Never let a pandemic go to waste: Applying an equity-focusedquality improvement framework to close gaps in patient portalactivation

ABSTRACT

Background Studies show that historically marginalized populations, such as racial/ethnic minorities, thoseliving in poverty, and those with limited English prociency are less likely to utilize patient portals that arebecoming increasingly integrated into clinical care. In March 2020, nearly all in-person clinical operations forour large primary care network were ordered to cease due to COVID-19. In order to pivot quickly whileensuring our most vulnerable children and families were not left behind, we leveraged an equity-focusedquality improvement (QI) framework. As we rolled out increased telehealth capacity we concurrently sought toreduce existing disparities in patient portal activation and utilization. Methodology We executed ourintervention in a large primary care network that cares for over 270,000 children in southeastern PA/NJ,including over 90,000 Medicaid-insured children. To determine baseline data, we queried our data warehouseand identied the patient portal activation status of all patients with a primary care visit between January 2018 - December 2019. We then stratied the data by sociodemographic variables race/ethnicity, insurance type(private or government), preferred language, and the percent of households in their neighborhoods(approximated by census tract) living below the federal poverty line. This analysis revealed disparities inactivation status, which prompted assembly of a multidisciplinary task force to ensure that barriers werequickly removed for families to access telehealth. We used an equity-focused QI approach to carry out cyclesof sequential interventions. Discussion During the two-year pre-intervention period, nearly 300,000 patientswere seen in our primary care practices. Notable disparities were observed across all four demographiccategories examined (Figure 1). Differential patient portal activation status was noted by race/ethnicity (69%among non-Hispanic white vs. 42% among non-Hispanic black patients);insurance types (67% amongprivately-insured vs. 42% among Medicaid patients);language (60% among English speaking vs. 22% among ofnon-English speaking patients);and poverty (66% in the lowest poverty neighborhoods vs. 38% in the highestpoverty neighborhoods). After iterative innovative interventions to remove technological and process barriersto portal utilization, rates of activation for the entire primary care population increased by 16% overall.Additionally, we observed marked improvement in activation rates among Medicaid-insured children (26%increase);among Spanish-speaking families (36% increase), and African-American families (23% increase).Conclusion We demonstrated signicant narrowing in baseline disparities in electronic patient portalutilization by race, ethnicity, insurance type, and language. This improvement was accomplished through useof an equity-focused QI framework that resulted in interventions focused on removing as many barriers aspossible and creating a value-add for patients. Next steps include demonstrating sustained improvement,evaluating patient satisfaction, and ascertaining which of our interventions were most contributory to our improvement.