Date of Award
Projects: SPU Access Only
Doctor of Nursing Practice (DNP)
Christine Hoyle DNP, ARNP, FNP-C
Carol McFarland MN, RN, CNE
The Centers for Medicare and Medicaid Services (CMS) have recommended using electronic health technologies like patient portals as viable solutions to overcome health disparities (Wallace et al., 2016). A patient portal is a secured online website that allows patients to access their health information and consolidates multiple healthcare functions and services designed to improve patient outcomes (ONC, 2017). Health care costs are reduced when patients with patient portal have increased access to providers, which reduces high cost services such as emergency visits (Sorondo et al., 2017). Despite patient portal’s growing potential and the recommendations from CMS, enrollment in community clinics is still less than 10% (Miller et al., 2016). Therefore, the purpose of this DNP project was to increase patient portal enrollment by implementing a quality improvement plan to close the gap between the CMS recommendations and clinical practice in a community health clinic.
This DNP project took place in a federally funded community health clinic with a team of two consenting providers, two medical assistants, and one nurse. Prior to implementing a Plan-Do-Study- Act (PDSA) cycle design, a literature review of relevant articles was synthesized and presented to the agency. This review revealed common barriers to patient portal enrollment and was subsequently used to develop an anonymous five-point Likert scale questionnaire for 40 unenrolled patients selected at random. With the information obtained from the questionnaires, a brochure was created for distribution to unenrolled patients by a chosen care team. Each week these brochures were counted and a new PDSA cycle was implemented based on the feedback from staff and number of brochures distributed.
To assess the increase in patient portal enrollment the project lead obtained data from the Health Quality Measure (HQM) reports. The HQM reports allowed the project lead to track the number of all individual providers’ patients who enrolled in patient portal in a given month. Consequently, the project lead used this information to measure the progress of the patient portal project on a monthly basis.
A pre- and post-questionnaire five-point Likert scale was distributed to the pilot care team before and after the project implementation. Data was collected and analyzed via Survey Monkey. This pre- and post-questionnaire was used to assess the staff’s perception of patient portal before and after the project implementation.
The project’s first aim was to have at least 20% of brochures distributed weekly. This was eventually met with interventions such as posting reminder cards on computers, providing verbal clarification, and distributing an outline of the project’s reasons and goals via email. Once the interventions were implemented, brochure distribution increased to 35%.
Aim 2 was to increase patient enrollment by 5%. This aim was not met since the total increase in enrollment was only 1.16%. This shortfall may be due to differences in patient panels: Provider 1 had more overall enrollments as a newer provider with a more diverse, English-speaking patient panel; Provider 2 had less enrollments as a result of an established panel consisting of more patients at least 65 years old and who speak Vietnamese.
Provider 1 and 2 both had the highest number of patient portal enrollment in January 2019. This increase in number may have been caused by the extended effects of volunteers who helped to enroll patients from October to December 2018.
Aim 3 was to increase staff’s perception of the value of patient portal by 10%. The post- questionnaire showed a 6.38% increase which did not satisfy the goal of Aim 3. The project lead can infer that the shortcomings of Aim 3 may have been due to the fact that not every team member participated in the project or attended the meetings. The majority of patient portal education with staff occurred through project participation and meeting attendance. Regardless of whether a staff member participated in the project or not, every staff member on the pilot care team was given the opportunity to take the pre- and post-questionnaire.
To maintain the sustainability of the project, the project has to be effective for patients and staff alike. Assessing patients’ understanding of the usefulness of patient portal would be beneficial for future PDSA cycles. To do this, patients’ current understanding of the portal would be surveyed in order to identify gaps in patients’ knowledge. Using this data, the agency would be able to address any gaps through the use of brochures, volunteers, videos, or verbal instructions that may be given to the patient in the waiting room.
Other recommendations to improve the patient portal project include the need for addressing the feedback obtained from the staff pre- and post-questionnaires. Staff mentioned the complicated patient portal software and the lack of language translation as barriers to improving patient portal enrollment. Modifying patient portal to be user-friendly and multi-lingual would support the sustainability of the present project and any similar future ones.
While the project did not significantly increase patient portal enrollment, it is nonetheless important for the providers and staff to continue to promote patient portal. With the support of organizational leadership, the pilot team would champion the expansion of the PDSA cycle to reach wider, more diverse patient populations and to increase the awareness of patient portal through promotion, education, and training. To ensure a seamless continuation and adjustment of the project, a written report will be shared with all stakeholders so that organizational leaders may have the tools required to expand the project to other care teams and clinics within the organization.
Limitations/ Implications for Practice
This project focused on one team in which only two out of four providers consented. Furthermore, both providers had a focused patient population (e.g. a high Vietnamese-speaking and elderly population) compared to other providers in the clinic. This limitation entailed a lack of generalizability to other patients, making it difficult to determine whether this project would work on other patient populations. In addition to the low provider participation, the project’s data analysis lasted only two months. Although there was improvement in patient portal enrollment using the PDSA cycle, there was a lack of accountability whether providers and staff verbally encouraged patients to enroll. Evaluating the strengths and weaknesses of the PDSA cycle was helpful in informing participating staff on the importance of patient portal enrollment— especially within underserved communities. Future practice should focus on addressing the usability of patient portal by designing user-friendly features and accommodating other languages. By addressing these common barriers, providers and staff would be more inclined to promote patient portal enrollment while patients themselves would be more inclined to enroll.
Miller, D. P., Latulipe, C., Melius, K. A., Quandt, S. A., & Arcury, T. A. (2016). Primary Care Providers’ Views of Patient Portals: Interview Study of Perceived Benefits and Consequences. Journal of Medical Internet Research, 18(1), e8. doi: https://doi.org/10.2196/jmir.4953
Sorondo, B., Allen, A., Fathima, S., Bayleran, J., & Sabbagh, I. (2017). Patient portal as a tool for enhancing patient experience and improving quality of care in primary care practices. The Electronic Data Methods Forum, 14(1), 1-13. doi: 10.13063/2327-9214.1262
The Office of the National Coordinator for Health Information Technology. (2017). What is patient portal? HealthIT.gov. Retrieved from https://www.healthit.gov/faq/what-patient-portal
Wallace, L.S., Angier, H., Huguet, N, Gaudino, J.A., Krist, Al, Dearing, M., Killerby, M, Marino, M, & Devoe, J.E. (2016). Patterns of electronic portal use among vulnerable patients in a nationwide practice-based research network: From the OCHIN practice-based research network. Journal of the American Board of Family Medicine, 29(5), 592-603. doi: 10.3122/jabfm.2016.05.160046
Chang, Gloria, "Improving Patient Portal Enrollment in a Community Health Clinic: A Quality Improvement Plan" (2020). Doctor of Nursing Practice (DNP) Scholarly Projects. 7.