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We share our experience on the strategies implemented for identifying and enrolling participants in a randomized remote implementation trial. We aimed to evaluate the effectiveness of various digital and traditional screening and outreach methods in participant enrollment. This study focuses on understanding the success and challenges associated with different approaches to patient engagement.

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Maintaining a healthy weight postintentional weight loss is crucial for preventing chronic health conditions, yet many regain weight postintervention. Electronic health record (EHR) portals offer a promising avenue for weight management interventions, leveraging patient-primary care relationships. Our previous research demonstrated that coaching alongside self-monitoring improves weight maintenance compared to monitoring alone. Integrating weight management into routine clinical practice by training existing staff could enhance scalability and sustainability. However, challenges such as inconsistent staff qualifications and high coach turnover rates could affect intervention effectiveness. Standardizing services, training, and coaching continuity seem crucial for success. To report on developing, testing, and evaluating an EHR-based coaching training program for clinical staff, guided by an implementation tool for the MAINTAIN PRIME study. Conducted across 14 University of Utah primary care sites, we developed, tested, and evaluated a coaching training for clinical staff. Guided by a planning model and the Predisposing, Enabling, and Reinforcing (PER) tool, stakeholders actively participated in planning, ensuring alignment with clinic priorities. All clinical staff were invited to participate voluntarily. Evaluation measures included staff interest, training effectiveness, confidence, and readiness. Data collection utilized REDCap, with survey results analyzed using descriptive statistics. Despite increased clinical workload and reassignments posed by coronavirus disease 2019, we were able to train 39 clinical staff, with 34 successfully coaching patients. Feedback indicated high readiness and positive perceptions of coaching feasibility. Coaches reported satisfaction with training, support, and enjoyed establishing connections with patients. The PER strategies allowed us to implement a well-received training program found effective by primary care coaches.

This report describes a training program for medical staff like nurses and medical assistants. The goal is to teach them how to coach patients through an online portal to help them keep their weight off after making healthy lifestyle changes. We worked with different clinic groups and used a planning tool called PER worksheet (predisposing, enabling, and reinforcing) to set up the training program. From September 2021 to March 2023, we offered the training in 14 clinics, and most interested staff completed it. The results showed that the training worked well. People who took part felt they learned enough to coach patients and felt ready to coach. They liked the training and found it helpful. This study suggests that we can teach coaching skills in just four hours of training and that ongoing support and mentorship are important to the trained coaches. Furthermore, this training set-up allows new staff to be trained as they join, which is especially important in places where staff changes frequently. Overall, using the PER tool enabled us to create a training program that staff can use in outpatient clinics to help patients improve their weight management.

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Background: In an increasing number of countries, patients are given online record access (ORA) to their clinical notes ("open notes"). In many places, psychotherapy notes are exempt, even if patients explicitly wish to read them. Previous research suggests that psychotherapists (PTs) have reservations that are not yet fully understood. Objective: To investigate the attitudes and perceived effects of open notes on psychotherapeutic care, patients, and individual psychotherapeutic practice in Germany. Methods: Psychological and medical therapists were invited to participate in a national online survey. Sociodemographic characteristics such as gender, age, professional group, and psychotherapeutic school were gathered. Descriptive statistics were used to analyze the 51-item survey. Results: 129 PTs completed the survey. Only a small proportion of respondents (30 out of 129, 23.3%) suspected that open notes would improve the efficiency of psychotherapeutic care. On the one hand, participants assumed that patients gain more control over their treatment (59 out of 129, 45.7%) and are better able to remember therapy goals (55 out of 129, 42.6%), although this was considered unlikely to lead to greater engagement in the therapy process (94 out of 129, 72.9%). On the other hand, PTs expected patients to misunderstand their notes, feel offended (98 out of 129, 76.0%), and approach them with questions (107 out of 129, 82.9%) or requests for changes (94 out of 129, 72.9%). The respondents also anticipated being less honest when writing (95 out of 129, 73.6%) and reported they needed more time for documentation (99 out of 129, 76.7%). A meaningful use of open notes for working with relatives was envisaged (101 out of 129, 78.3%). Conclusion: PTs in Germany tend to have a negative attitude towards patients' ORA on open notes. Further research on clinical efficacy and feasibility is necessary to demonstrate whether open notes add value in the context of psychotherapy.

