Examining the Relationship between Health Literacy, Health Numeracy, and Patient Portal Use.

OBJECTIVES: The objective of this study is to investigate the relationships between health literacy and numeracy (HLN) and patient portal use, measured in inpatient and outpatient settings. METHODS: Using data collected as part of a pragmatic randomized controlled trial conducted across the inpatient population of a U.S.-based academic medical center, the present study evaluated the relationships between patients' perceptions of health literacy and their skills, interpreting medical information with metrics of engagement with patient portals. RESULTS: Self-reported levels of HLN for patients in the study sample (n = 654) were not significantly associated with inpatient portal use as measured by frequency of use or the number of different inpatient portal functions used. Use of the outpatient version of the portal over the course of 6 months following hospital discharge was also not associated with HLN. A subsequent assessment of patients after 6 months of portal use postdischarge (response rate 40%) did not reveal any differences with respect to portal use and health numeracy; however, a significant increase in self-reported levels of health literacy was found at this point. CONCLUSION: While previous studies have suggested that low HLN might represent a barrier to inpatient portal adoption and might limit engagement with outpatient portals, we did not find these associations to hold. Our findings, however, suggest that the inpatient setting may be effective in facilitating technology acceptance. Specifically, the introduction of an inpatient portal made available on hospital-provided tablets may have practical implications and contribute to increased adoption of patient-facing health information technology tools.

Developing Dashboards to Address Children's Health Disparities in Ohio.

OBJECTIVES: Social determinants of health (SDoH) can be measured at the geographic level to convey information about neighborhood deprivation. The Ohio Children's Opportunity Index (OCOI) is a composite area-level opportunity index comprised of eight health domains. Our research team has documented the design, development, and use cases of a dashboard solution to visualize OCOI. METHODS: The OCOI is a multidomain index spanning the following eight domains: (1) family stability, (2) infant health, (3) children's health, (4) access, (5) education, (6) housing, (7) environment, and (8) criminal justice. Information on these eight domains is derived from the American Community Survey and other administrative datasets. Our team used the Tableau Desktop visualization software and applied a user-centered design approach to developing the two OCOI dashboards-main OCOI dashboard and OCOI-race dashboard. We also performed convergence analysis to visualize the census tracts where different health indicators simultaneously exist at their worst levels. RESULTS: The OCOI dashboard has multiple, interactive components as follows: a choropleth map of Ohio displaying OCOI scores for a specific census tract, graphs presenting OCOI or domain scores to compare relative positions for tracts, and a sortable table to visualize scores for specific county and census tracts. A case study using the two dashboards for convergence analysis revealed census tracts in neighborhoods with low infant health scores and a high proportion of minority population. CONCLUSION: The OCOI dashboards could assist health care leaders in making decisions that enhance health care delivery and policy decision-making regarding children's health particularly in areas where multiple health indicators exist at their worst levels.

Examining the Dimensionality of Trust in the Inpatient Setting: Exploratory and Confirmatory Factor Analysis.

BACKGROUND: Trust in healthcare providers is associated with important outcomes, but has primarily been assessed in the outpatient setting. It is largely unknown how hospitalized patients conceptualize trust in their providers. OBJECTIVE: To examine the dimensionality of a measure of trust in the inpatient setting. DESIGN: Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). PARTICIPANTS: Hospitalized patients (N = 1756; 76% response rate) across six hospitals in the midwestern USA. The sample was randomly split such that approximately one half was used in the EFA, and the other half in the CFA. MAIN MEASURES: The Trust in Physician Scale, adapted for inpatient care. KEY RESULTS: Based on the Kaiser-Guttman criterion and parallel analysis, EFAs were inconclusive, indicating that trust may be comprised of either one or two factors in this sample. In follow-up CFAs, a 2-factor model fit best based on a chi-squared difference test (Δχ2 = 151.48(1), p < .001) and a Comparative Fit Index (CFI) difference test (CFI difference = .03). The overall fit for the 2-factor CFA model was good (χ2 = 293.56, df = 43, p < .01; CFI = .95; RMSEA = .081 [90% confidence interval = .072-.090]; TLI = .93; SRMR = .04). Items loaded onto two factors related to cognitive (i.e., whether patients view providers as competent) and affective (i.e., whether patients view that providers care for them) dimensions of trust. CONCLUSIONS: While measures of trust in the outpatient setting have been validated as unidimensional, in the inpatient setting, trust appears to be composed of two factors: cognitive and affective trust. This provides initial evidence that inpatient providers may need to work to ensure patients see them as both competent and caring in order to gain their trust.

