The Effect of a Patient Portal With Electronic Messaging on Patient Activation Among Chronically Ill Patients: Controlled Before-and-After Study

1]. Such conditions currently account for between 70% and 80% of health care costs in these regions. To ease the burden of growing demand and restricted resources, health care providers have begun developing and implementing practices to engage the most underutilized asset of health care—the patient—in the care process. By engaging chronically ill patients in monitoring and managing their health, care providers can shift to the patients some aspects of the work previously performed by professionals. However, diminishing resource use is not the only expected benefit of activating patients. Activated patients who are knowledgeable, skilled, and confident in the self-management of their condition are shown to engage in preventive behavior by following care recommendations and a healthy lifestyle [24]. Engaging patients in self-management of their conditions may, therefore, also improve health outcomes and quality of care.

A growing body of research shows that sharing information regarding the state and goals of care and improving access to communication with a health care professional can strengthen a patient’s active role in the management of their own condition [57]. Along with the recent progress in information technology, new channels of communication between the patient and the professional, and opportunities for the care providers to effectively share information on the care process with the patient have emerged. One of the outputs of this progress is the electronic patient portal which offers the patient access to the health information that is documented and managed by a health care institution [7,8].Typically, the available information consists of the medical records of the patient, but other services and applications, such as electronic messaging with a health care professional, medication refills, and access to medical information, may also be offered [8]. Although previous studies [9,10] have shown positive effects of access to electronic patient portals on patient activation (knowledge, skills, and confidence in managing one’s condition), further empirical evidence is still required [2,8]. Moreover, little is known of the contextual factors that may promote or diminish the effect of patient portals and other self-management interventions.

We address 2 essential factors that may promote or dilute the effect of self-management interventions; namely, the level of a patient’s activation when entering an intervention and the temporal proximity of a diagnosis. Patient activation may have an impact on self-management intervention outcomes, especially when the intervention requires some level of patient participation. Temporal proximity of a diagnosis is related to a patient’s perception of their health and the consequential interest in managing their health. The health belief model by Rosenstock and colleagues [11] hypothesizes that a threat perceived by the patient of falling ill motivates health-related action if the patient believes that they may reduce the perceived threat. A strong indication of falling ill, even when the symptoms are mild, is the diagnosis made by a health care professional: “…from a patient’s perspective, [a diagnosis] is the starting point for an altered life situation” [12]. In this study, we analyzed the independent effect of time since a patient’s new diagnosis on patient activation and the moderating effect that the temporal proximity of a diagnosis may have on the activating effect of a patient portal. The more severe the disease is, the more its onset will affect patients’ attitudes toward managing their health [13]. In this study, we limited the analysis of time since diagnosis to diagnoses considered severe (eg, cancer) in contrast to diagnoses considered less severe (eg, hypertension).

This paper describes the results of a controlled before-and-after study in which the effect on patient activation of a simple patient portal with access to personal clinical information and electronic messaging with clinicians was examined. In addition, we assessed the effects of patient activation at baseline and time since severe diagnosis on change in patient activation. The study was conducted among the chronically ill patients in public primary care in a medium-sized town in Finland (approximately 68,000 citizens). Because it has been suggested that the benefits of a patient portal apply to all regular primary care customers, we did not restrict study participation on the basis of specific diagnoses, but instead based it on a professional’s perception of the chronic, but treatable, nature of a patient’s condition.


Study Setting, Participants, and the Intervention

This was a controlled before-and-after study conducted in Finnish public primary care. Patients visiting 1 of the 10 health centers in the town of Hämeenlinna during the recruitment phase from October 2011 to March 2012 were considered potential study participants. To study the impact of a patient portal among those most likely to become users of such a service in the future, the following eligibility criteria were applied: (1) age at least 18 years, (2) at least 2 treatable health conditions assessed by a health professional, (3) bank identifiers (electronic credentials for online authentication provided by their bank) and access to the Internet, (4) willing and able, both according to themselves and to a health care professional, to engage in using the portal.

The eligible patients were approached during their visits to primary health care facilities. The nurses and doctors were advised to consider each patient as a potential participant. Once a patient was found eligible, invited to participate, and showed interest in taking part in the study, they were allocated either to the intervention group or the control group on the basis of their date of birth. Patients born on odd dates were assigned to the intervention group and patients born on even dates were assigned to the control group. The intervention group received immediate access to the patient portal and participants in the control group were to receive delayed portal access after 6 months. Ethical approval was granted by the ethical board of the local authority (Pirkanmaa Hospital District). Patients who returned the informed consent to participate were included in the study, whereas patients who did not return the informed consent were considered to have declined to participate (Figure 1).

Once a patient enrolled in the study, they formed a care plan together with a health care professional. The plan was personally tailored for each patient to holistically care for their health and to involve them in the planning of their own health care. Although a care plan was created for all study participants, only the patients in the intervention group were given online access to their care plan through the portal. Patients in the control group received a printed copy of their plan. Other features of the patient portal were access to (1) customer’s own patient records provided and maintained by the health care provider with diagnoses of chronic illnesses and permanent medication prescriptions (Figure 2), (2) laboratory results with statements from a health care professional, (3) vaccination history, and (4) electronic messaging with a health care professional. The names of diagnoses, medicines, and laboratory results were linked to relevant additional information in the online medical information service, Health Library [14], administered by The Finnish Medical Society, Duodecim. The users could visit the portal through the care provider’s webpages. For secure identification, the patient used their bank identifiers to sign in. Whenever the customer received a message or a laboratory result through the portal, a text message reminder was sent to their mobile phone. A reminder was also sent if changes to their next follow-up appointment were made.

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