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When traditionally inseparable services are separated by technology: the case of patient portal features offered by primary care providers

  • Original Article
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Health Systems

Abstract

Health-care services have traditionally been provided and consumed simultaneously, as exemplified by in-person patient visits to primary care providers (PCPs), where clinical assessment and treatment are provided and consumed face-to-face. Technological intermediation is changing this traditional assumption, however, as patient-centric technologies, such as patient portals, are creating service separation opportunities. While service separation facilitated by patient portals may bring welcome changes to access, efficiency, and clinical outcomes, usage of patient portals by health-care consumers remains low. Suboptimal demand-side usage of patient portals, especially at the primary care level, could have significant negative implications for patient-centered policy initiatives predicated on patient empowerment and engagement. This paper contributes to this important policy context by reporting findings from a study designed to assess patient perceptions associated with hypothetical patient portal features offered by PCPs and potential subsequent impacts to PCP loyalty and switching propensity. We find that patient portal features focused on back-office (clinical) self-service capabilities (such viewing health records or summaries from prior visits) are perceived positively by consumers, but, interestingly, clinical digital communication and collaboration features (such as online video consultations with physicians) do not have significant perception impacts. These findings suggest that patient portals may act as a complement to health-care service delivery, while substitution for clinical in-person interactions may not be viewed positively.

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Notes

  1. Terms from the self-service literature (e.g., Bitner et al, 2000) where high-touch suggests a greater degree of in-person interactions and high-tech suggests a greater degree of technology intermediation.

  2. According to the HIMSS Analytics data collected via nationwide survey in 2013, 4634 of 29,289 (15.82%) surveyed ambulatory care providers had a live and operational patient portal.

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Acknowledgements

Partial funding for this research was provided by the Mayo Clinic Centre for the Science of Health Care Delivery (CSHCD) and the W. P. Carey School of Business, Arizona State University.

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Correspondence to Aaron Baird.

Appendices

Appendix A:

Survey Items

The following survey was administered by a survey research firm using an online panel of U.S. residents. Only those 18 and older who specified having a PCP were allowed to complete the survey.

The following definitions were provided to respondents:

A patient portal is a free and secure Website that provides patients of a doctor’s office (PCP) direct online access to their own health-care information at that medical practice. With a patient portal, patients have 24/7 secure Internet access to relevant information and health services at the practice.

A PCP is a doctor or group of doctors and health professionals (such as a nurse practitioners and/or physician assistants) who serve as the patient’s first point of entry into the health-care system and as the continuing focal point for all needed health-care services. Primary care practices provide health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis, and treatment of acute and chronic illnesses in a variety of health-care settings (e.g., office, inpatient, critical care, long-term care, home care, day care and so on). Primary care practices are generally located in the community of the patients, thereby facilitating access to health care while maintaining a wide variety of specialty and institutional consultative and referral relationships for specific care needs.

The following screening and adoption intention questions were included on the survey:

Screening questions

  • Are you 18 years of age or older? Yes; No

  • Do you have a PCP? Yes, a General Practitioner; Yes, a Family Practitioner (MD or DO); Yes, an Internist; Yes a Geriatrician; Yes, an Obstetrician/Gynecologist; Yes, but I am not sure what type (or another type than what is listed here); No, I do not have a PCP for myself, but I take my children to a Pediatrician; No, I do not have a PCP

Feature sets

Each respondent saw only one of the following four sets of features and then responded to the questions listed below. They were instructed as follows: ‘Assume that your Primary Care Provider (PCP) was to offer a free, secure, online Patient Portal that allowed you to …’

  • Feature Set A: Front-office self-service

    • ° Request appointments

    • ° View billing statements and history

    • ° Maintain a personal profile (contact information, insurance information, dependent information and so on)

  • Feature Set B: Everything in Feature Set A (Front-office self-service)+Back-office self-service

    • ° View medical test results (laboratory, radiology, and/or pathology)

    • ° Maintain lists of medical conditions, allergies, immunizations, and/or prescriptions

    • ° View health records or summaries from past office visits

  • Feature Set C: Everything in Feature Set A (Front-office self-service)+Digital communication and collaboration

    • ° Send/receive non-urgent, secure e-mails/messages to doctor/provider

    • ° Keep track of your own information on a regular basis (such as weight, blood pressure, glucose readings, and/or peak flow measurements) and share information with physician

    • ° Online video consultations with physician (a.k.a. virtual office visit)

  • Feature Set D: Everything in Feature Sets A, B, and C

    • ° (all features listed)

DVs questions related to feature sets (Taylor & Todd, 1995; Oliver, 1999; Jones et al, 2002; Burnham et al, 2003; Gustafsson et al, 2005)

  • (ExpSat) How satisfied or dissatisfied would you be with this set of patient portal functions? 1=Very dissatisfied; 2=Dissatisfied; 3=Somewhat dissatisfied; 4=Neutral; 5=Somewhat satisfied; 6=Satisfied; 7=Very satisfied

  • (ExpUsage) How often would you expect to use these patient portal functions? 1=Never; 2=Less than once a month; 3=Once a month; 4=2–3 times a month; 5=Once a week; 6=2–3 times a week; 7=Daily

  • (PCPLyl) How would your loyalty to your PCP be affected if they offered a patient portal with these functions? 1=I would be extremely less loyal; 2=I would be much less loyal; 3=I would be somewhat less loyal; 4=No change; 5=I would be somewhat more loyal; 6=I would be much more loyal; 7=I would be extremely more loyal

