Date of Degree
Doctor of Public Health (DPH)
Health Policy and Management
Patient portals, Clinician support for patient self-management, patient activation, patient self-management
This dissertation was designed to: (1) explore variations in clinicians’ views about patient self-management, (2) explore variation in patient activation and (3) explore variation in patients’ and their primary care physicians’ characteristics in the use of a patient portal and the main effects of patient activation and primary care physician support for patient self-management on portal use in an understudied closed multi-specialty ambulatory center. The main hypothesis is that primary care physician support for patient self-management will be an effect modifier on the association between patient activation and patient portal use.
The New York Hotel Trades Council and Hotel Association of New York City, Inc. Health Center, Inc. (HCI) provides multi-specialty ambulatory services to unionized hotel workers, retirees and their families (~90,000 lives) at one of four health centers located in Brooklyn, Midtown Manhattan, Harlem and Queens. Services include all primary and specialty care, radiology, laboratory and pharmacy services. All providers are salaried employees. Patients using the health centers receive are treated by care teams that can include general medicine and specialist physicians, nurses, medical assistants, pharmacists, physical therapists and technicians (radiology, pharmacy and laboratory). HCI conducted surveys of all salaried clinicians from July through September of 2015 using the commercially licensed CS-PAM®. HCI also conducted surveys of patients using the commercially licensed PAM-10® from September 2015 to February 2016. Both of these surveys are available for licensing through Insignia, Inc. who scores the surveys using a proprietary scoring system. HCI introduced a patient portal in 2014 and offered all patients the opportunity to enroll and use the portal through a combination of mailings, in center advertising and information sessions. HCI offers six features: viewing laboratory results, requesting an appointment, viewing the medical record, viewing the patient’s demographics, requesting a prescription refill and messaging the provider.
Using de-identified clinician and patient data supplied by the New York Hotel Trades Council and Hotel Association of New York City, Inc. Health Center, Inc., analyses were conducted to (1) describe clinician characteristics associated with support of patient self-management (using CS-PAM® survey results), (2) describe patient characteristics associated with patient activation (using PAM-10® survey results) and (3) explore whether either of these two latent variables and/or patient and primary care physician characteristics were associated with the use of a patient portal and if primary care physician support for patient self-management modified the association between patient activation and patient portal use. CS-PAM® and PAM-10® levels were assessed for statistical significance using a chi-square test. CS-PAM® and PAM-10® scores were assessed for statistical significance using t-tests and ANOVA. Crude and adjusted logistic regression modes were run to assess the association of clinician and patient characteristics with survey levels (high vs. medium and low for clinicians and level 4 vs. levels 1, 2, or 3 for patients). Crude and adjusted linear regression models were run to assess the association of clinician and patient characteristics with survey scores. To reduce the risk of making a type 2 error due to oversaturation, we used backward stepwise linear and logistic regression for the clinician analyses with α=.02 cutoff for retaining variables in the model. We assessed statistical significance of each patient and primary care physician variable on patient portal use using a chi-square test and with frequency of use with a t-test or ANOVA. We used univariate and multivariate logistic regression to assess the crude and adjusted association of each patient and provider characteristic with ever or never having used the portal and we used a t-test or ANOVA to assess statistical significance of portal use of each of the six portal features (used or never used). In multivariate analysis, we estimated the degree of clustering by calculating and intra-class correlation to account for observed clustering of multiple patients with individual primary care providers using a General Estimating Equation (GEE). Finally, we added the interaction term CS-PAM® level * PAM-10® level to the multivariable model to assess joint effects.
CS-PAM® scores were significantly lower for Specialty MDs and Technicians compared to General Medicine MDs and those clinicians employed for more than 11 years. The odds of scoring high vs. medium or low among clinicians were also significantly lower for Specialty MDs and Technicians and for those employed for 11 or more years. PAM-10® scores were significantly lower for those patients who were over 50 compared to those under 35. Those patients surveyed in Brooklyn scored significantly higher than those in Midtown Manhattan and those with circulatory diseases scored significantly lower than those with Endocrine disease. The odds of scoring level 4 vs. levels 1, 2, or 3 were significantly lower for those over age 65 and for those with circulatory diseases. Those patients surveyed in Brooklyn had significantly higher odds of scoring level 4 than those in Midtown Manhattan.
The patient portal was used by 8.5% of the study population. The odds of using the patient portal was significantly lower for those over the age of 35, decreasing with each age category. In the multivariable analysis, crude results showed that those surveyed in Midtown Manhattan, Harlem and Queens were significantly less likely to use the portal than those in Brooklyn. Patients who had more than 11 years in the plan were also significantly less likely to use the portal; when assessing primary care clinician characteristics, patients whose primary care physician worked in Midtown Manhattan, Harlem or Queens were significantly less likely to use the portal than those whose primary care physician worked in Brooklyn. In the adjusted model, those patients with primary care physicians who worked in Harlem and who were aged 35 or older were significantly less likely to use the patient portal. We did not find evidence of joint effects between patient activation and physician support for patient self-management.
While the results do not show evidence that patient activation or physician support for patient self-management are individually or jointly significantly associated with patient portal use, findings suggest approaches that HCI can take to improve patient activation, clinician support for patient self-management and patient portal use. Specifically, differences in results between older and younger clinicians suggest that older clinicians might benefit from training and coaching designed to engage patients and improve clinician support. Location differences suggest that there may be some underlying operational differences or patient or clinician characteristics that could account for more significant positive findings in the Brooklyn health center. Further studies might identify these differences and offer insight into results in other locations. Low usage of the patient portal could be explored qualitatively to identify patient and physician views of the features, ease of use or general applicability of the portal to the physician-patient relationship.
This study adds to the literature that has shown mixed results in patient activation and clinician support for patient self-management. Further exploration of the relationship between patient portal use and patient engagement might reveal opportunities for improving both. Understanding factors such as organizational readiness and intent, marketing, and views of and use of technology by both patients and clinicians would further add to the body of knowledge needed to assess the success of patient portals.
Greenspan, Linda Anne, "EXPLORING THE MAIN EFFECTS OF PATIENT ACTIVATION AND PROVIDER SUPPORT FOR PATIENT SELF-MANAGEMENT ON PATIENT PORTAL USE" (2019). CUNY Academic Works.