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Objective: The goal of this research was to demonstrate the efficacy of telemedicine via design, implementation and evaluation of a web-based remote patient monitoring system (WB-RPMS) across the tertiary/university teaching hospitals in a developing country Nigeria, as a tool to continue to expand access to an affordable and resilient tertiary healthcare system through the challenging times of the COVID-19 pandemic or any future disruptions. Methods: This research employed an agile and human-centred design thinking philosophy, which saw the researchers iteratively collaborate with clinicians across the system development value chain. It also employed qualitative and quantitative research methods for new system evaluations. After the system's development, a 20-patient sample was randomly selected from members of the National Youth Service Corp to evaluate the WB-RPMS Patient Portal for usability and user experience through a survey based on the system usability scale. Again, the COREQ standards for reporting research result were adopted for this study. Results: The evaluation of the WB-RPMS Patient Portal by a select patient sample showed that 95.0% of the respondents believed that they would like to use the system frequently. It was also discovered that 90.0% of all respondents also indicated that they found the Patient Portal to be simple; 85.0% of the respondents believed and indicated that the WB-RPMS Patient Portal was easy to use. Conclusions: The result of the usability evaluation of the developed WB-RPMS Patient Portal showed that it was well received by the select patient sample and by the clinicians who participated in the development process. In fact, the performance of the system shows that it has the potential to remotely support and sustain improved access to affordable healthcare for outpatients in developing countries even during times of uncertainties and disruptions as recently occasioned by COVID-19 pandemic.

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BACKGROUND: Community health centers (CHCs) are safety-net health care facilities in the United States that provide care for a substantial number of low-income, non-English speaking adults with type 2 diabetes (T2D). Whereas patient portals have been shown to be associated with significant improvements in diabetes self-management and outcomes, they remain underused in CHCs. In addition, little is known about the specific barriers to and facilitators of patient portal use in CHCs and strategies to address the barriers. OBJECTIVE: The objectives of this qualitative study were to explore the barriers to and facilitators of the use of patient portals for managing diabetes in 2 CHCs from the perspective of adults with T2D and clinicians (community health workers, nurses, nurse practitioners, and physicians) and to make recommendations on strategies to enhance use. METHODS: A qualitative description design was used. A total of 21 participants (n=13, 62% clinicians and n=8, 38% adults with T2D) were purposively and conveniently selected from 2 CHCs. Adults with T2D were included if they were an established patient of one of the partner CHCs, aged ≥18 years, diagnosed with T2D ≥6 months, and able to read English or Spanish. Clinicians at our partner CHCs who provided care or services for adults with T2D were eligible for this study. Semistructured interviews were conducted in either Spanish or English based on participant preference. Interviews were audio-recorded and transcribed. Spanish interviews were translated into English by a bilingual research assistant. Data were collected between October 5, 2022, and March 16, 2023. Data were analyzed using a rapid content analysis method. Standards of rigor were implemented. RESULTS: Themes generated from interviews included perceived usefulness and challenges of the patient portal, strategies to improve patient portal use, and challenges in diabetes self-management. Participants were enthusiastic about the potential of the portal to improve access to health information and patient-clinician communication. However, challenges of health and technology literacy, maintaining engagement, and clinician burden were identified. Standardized implementation strategies were recommended to raise awareness of patient portal benefits, provide simplified training and technology support, change clinic workflow to triage messages, customize portal notification messages, minimize clinician burden, and enhance the ease with which blood glucose data can be uploaded into the portal. CONCLUSIONS: Adults with T2D and clinicians at CHCs continue to report pervasive challenges to patient portal use in CHCs. Providing training and technical support on patient portal use for patients with low health literacy at CHCs is a critical next step. Implementing standardized patient portal strategies to address the unique needs of patients receiving care at CHCs also has the potential to improve health equity and health outcomes associated with patient portal use.

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BACKGROUND: Logic models graphically present the socio-technical components of a variety of 'programs' such as educational programs. They show the underlying logic and assumptions of how a program is supposed to work. We suggest that they can be used to describe the mechanisms of complex socio-technical health IT interventions. OBJECTIVE: To assess the suitability of logic models to describe cause-effect chains of health IT. RESULTS: We are currently conducting an integrative review of the impact of patient portals on patient outcomes. We extracted the following elements of logic models from the found publications: resources, activities, output, outcome, and impact. These factors are then used to populate the logic model and form a structured graphical representation of the evidence. Until now, all the evidence we found could be fit into the logic model. The logic model was able to accommodate diverse types of evidence. CONCLUSION: Logic models seem to be suitable for representing evidence on the impact of health IT.

