training to customize the AVS for their patients.

The Patient Portal

After discussing the AVS, the PP was introduced as an online interactive version of the information in the AVS and a patient’s health record.

Barriers to PP use for patients. Almost all reported having a computer and Internet access nearby, if not at home. Despite access, 5 patients were not confident using computers, although all knew someone who could help access the Internet. Lack of awareness of the PP and knowledge about its use for health management was the main barrier to PP enrollment. Although information on the PP had been mailed to patients and was available in many clinics, and although providers were encouraged to mention it to patients, the level of awareness and knowledge was low. Just over half (13 of 21, or 62%) had heard of the PP. Most patients (11 of 13) with awareness did not know specifics of portal functionality. Only a third (7 of 21) reported signing up for the PP and only 5 of those 7 had logged on. Almost all who had logged on reported that their provider discussed the PP with them or suggested a specific use (eg, viewing test results). Of those who logged on, only 1 reported using it actively to manage health. The others had only logged on once or twice for test results. A few (3 out of 21) distrusted technology and worried about confidentiality. Some believed the PP would be a barrier to communicating with their providers.

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