Adoption of a Portal for the Primary Care Management of Pediatric Asthma: A Mixed-Methods Implementation Study

Abstract

BackgroundPatient portals may improve communication between families of children with asthma and their primary care providers and improve outcomes. However, the feasibility of using portals to collect patient-reported outcomes from families and the barriers and facilitators of portal implementation across diverse pediatric primary care settings have not been established.ObjectiveWe evaluated the feasibility of using a patient portal for pediatric asthma in primary care, its impact on management, and barriers and facilitators of implementation success.MethodsWe conducted a mixed-methods implementation study in 20 practices (11 states). Using the portal, parents of children with asthma aged 6-12 years completed monthly surveys to communicate treatment concerns, treatment goals, symptom control, medication use, and side effects. We used logistic regression to evaluate the association of portal use with child characteristics and changes to asthma management. Ten clinician focus groups and 22 semistructured parent interviews explored barriers and facilitators of use in the context of an evidence-based implementation framework.ResultsWe invited 9133 families to enroll and 237 (2.59%) used the portal (range by practice, 0.6%-13.6%). Children of parents or guardians who used the portal were significantly more likely than nonusers to be aged 6-9 years (vs 10-12, P=.02), have mild or moderate/severe persistent asthma (P=.009 and P=.04), have a prescription of a controller medication (P<.001), and have private insurance (P=.002). Portal users with uncontrolled asthma had significantly more medication changes and primary care asthma visits after using the portal relative to the year earlier (increases of 14% and 16%, respectively). Qualitative results revealed the importance of practice organization (coordinated workflows) as well as family (asthma severity) and innovation (facilitated communication and ease of use) characteristics for implementation success.ConclusionsAlthough use was associated with higher treatment engagement, our results suggest that achieving widespread portal adoption is unlikely in the short term. Implementation efforts should include workflow redesign and prioritize enrollment of symptomatic children.ClinicalTrialClinicaltrials.gov NCT01966068; https://clinicaltrials.gov/ct2/show/NCT01966068 (Archived by WebCite at http://www.webcitation.org/6i9iSQkm3)

Long-term Patterns of Patient Portal Use for Pediatric Patients at an Academic Medical Center

“…In our study, the majority of patients for whom portal accounts were created were Caucasian, a finding that is not surprising as the referral base for VUMC is 77-87% Caucasian [41,42]. Other studies have reported similar disparities with a disproportionate number of Caucasian users in both pediatric [35,43] and adult [4,38,40] populations. At our institution, pediatric accounts were created for male and female pediatric patients in nearly equal numbers.…”

A review of the use and effectiveness of digital health technologies in patients with asthma

“…Among the 16 studies that focused on children, most of the interventions that used interactive websites reported at least some benefit (Table 2), although results varied based on the specific outcome and method of assessment. [24][25][26][27][28][29][30] For example, a 1-year RCT of the websitebased Puff City intervention was associated with significant reductions in asthma symptom days ( ≥ 2 days/week/30 days; adjusted odds ratios [aOR] = 0.5 [95% confidence interval (CI): 0.2-0.8]; P = .006), asthma symptom nights ( ≥ 3 nights; aOR = 0.6 [95% CI: 0.4-1.0]; P = .074), and restricted activity days ( > 4 days; aOR = 0.5 [95% CI: 0.3-0.9]; P = .010) vs no intervention among 422 urban (Detroit) high school students aged 15 to 19 years. 27 In a 1-year RCT in 237 children aged 6 to 12 years from 20 medical practices in the United States, increases in medication changes/refills (14% [95% CI: 2%-27%]) and asthma-related primary care visits (16% [95% CI: 3%-28%]) were observed in the subset of 76 patients with uncontrolled asthma after parents used the portal compared with the same period the year prior.…”

“…27 In a 1-year RCT in 237 children aged 6 to 12 years from 20 medical practices in the United States, increases in medication changes/refills (14% [95% CI: 2%-27%]) and asthma-related primary care visits (16% [95% CI: 3%-28%]) were observed in the subset of 76 patients with uncontrolled asthma after parents used the portal compared with the same period the year prior. 25 In a 2-week RCT involving 98 children aged 12 to 17 years from academic outpatient settings in the United States, use of the MyMediHealth website vs usual care was associated with significant improvements in self-reported medication adherence (median data not shown; P = .011), quality of life (increase by a median of 5.7-6.3 on a 7-point scale; P = .037), and self-efficacy (perceived ability to prevent and manage asthma attacks 31 ; increase by a median of 4.1 to 4.4, between "quite sure" and "completely sure" of self-efficacy in asthma management; P = .016). 26 In a 6-month RCT conducted at an inner-city (Boston) hospital, use of a website (BostonBreathes), vs usual care, by 58 children aged 7 to 17 years and their parents was associated with improved adherence in the subgroup of 23 patients with low controller medication adherence ( < 75% adherence) at baseline (mean change in primary controller compliance: +29.8%; P = .01).…”

Care Delivered by Pediatric Surgical Specialties Through Patient Portal Messaging

“…22,27,31 At other institutions, studies about portal usage for pediatric patients with chronic diseases found disproportionately increased usage by white patients, their families, and those privately insured, and decreased usage by black patients, Hispanic patients, and those on Medicaid. 28,29,32 While most patient portal research has been done in primary care or medical specialties, our findings add to the growing body of evidence that patient portals may also create disparities for surgical patients. 21,22,33 As patient portal adoption increases and more patients receive care through portal messaging, healthcare institutions must carefully consider whether this technology is exacerbating disparities in access to care.…”

“…27 Multiple other studies have demonstrated predominately white users of patient portals for both pediatric and adult patients. 17,20,[28][29][30] Prior studies at our institution in pediatric patients and adult surgical patients found that the majority of portal users were white, non-Hispanic patients, and portal usage was associated with increased health literacy and education. 22,27,31 At other institutions, studies about portal usage for pediatric patients with chronic diseases found disproportionately increased usage by white patients, their families, and those privately insured, and decreased usage by black patients, Hispanic patients, and those on Medicaid.…”