Running head: PATIENT PORTALS: PROVIDER

Patient Portals: An Educational Project to Improve Provider Readiness
Laura L. Leal
Arizona State University

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Abstract:

Background: With the adoption of the Health Information Technology for Economical and
Clinical Health (HITECH) Act of 2009, came the implementation of the electronic health record
(EHR) and incentivized provider programs called Meaningful Use (MU). A goal of MU is to
utilize patient portals to improve access to care. Current evidence supports patient portal use
however providers are concerned about increased work load and lost revenue because of the time
spent managing the portals rather than providing direct, billable patient care. Purpose: The
purpose of this project was to assess provider readiness for patient portals and provide an
educational intervention to address perceived barriers. Method: Nine providers at a large family
practice clinic in the Southwest United States were surveyed using a provider readiness
questionnaire (Kepplinger, et al., 2013) prior to and after an educational intervention. Results:
Improved response to patient portal use after the provider viewed the learning module. A pairedsamples t-test was conducted to compare pre-learning module readiness questionnaire results to
post learning module readiness questionnaire results. There was a significant difference in the
scores for question about increased workload pre-module (M= 3.78, SD=1.201) and increased
workload post module (M=2.67, SD=1.225) conditions; t (8) =5.547, p = .001. There was a
significant difference in the scores for question about increased provider professional satisfaction
pre-module (M=3.89, SD= .333) and increased provider professional satisfaction post module
(M= 4.44, SD=.527) conditions; t (8) = -2.294, p=.051). Implications: Providing portal education
can assist the provider in understanding the value of the portals to improve patient outcomes and
patient centered care. Improving portal use with also foster patient provider relationships and
allow the practice to attest to Meaningful Use and obtain allotted incentives.

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Keywords: Patient Portals, Meaningful Use, electronic medical record, electronic health record,
HITECH act, provider readiness

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Patient Portals: An Educational Project to Improve Provider Readiness
With the adoption of the Health Information Technology for Economical and Clinical
Health (HITECH) Act of 2009, came the implementation of the electronic health record (EHR)
(Devine et al., 2010). Since the implementation of the EHR, incentivized provider programs
called Meaningful Use (MU), supported by Centers for Medicare and Medicaid (CMS), guide the
use of the data achieved through the health record (CMS, 2014). Most notably, MU utilizes the
information from EHR’s to improve upon patient communication, records retrieval, preventative
care, and prescribing ability among other components of care delivery. One goal of MU is to
utilize patient portals as a means of improving access to care. The objective of the patient portal
is to give the patient access to personal records and increase contact with their health care
provider (Goel et al., 2011). Patient portals have been shown to engage patients in their care,
provide medical record transfer for continuity of care, and to increase access to health providers
improving patient health outcomes and patient satisfaction (Otte-Trojel, De Bont, Van
DeKlunder, Rundall, 2014; Kruse, Argueta, Lopez, & Nair, 2015).
The EHR is a permanent and prominent fixture in the healthcare market. As patient portal
use increases, provider support becomes needed to ensure adoptability and use. While evidence
supports the use of patient portals to promote patient access, many providers remain resistant.
Providers report being overwhelmed with yet another task driven requirement that ultimately
takes time away from direct patient care (Keplinger, Koopman, Davie, Merh, Kruse et al, 2013).
One way to understand why patient portal use is so important is to examine MU guidelines. MU
has three stages that, over time, cover a wide range of data sharing of the EHR. The MU
objective dates allow for outpatient clinics and hospitals to qualify for program incentive dollars
from CMS. Currently, the dates for MU range from 2011 through 2017. The first stage began in