Differential Effects of Outpatient Portal User Status on Inpatient Portal Use: Observational Study.

BACKGROUND: The decision to use patient portals can be influenced by multiple factors, including individuals' perceptions of the tool, which are based on both their personal skills and experiences. Prior experience with one type of portal may make individuals more comfortable with using newer portal technologies. Experienced outpatient portal users in particular may have confidence in their ability to use inpatient portals that have similar functionality. In practice, the use of both outpatient and inpatient portal technologies can provide patients with continuity of access to their health information across care settings, but the influence of one type of portal use on the use of other portals has not been studied. OBJECTIVE: This study aims to understand how patients' use of an inpatient portal is influenced by outpatient portal use. METHODS: This study included patients from an academic medical center who were provided access to an inpatient portal during their hospital stays between 2016 and 2018 (N=1571). We analyzed inpatient portal log files to investigate how inpatient portal use varied by using 3 categories of outpatient portal users: prior users, new users, and nonusers. RESULTS: Compared with prior users (695/1571, 44.24%) of an outpatient portal, new users (214/1571, 13.62%) had higher use of a select set of inpatient portal functions (messaging function: incidence rate ratio [IRR] 1.33, 95% CI 1.06-1.67; function that provides access to the outpatient portal through the inpatient portal: IRR 1.34, 95% CI 1.13-1.58). Nonusers (662/1571, 42.14%), compared with prior users, had lower overall inpatient portal use (all active functions: IRR 0.68, 95% CI 0.60-0.78) and lower use of specific functions, which included the function to review vitals and laboratory results (IRR 0.51, 95% CI 0.36-0.73) and the function to access the outpatient portal (IRR 0.53, 95% CI 0.45-0.62). In comparison with prior users, nonusers also had lower odds of being comprehensive users (defined as using 8 or more unique portal functions; odds ratio [OR] 0.57, 95% CI 0.45-0.73) or composite users (defined as comprehensive users who initiated a 75th or greater percentile of portal sessions) of the inpatient portal (OR 0.42, 95% CI 0.29-0.60). CONCLUSIONS: Patients' use of an inpatient portal during their hospital stay appeared to be influenced by a combination of factors, including prior outpatient portal use. For new users, hospitalization itself, a major event that can motivate behavioral changes, may have influenced portal use. In contrast, nonusers might have lower self-efficacy in their ability to use technology to manage their health, contributing to their lower portal use. Understanding the relationship between the use of outpatient and inpatient portals can help direct targeted implementation strategies that encourage individuals to use these tools to better manage their health across care settings.

Inpatient portal clusters: identifying user groups based on portal features.

Objective: Conduct a cluster analysis of inpatient portal (IPP) users from an academic medical center to improve understanding of who uses these portals and how. Methods: We used 18 months of data from audit log files, which recorded IPP user actions, of 2815 patient admissions. A hierarchical clustering algorithm was executed to group patient admissions on the basis of proportion of use for each of 10 IPP features. Post-hoc analyses were conducted to further understand IPP use. Results: Five cluster solutions were developed for the study sample. Our taxonomy included users with high levels of accessing features that were linked to reviewing schedules, results, tutorials, and ordering food. Patients tended to stay within their clusters over multiple admissions, and the clusters had differences based on patient and clinical characteristics. Discussion: Distinct groups of users exist among IPP users, suggesting that training on IPP use to enhance patient engagement could be tailored to patients. More exploration is also needed to understand why certain features were not used across all clusters. Conclusions: It is important to understand the specifics about how patients use IPPs to help them better engage with their healthcare. Our taxonomy enabled characterization of 5 groups of IPP users who demonstrated distinct preferences. These results may inform targeted improvements to IPP tools, could provide insights to improve patient training around portal use, and may help care team members effectively engage patients in the use of IPPs. We also discuss the implications of our findings for future research.