  • (PCPRmn) How likely would you be to remain a patient of your current PCP (and not switch to another PCP) if your current PCP offered a patient portal with these functions? 1=Very unlikely to remain a patient; 2=Unlikely to remain a patient; 3=Somewhat unlikely to remain a patient; 4=Undecided; 5=Somewhat likely to remain a patient; 6=Likely to remain a patient; 7=Very likely to remain a patient

PCP: General questions (Safran et al, 1998; Verhoef et al, 2002)

  • (PCPRelAge) How long has your PCP been your primary care health provider? 1=Less than 1 year; 2=1–2 years; 3=3–5 years; 4=More than 5 years

  • (PCPUtil) How many times have you visited your PCP in the past 6 months? 1=None; 2=1–2 times; 3=3–5 times; 4=More than 5 times

  • (PCPUtilOther) How many times have you visited health-care providers other than your PCP in the past 6 months? 1=None; 2=1–2 times; 3=3–5 times; 4=More than 5 times

  • (PCPPatPortalOffered) Does your PCP currently offer a patient portal for you to use? 0=No; 1=Yes

Patient Portal Adoption Intentions (based on Venkatesh et al, 2003)

  • (PCPPatPortalAI) Which of the following best describes your use of a patient portal? 1=I do not plan to use a patient portal in the future; 2=I would like to use a patient portal, if offered; 3=I currently use a patient portal.

PCP: Satisfaction with Clinician: (PCPSatClin) All questions answered using a 7-point Likert scale ranging from 1=Very Dissatisfied to 7=Very satisfied (Harris, Swindle et al, 1999)

  • Knowing who I am*

  • Apologizing if I have to wait*

  • Letting me tell my story

  • Listening carefully

  • Showing interest in me as a person

  • Warning me during the physical exam

  • Telling me what he/she found during the exam

  • Encouraging me to ask questions

  • Using words I can understand

  • Explaining my problems

  • Explaining how to take my medicine

  • Discussing options with me

  • Making sure I learn about my test results

  • Length of time spent with the clinician

  • Personal manner of the clinician

  • Technical skills of the clinician

  • Explanation of what was done for me

NFI: All questions answered using a 7-point Likert scale ranging from 1=Strongly disagree to 7=Strongly agree (Dabholkar, 1996; Dabholkar & Bagozzi, 2002):

  • Human contact in providing services makes the process enjoyable for the consumer

  • I like interacting with the person who provides the service

  • Personal attention by the service employee is not very important to me*

  • It bothers me to use a machine when I could talk to a person instead.*

TTA: All questions answered using a 7-point Likert scale ranging from 1=Strongly disagree to 7=Strongly agree (based on Liang & Xue, 2010):

  • Using secure online portals would invade my privacy*

  • My personal information collected by a secure online portal could be misused

  • My personal information collected by a secure online portal could be subject to unauthorized secondary use

Technology Readiness Index: Innovativeness (TRIINN): All questions answered using a 7-point Likert scale ranging from 1=Strongly disagree to 7=Strongly agree (based on Parasuaraman, 2000):

  • Other people come to me for advice on new technologies*

  • It seems that my friends are learning more about the newest technologies than I am*

  • In general, I am among the first in my circle of friends to acquire new technology when it appears

  • I can usually figure out new high-tech products and services without help from others

  • I keep up with the latest technological developments in my areas of interest

  • I enjoy the challenge of figuring out high-tech gadgets

  • I find that I have fewer problems than other people in making technology work for me

Demographics and health perceptions:

  • Gender: 0=Male; 1=Female

  • Age: Under 20, 20–29, 30–39, 40–49; 50–59; 60–69; 70 or older

  • Annual household income: I do not wish to disclose; Less than $25,000; $25,000–$49,000; $50,000–$99,999; More than $100,000

  • How many people live in your household? 1; 2; 3; 4; 5, or more

  • Were you born in the U.S.? No; Yes

  • What is your race? White/Caucasian; African American; Hispanic; Asian; Native American; Pacific Islander; Other; I do not wish to disclose

  • What is the highest level of education you have completed? Less than High School; High School/GED; Some College; 2-year College Degree; 4-year College Degree; Masters Degree; Doctoral Degree; Professional Degree (JD, MD)

  • What is your employment status? Employed full-time; Employed part-time; Self-employed; Retired; Unemployed; Disabled; Other

  • Do you have medical insurance coverage? No; Yes

  • In general, would you say your health is: Poor; Fair; Good; Very Good; Excellent

  • Are you currently under the care of a doctor or medical provider for: diabetes, hypertension, arthritis-related conditions, high cholesterol, asthma, heart disease, depression, cancer, or a disability? No; Yes

  • Do you currently care for a family member or friend with: diabetes, hypertension, arthritis-related conditions, high cholesterol, asthma, heart disease, depression, cancer, or a disability? No; Yes

* These items were dropped from the final analysis because of low reliability.

Appendix B:

Supporting Information

Table B1

Table B1 Correlations

Table B2

Table B2 Factor analysis (of multi-item scales)

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Baird, A., Raghu, T., North, F. et al. When traditionally inseparable services are separated by technology: the case of patient portal features offered by primary care providers. Health Syst 3, 143–158 (2014). https://doi.org/10.1057/hs.2013.13

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