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This study aims to assess the value of a help desk in a Personal Health Record (PHR) for monitoring and improving PHR functionalities and processes. Through analysis of 327 help desk tickets categorized by users as telemedicine and PHR requests, we identified four main gaps: information and feedback, access to clinical documents, usability, and ubiquity. The tickets highlighted end users' needs such as timely feedback, contextual information, effective communication, and ease of access to clinical documentation. These findings were crucial for initiating improvement cycles for various functionalities and processes within the PHR.

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BACKGROUND: The NORDeHEALTH project studies patient-accessible electronic health records (PAEHRs) in Estonia, Finland, Norway, and Sweden. Such country comparisons require an analysis of the sociotechnical context of these services. Although sociotechnical analyses of PAEHR services have been carried out in the past, a framework specifically tailored to in-depth cross-country analysis has not been developed. OBJECTIVE: This study aims to develop and evaluate a method for a sociotechnical analysis of PAEHRs that advances a framework for sociotechnical analysis of eHealth solutions first presented by Sittig and Singh. This first article in a series presents the development of the method and a cross-country comparison of the contextual factors that enable PAEHR access and use. METHODS: The dimensions of the framework for sociotechnical analysis were thoroughly discussed and extended in a series of workshops with international stakeholders, all being eHealth researchers focusing on PAEHRs. All countries were represented in the working group to make sure that important national perspectives were covered. A spreadsheet with relevant questions related to the studied services and the various dimensions of the sociotechnical framework was constructed and distributed to the 4 participating countries, and the project participants researched various national sources to provide the relevant data for the comparisons in the 10 sociotechnical dimensions. RESULTS: In total, 3 dimensions were added to the methodology of Sittig and Singh to separate clinical content from features and functions of PAEHRs and demonstrate basic characteristics of the different countries regarding national and regional steering of health care and information and communications technology developments. The final framework contained the following dimensions: metadata; hardware and software computing infrastructure; features and functions; clinical content shared with patients; human-computer interface; people; workflow and communication; the health care organization's internal policies, procedures, and culture; national rules, regulations, and incentives; system measurement and monitoring; and health care system context. The dimensions added during the study mostly concerned background information needed for cross-country comparisons in particular. Several similarities were identified among the compared countries, especially regarding hardware and software computing infrastructure. All countries had, for example, one national access point, and patients are provided a PAEHR automatically. Most of the differences could be identified in the health care system context dimension. One important difference concerned the governing of information and communications technology development, where different levels (state, region, and municipality) were responsible in different countries. CONCLUSIONS: This is the first large-scale international sociotechnical analysis of services for patients to access their electronic health records; this study compared services in Estonia, Finland, Norway, and Sweden. A methodology for such an analysis was developed and is presented to enable comparison studies in other national contexts to enable future implementations and evaluations of PAEHRs.

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Background: Children's Health Ireland (CHI), who govern and operate acute paediatric services for the greater Dublin area, are also the client for the new children's hospital project which will be Ireland's first fully digital hospital. Design, development and implementation of digital solutions has been prioritised by the National Strategy for Children's Nursing to transform and accelerate nurse-led services. Aim: The aim of this phase of a larger study was to explore the perspectives and opinions of key stakeholders on the requirements, benefits, and challenges for a bespoke patient portal, with a specific focus on the ANP-led Neurosurgical Service and children and young people with hydrocephalus. Methods: Interviews and focus groups were held online, and data were recorded and transcribed verbatim. Twenty-three participants across eight sites were interviewed including parents, healthcare professionals, experts and management/administrators. Data were analysed using Braun and Clarke's (2006) framework. Results: Four key findings and considerations were identified in relation to patient portals in general and their interoperability with Electronic Health Records, as well as a bespoke patient portal for children and young people with hydrocephalus. Conclusions: The availability of a patient portal for children and young people with hydrocephalus would be hugely advantageous to their parents, the ANP led nursing service, and healthcare professionals in both the neurosurgical service at CHI and at regional healthcare organisations as well as for administration, research, and reports. More timely access to health data as well as a consistent log of information and communications between patients and healthcare professionals, would be more efficient and effective than current practices.The augmented ANP-led Neurosurgical Nursing Service at CHI will act as a pilot project from which other nurse-led digital patient services can learn from. Study Registration: This study was conducted between September 2022 and June 2023. It was registered in Trinity College Dublin, Ireland. Twitter Abstract: A study exploring requirements, benefits, & challenges for an interoperable patient portal in an ANP led Service for children with hydrocephalus.

