Aaron Jones

Background: Patient portals can improve care delivery and optimize health service efficiency, but they are not always adopted by patients and staff. To improve adoption of patient portals, existing research has focused on examining implementation processes from the perspectives of end users. However, to our knowledge, the views of the implementers, who have in-depth insight into interorganizational and intraorganizational factors impacting implementation, have not been previously explored. Objective: The aim of this study was to explore implementers’ perspectives on the key facilitators and barriers to implementing a patient portal. Methods: This was a cross-sectional qualitative study conducted at a dental hospital in Sydney, New South Wales, Australia. Participants were implementers of a patient portal who were (1) administrative staff managers working at the dental hospital or (2) IT staff members who either worked within the district where the hospital is located or with the vendor. All implementers of the portal (N=13) took part in the interviews. Data were analyzed thematically and mapped to the Consolidated Framework for Implementation Research. Results: Eighteen factors were reported to affect the implementation of the patient portal: 7 (39%) acted as facilitators, 8 (44%) acted as barriers, and 3 (17%) factors both facilitated and hindered implementation. Many of the facilitators were related to the implementation process, such as planning and project management, leadership support, stakeholder motivation, and co-design. Most of the barriers occurred at the interorganizational level, such as delayed training for new staff, unique workflow and clinic characteristics, challenges with timeline and budget, and lack of direct vendor access to end users. While participants saw potential benefits of the portal for patients and the health service, they had concerns about increased staff workload related to the portal implementation. From the intraorganizational perspective, the lack of direct vendor access to end users was identified as a key barrier to implementation. From both interorganizational and intraorganizational perspectives, challenges with integrating the portal into the electronic medical record were identified as a persistent barrier to portal implementation. Conclusions: In addition to factors directly impacting clinicians and patients, our study highlighted that numerous organizational factors at multiple levels within and across organizations impacted successful patient portal implementation and adoption. Portal implementations would benefit from interoperability with existing systems, adequate resourcing, regular policy review related to technological change, and strategies to improve interagency communication among portal implementers. Our study offers learnings to health service organizations, implementers, and policymakers who aim to implement new portals or optimize existing patient portals.

Background: Patient portals can improve care delivery and the efficient use of health care resources. Barriers to uptake can hinder the realization of expected benefits for health services and patients, particularly for older adults (≥65 y) and those who are culturally and linguistically diverse (CALD). Objective: This study aimed to evaluate the usability and overall patient experience of a patient portal, particularly for CALD and older adults. Methods: A mixed methods study at a dental hospital was performed including a patient experience survey that was administered before (2111 patients) and after (2445 patients) portal implementation to all patients, semistructured interviews (18 patients), and a usability survey (235 patients) that was administered to all patients who had registered to use the portal and had an appointment at the clinic. Also, we conducted a scenario-based usability evaluation (17 patients) with CALD and people. Results: The patient experience survey revealed that the portal had no impact on the ease of changing appointments when the clinic with the portal (Wilcoxon z=−1.62; P=.05) was compared with clinics without the portal in the same hospital (z=−1.54; P=.06). For the usability survey, >82% were completed by patients and 18% by carers, and 47.3% of respondents were older adults (≥65 years old). The majority spoke English (n=191, 81.3%), while others preferred to speak other languages (n=44, 18.7%) and were identified as CALD. Adult participants (18‐64 years old) reported that the portal was easy to use and simple. However, design problems, including inadequate incorporation of inclusivity, were found to more often limit usability for older (≥65) and CALD people. The overall Simplified System Usability Scale (SUS) mean score was 63.3 (95% CI 60.9‐65.7). Adult participants reflected higher SUS scores than older participants (F=10.4; P=.001). Interview results revealed how the portal was used and barriers to its uptake. Barriers related to poor usability and gaps in the implementation approach (eg, limited awareness of the purpose of the portal). Usability evaluations indicated that all participants could log in with the one-time password (OTP), but most were assisted. Only 3 of 17 participants were able to send a message to the clinic. Other usability problems identified were focused on display, content, layout, functionality, and navigation categories. Conclusions: The use of inclusive design principles when designing patient portals is necessary for successfully engaging all patients. Our study highlights the importance of normalizing inclusive designs in patient portals to ensure that priority populations, such as older and CALD people, are not marginalized by design. We provide recommendations to guide future design and implementation of patient portals.