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2011-2012 and included data capture and sharing. In this stage, most outpatient clinics began to
adopt software, which lead to the transition of electronic records versus traditional paper
charting. The second stage dated 2014-2016 focused on clinical processes. This current phase has
several objectives aimed at improving patient’s access to records and communication with
providers. Specifically, CMS (2014) defines this portion of stage 2 as the capacity to provide
patients the ability to view online, download and transmit their health information within four
business days of the information being available. In addition, it requires the use of secure
electronic messaging to communicate with patient on relevant health information (CMS, 2014).
It is time to examine the barriers of an electronic portal to obtain information and communicate
with patients. Specifically, this project targets the readiness of the provider to use patient portals.
Problem Statement
The problem some family practice offices face is provider support and use of portals.
While questions remain as to the validity of patient portals, many family practice offices are
moving forward with portal adoption and implementation as guided by government policy. One
very important first step to portal implementation is first to assess provider readiness. With the
MU guidelines requiring increased patient access to records and medical providers, outpatient
clinics need to find an approach to increase portal use by providers. This inquiry led to the
clinically relevant PICO question, “For primary care providers, does the implementation of
provider readiness training assist in the use of patient portals compared to no provider readiness
training.”
Search Process
The following databases were used to research the stated PICO question: Cumulative Index to
Nursing and Allied Health Literature (CINAHL), Pub Med, MEDLINE, and Cochrane Database

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of Systematic Reviews. Search terms included meaningful use (MU), EHR or Electronic Health
Record or Electronic Health Records, Medicare guidelines, CMS guidelines, patient portal,
personal health record (PHR), health information technology (HIT), provider readiness and
health information exchange (HIE). The search was limited to: the English language, studies
published in the past five years, and to full text articles. Also included were Boolean phrases and
attempt at MeSH terms generated the final references used.
Evidence Synthesis
Ten studies provided support for furthering patient portal access as supported by office staff
guided by CMS standards. The evidence was concentrated with level III with qualitative studies.
The overwhelming theme is expression of personal experiences with the portals. Identification of
thoughts and actions that described the phenomena of portal adoption, patterned around
experience with electronic communication, perceived benefits and likelihood of improved patient
outcomes link the evidence. Major variables studied include readiness for adoption, age, gender,
ethnicity, MU incentive and EHR functionality. Data collection focused on typical qualitative
methods of surveys, questionnaires, and interviews. Analysis proved to be rigorous citing
multiple measures of descriptive statistics. The sample had a great deal of heterogeneity with
four study samples assessing patient’s perception and three studies highlighting provider
attitudes and two demonstrating concern for interoperability. Noted strengths of this body of
evidence includes the range of attitudes and perceptions apparent to both patient and provider.
The evidence is clear; adoption of patient portals is suitable however, some resistance eludes to
the problem of provider readiness. Clinicians examining this evidence can confidently move
forward with practice changes to assist with provider readiness and patient portal use.
Weaknesses encountered with these 10 studies include the controversial Medicare funded

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incentives pushing outpatient clinics to be compliant with portal activation without monitoring
utilization. Furthermore, the generalizability is questionable as many studies were focused on a
small demographic or region.
EBP Model/Conceptual Model
The Iowa model was used to guide this project. This model is valuable as it allows for
utilization in larger groups and directs a pilot process to assist larger offices in a practice change.
This Model guides the project by examining problem focused triggers, team engagement and
involves the research component that is applicable with patient portals in the age of the EHR.
The ATTC Network Technology Transfer Model provided the framework for this project. This
model applies some principals of Rogers (1962). Diffusion of Innovation with a basis in the
transfer of technology to promote innovations, knowledge, technologies and skills from one
setting to another. The model guides this project related to technology transfer of information
from the EHR to the provider, between the patient and the provider, and to interoperate for
dissemination.
The process of implementing a fully functioning portal include assessing readiness for
provider to take on the “extra work” needed to provide this service. Also, changing to clinical
workflows to adopt portals are met with mixed reviews. This Model can assist in the
transformation of technology to EBP practice. Incentive programs are an influential factor related
to the enrollment of patient portal success (Goel, et al, 2011; Neuner, Fedders, Caravella &
Schapria, 2010; Kannry, Pratharna, Wang & Nissim, 2012). However, success of patient portals
enrollment is not linked to utilization of the portal thus far (Studeny, & Coustasse, 2014; BurkeBebee et al., 2012). Multiple studies assess the effect of incentive programs on the use of EHR
along with prescriber perceptions when implementing new HIT technologies. Provider