BACKGROUND Patient portals can improve care delivery and optimize health service efficiency, but they are not always adopted by patients and staff. To improve adoption of patient portals, existing research has focused on examining implementation processes from the perspectives of end users. However, to our knowledge, the views of the implementers, who have in-depth insight into interorganizational and intraorganizational factors impacting implementation, have not been previously explored. OBJECTIVE The aim of this study was to explore implementers’ perspectives on the key facilitators and barriers to implementing a patient portal. METHODS This was a cross-sectional qualitative study conducted at a dental hospital in Sydney, New South Wales, Australia. Participants were implementers of a patient portal who were (1) administrative staff managers working at the dental hospital or (2) IT staff members who either worked within the district where the hospital is located or with the vendor. All implementers of the portal (N=13) took part in the interviews. Data were analyzed thematically and mapped to the Consolidated Framework for Implementation Research. RESULTS Eighteen factors were reported to affect the implementation of the patient portal: 7 (39%) acted as facilitators, 8 (44%) acted as barriers, and 3 (17%) factors both facilitated and hindered implementation. Many of the facilitators were related to the implementation process, such as planning and project management, leadership support, stakeholder motivation, and co-design. Most of the barriers occurred at the interorganizational level, such as delayed training for new staff, unique workflow and clinic characteristics, challenges with timeline and budget, and lack of direct vendor access to end users. While participants saw potential benefits of the portal for patients and the health service, they had concerns about increased staff workload related to the portal implementation. From the intraorganizational perspective, the lack of direct vendor access to end users was identified as a key barrier to implementation. From both interorganizational and intraorganizational perspectives, challenges with integrating the portal into the electronic medical record were identified as a persistent barrier to portal implementation. CONCLUSIONS In addition to factors directly impacting clinicians and patients, our study highlighted that numerous organizational factors at multiple levels within and across organizations impacted successful patient portal implementation and adoption. Portal implementations would benefit from interoperability with existing systems, adequate resourcing, regular policy review related to technological change, and strategies to improve interagency communication among portal implementers. Our study offers learnings to health service organizations, implementers, and policymakers who aim to implement new portals or optimize existing patient portals.

BACKGROUND Patient portals can improve care delivery and efficient use of healthcare resources. Barriers to uptake can hinder the realisation of expected benefits for health services and patients, particularly for older people (>65 years) and those who are culturally and linguistically diverse (CALD). OBJECTIVE The aim of our study was to evaluate the usability and overall patient experience of a patient portal, particularly for CALD and older people. METHODS A mixed methods study at a dental hospital was performed including a patient experience survey that was administered before (2,111 patients) and after (2,445 patients) portal implementation to all patients, semi-structured interviews (18 patients), and a usability survey (235 patients) that was administered to all patients who had registered to use the portal and had an appointment at the clinic. Also, we conducted a scenario-based usability evaluation (17 patients) with CALD and people. RESULTS The patient experience survey revealed that the portal had no impact on the ease of changing appointments when the clinic with the portal (Wilcoxon z=-1.62, p=0.052) was compared with clinics without the portal in the same hospital (z=-1.54, p=0.061). For the usability survey, >82% were completed by patients and 18% by carers, and 47.3% of respondents were older people (≥65 years old). The majority spoke English (N=191, 81.3%), while others preferred to speak other languages (N=44, 18.7%) and were identified as CALD. Adult participants (18-64 years old) reported that the portal was easy to use and simple. However, design problems, including inadequate incorporation of inclusivity, was found to more often limit usability for older (≥65) and CALD people. The overall SUS mean score was 63.3 (95%CI: 60.9–65.7). Adult participants reflected higher SUS scores than older participants (F=10.4, p=0.001). Interview results revealed how the portal was used, and barriers to its uptake. Barriers related to poor usability and gaps in the implementation approach (e.g. limited awareness of the purpose of the portal). Usability evaluations indicated that all participants could log in with the one-time password, but most were assisted. Only 3 of 17 participants were able to send a message to the clinic. Other usability problems identified were focused on display, content, layout, functionality and navigation categories. CONCLUSIONS The use of inclusive design principles when designing patient portals is necessary for successfully engaging all patients. Our study highlights the importance of normalising inclusive designs in patient portals to ensure that priority populations such as older and CALD people are not marginalised by design. We provide recommendations to guide future design and implementation of patient portals. CLINICALTRIAL

A National Nursing and Midwifery Digital Health Capability Framework was developed in 2020 to define and complement digital health knowledge and skills for professional practice. This mixed-methods study explored nurses’ and midwives’ Framework knowledge and its applicability, types and extent of nursing and midwifery informatics roles, and barriers and enablers to working in informatics. Survey respondents reported familiarity with the Framework, with content analysis identifying three themes - informatics as part of nursing or midwifery roles, descriptions and variability of informatics roles, and the need for informatics role development and recognition. Framework knowledge can be improved through standardised and defined roles and a career pathway that includes national, organisational, local, and individual support.

Background: Australia has successfully controlled the COVID-19 pandemic. Similar to other high-income countries, Australia has extensively used telehealth services. Virtual health care, including telemedicine in combination with remote patient monitoring, has been implemented in certain settings as part of new models of care that are aimed at managing patients with COVID-19 outside the hospital setting. Objective: This study aimed to describe the implementation of and early experience with virtual health care for community management of patients with COVID-19. Methods: This observational cohort study was conducted with patients with COVID-19 who availed of a large Australian metropolitan health service with an established virtual health care program capable of monitoring patients remotely. We included patients with COVID-19 who received the health service, could self-isolate safely, did not require immediate admission to an in-patient setting, had no major active comorbid illness, and could be managed at home or at other suitable sites. Skin temperature, pulse rate, and blood oxygen saturation were remotely monitored. The primary outcome measures were care escalation rates, including emergency department presentation, and hospital admission. Results: During March 11-29, 2020, a total of 162 of 173 (93.6%) patients with COVID-19 (median age 38 years, range 11-79 years), who were diagnosed locally, were enrolled in the virtual health care program. For 62 of 162 (38.3%) patients discharged during this period, the median length of stay was 8 (range 1-17) days. The peak of 100 prevalent patients equated to approximately 25 patients per registered nurse per shift. Patients were contacted a median of 16 (range 1-30) times during this period. Video consultations (n=1902, 66.3%) comprised most of the patient contacts, and 132 (81.5%) patients were monitored remotely. Care escalation rates were low, with an ambulance attendance rate of 3% (n=5), emergency department attendance rate of 2.5% (n=4), and hospital admission rate of 1.9% (n=3). No deaths were recorded. Conclusions: Community-based virtual health care is safe for managing most patients with COVID-19 and can be rapidly implemented in an urban Australian setting for pandemic management. Health services implementing virtual health care should anticipate challenges associated with rapid technology deployments and provide adequate support to resolve them, including strategies to support the use of health information technologies among consumers.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Australia has successfully controlled the COVID-19 pandemic. Similar to other high-income countries, Australia has extensively used telehealth services. Virtual health care, including telemedicine in combination with remote patient monitoring, has been implemented in certain settings as part of new models of care that are aimed at managing patients with COVID-19 outside the hospital setting. Objective: This study aimed to describe the implementation of and early experience with virtual health care for community management of patients with COVID-19. Methods: This observational cohort study was conducted with patients with COVID-19 who availed of a large Australian metropolitan health service with an established virtual health care program capable of monitoring patients remotely. We included patients with COVID-19 who received the health service, could self-isolate safely, did not require immediate admission to an in-patient setting, had no major active comorbid illness, and could be managed at home or at other suitable sites. Skin temperature, pulse rate, and blood oxygen saturation were remotely monitored. The primary outcome measures were care escalation rates, including emergency department presentation, and hospital admission. Results: During March 11-29, 2020, a total of 162 of 173 (93.6%) patients with COVID-19 (median age 38 years, range 11-79 years), who were diagnosed locally, were enrolled in the virtual health care program. For 62 of 162 (38.3%) patients discharged during this period, the median length of stay was 8 (range 1-17) days. The peak of 100 prevalent patients equated to approximately 25 patients per registered nurse per shift. Patients were contacted a median of 16 (range 1-30) times during this period. Video consultations (n=1902, 66.3%) comprised most of the patient contacts, and 132 (81.5%) patients were monitored remotely. Care escalation rates were low, with an ambulance attendance rate of 3% (n=5), emergency department attendance rate of 2.5% (n=4), and hospital admission rate of 1.9% (n=3). No deaths were recorded. Conclusions: Community-based virtual health care is safe for managing most patients with COVID-19 and can be rapidly implemented in an urban Australian setting for pandemic management. Health services implementing virtual health care should anticipate challenges associated with rapid technology deployments and provide adequate support to resolve them, including strategies to support the use of health information technologies among consumers.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet

BACKGROUND The demand for an eHealth-ready and adaptable workforce is placing increasing pressure on universities to deliver eHealth education. At present, eHealth education is largely focused on components of eHealth rather than considering a curriculum-wide approach. OBJECTIVE This study aimed to develop a framework that could be used to guide health curriculum design based on current evidence, and stakeholder perceptions of eHealth capabilities expected of tertiary health graduates. METHODS A 3-phase, mixed-methods approach incorporated the results of a literature review, focus groups, and a Delphi process to develop a framework of eHealth capability statements. RESULTS Participants (N=39) with expertise or experience in eHealth education, practice, or policy provided feedback on the proposed framework, and following the fourth iteration of this process, consensus was achieved. The final framework consisted of 4 higher-level capability statements that describe the learning outcomes expected of university graduates across the domains of (1) digital health technologies, systems, and policies; (2) clinical practice; (3) data analysis and knowledge creation; and (4) technology implementation and codesign. Across the capability statements are 40 performance cues that provide examples of how these capabilities might be demonstrated. CONCLUSIONS The results of this study inform a cross-faculty eHealth curriculum that aligns with workforce expectations. There is a need for educational curriculum to reinforce existing eHealth capabilities, adapt existing capabilities to make them transferable to novel eHealth contexts, and introduce new learning opportunities for interactions with technologies within education and practice encounters. As such, the capability framework developed may assist in the application of eHealth by emerging and existing health care professionals. Future research needs to explore the potential for integration of findings into workforce development programs.