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performance and core measures can be time consuming, intimidating and daunting to evaluate
(Kruse, Argueta, Lopez & Nair 2015).
Methods
Permission was obtained from southwestern medical practice to deliver confidential
questionnaire packet which included instructions on how to create a unique identifier that was
kept private. Internal Review Board approval was received from Arizona State University on
October 21, 2016. Participants were solicited during a monthly staff meeting where the project
was explained and described. Once individuals agree to participate in the project, they were each
given a packet containing one pretest questionnaire, one learning module and one posttest
questionnaire. Results were mailed to student project director. The survey was adapted from the
Faculty and Resident Physician Agreement* With Statements Regarding the Potential impact of
Implementing a Patient Portal (Keplinger, Koopman, Davis, Mehr, Kurse et al, 2013) and served
as the pretest and posttest questionnaire. The survey consists of eight questions measured using a
Likert scale ranging from strongly disagree, disagree, neutral, agree and strongly agree. There are
2 questions that are yes or no answers with regards provider preference for portals.
The participants initially completed the questionnaire prior to reviewing the learning
module. The module includes 3 topics, My Financial Risk (Module 1) My Increased Work Load
(Module 2), and My Patient Satisfaction (Module 3). Each module includes current evidence on
the topics and provides electronic links to additional resources. Once all the modules were
completed the participant, they then completed the posttest questionnaire.
Results

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A paired-samples t-test was conducted to compare pre-learning module readiness
questionnaire results to post learning module readiness questionnaire results. There was a
significant difference in the scores for question about increased workload pre module (M= 3.78,
SD=1.201) and increased workload post module (M=2.67, SD=1.225) conditions; t(8)=5.547, p
= .001. There was a significant difference in the scores for question about increased provider
professional satisfaction pre module (M=3.89, SD= .333) and increased provider professional
satisfaction post module (M= 4.44, SD=.527) conditions; t(8)= -2.294, p=.051).
Discussion
To fully implement patient portals there needs to be provider buy-in. The purpose of this
project was to determine if an educational intervention would improve provider readiness to use
patient portals. Since a component of a fully functioning EMR includes a patient portal, provider
readiness training is a way to assist with adoption (White , Dudley-Brown & Terhaar 2016).
Once readiness training is in place, the outcome should favor a reliable and accurate transactional
system with a lifetime clinical record that is transferable across multi-specialties.
Internal evidence indicated that providers at a busy family practice in southwestern
United States were concerned that the use of patient portals would increase workload and reduce
time for direct patient care. The use of and educational intervention was shown to reduce
concerns about workload and at the same time, increase provider satisfaction. The transparency
of medicine and its ability to interoperate in and between specialists is a technological shift that
is supported by inclusion of portal use by CMS with MU guidelines (Keplinger, Koopman,
Davis, Mehr, Kurse et al, 2013). Additionally, portal adoption comes with potential financial
gain or penalties depending on how each practice will attest to MU.

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How best to use and manage patient portals portal should start with the newly graduated
clinician. Fostering new providers in portal use is crucial to outpatient changing workflows.
Employers are looking for providers who are able to effectively manage portals thereby,
increasing revenue by qualifying for monetary incentives once portal use meets Medicare
guidelines.
Strengths of this project included good provider response and organizational support.
Limitations included the small sample size. There was some difficulty with the instruction for the
posttest survey instructions resulting in one participant being excluded for not completing the
second survey. Additionally, the practice site was an established and busy practice resulting in
low recruitment.
Conclusion
To fully implement patient portals, providers need to be prepared to effectively manage
portals and to support their use. This project found that provider readiness training for patient
portal adoption improved perceptions about portals increasing workload. It also found increased
professional satisfaction with portal use. In general, results were positive, supporting portal
adoption. Adoption of portals with current and new providers further supports MU attestation
required for EHR’s. Significant financial incentives are granted through Medicare for portal use.
Conversely, sharp penalties may be instituted to those not meeting MU guidelines. Evolving
technologies shape the relationship between patient and providers. Providing an educational
intervention to improve provider readiness may increase provider use of portals tofacilitate
provider-patient communication that may ultimately improve patient health outcomes.

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