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BACKGROUND: Persons with multiple chronic conditions face complex medical regimens and clinicians may not focus on what matters most to these patients who vary widely in their health priorities. Patient Priorities Care is a facilitator-led process designed to identify patients' priorities and align decision-making and care, but the need for a facilitator has limited its widespread adoption. OBJECTIVE: The aims of this study are to design and test mechanisms for patients to complete a self-directed process for identifying priorities and providing their priorities to clinicians. METHODS: The study involved patients of at least 65 years of age at 2 family medicine practices with 5 physicians each. We first tested 2 versions of an interactive website and asked patients to bring their results to their visit. We then tested an Epic previsit questionnaire derived from the website's questions and included standard previsit materials. We completed postintervention phone interviews and an online survey with participating patients and collected informal feedback and conducted a focus group with participating physicians. RESULTS: In the test of the first website version, 17.3% (35/202) of invited patients went to the website, 11.4% (23/202) completed all of the questions, 2.5% (5/202) brought results to their visits, and the median session time was 43.0 (IQR 28.0) minutes. Patients expressed confusion about bringing results to the visit. After clarifying that issue in the second version, 15.1% (32/212) of patients went to the website, 14.6% (31/212) completed the questions, 1.9% (4/212) brought results to the visit, and the median session time was 35.0 (IQR 35.0) minutes. In the test of the Epic questionnaire, 26.4% (198/750) of patients completed the questionnaire before at least 1 visit, and the median completion time was 14.0 (IQR 23.0) minutes. The 8 main questions were answered 62.9% (129/205) to 95.6% (196/205) of the time. Patients who completed questionnaires were younger than those who did not (72.3 vs 76.1 years) and were more likely to complete at least 1 of their other assigned questionnaires (99.5%, 197/198) than those who did not (10.3%, 57/552). A total of 140 of 198 (70.7%) patients responded to a survey, and 86 remembered completing the questionnaire; 78 (90.7%) did not remember having difficulty answering the questions and 57 (68.7%) agreed or somewhat agreed that it helped them and their clinicians to understand their priorities. Doctors noted that the sickest patients did not complete the questionnaire and that the discussion provided a good segue into end-of-life care. CONCLUSIONS: Embedding questionnaires assaying patient priorities into patient portals holds promise for expanding access to priorities-concordant care.

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BACKGROUND: Previous research and safety advocacy groups have proposed various behaviors for older adults to actively engage in medication safety. However, little is known about how older adults perceive the importance and reasonableness of these behaviors in ambulatory settings. OBJECTIVE: This study aimed to assess older adults' perceptions of the importance and reasonableness of 8 medication safety behaviors in ambulatory settings and compare their responses with those of younger adults. METHODS: We conducted a survey of 1222 adults in the United States using crowdsourcing to evaluate patient behaviors that may enhance medication safety in community settings. A total of 8 safety behaviors were identified based on the literature, such as bringing medications to office visits, confirming medications at home, managing medication refills, using patient portals, organizing medications, checking medications, getting help, and knowing medications. Respondents were asked about their perception of the importance and reasonableness of these behaviors on a 5-point Likert rating scale in the context of collaboration with primary care providers. We assessed the relative ranking of behaviors in terms of importance and reasonableness and examined the association between these dimensions across age groups using statistical tests. RESULTS: Of 1222 adult participants, 125 (10.2%) were aged 65 years or older. Most participants were White, college-educated, and had chronic conditions. Older adults rated all 8 behaviors significantly higher in both importance and reasonableness than did younger adults (P<.001 for combined behaviors). Confirming medications ranked highest in importance (mean score=3.78) for both age groups while knowing medications ranked highest in reasonableness (mean score=3.68). Using patient portals was ranked lowest in importance (mean score=3.53) and reasonableness (mean score=3.49). There was a significant correlation between the perceived importance and reasonableness of the identified behaviors, with coefficients ranging from 0.436 to 0.543 (all P<.001). CONCLUSIONS: Older adults perceived the identified safety behaviors as more important and reasonable than younger adults. However, both age groups considered a behavior highly recommended by professionals as the least important and reasonable. Patient engagement strategies, common and specific to age groups, should be considered to improve medication safety in ambulatory settings.

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BACKGROUND: Direct access of patients to their web-based patient portal, including laboratory test results, has become increasingly common. Numeric laboratory results can be challenging to interpret for patients, which may lead to anxiety, confusion, and unnecessary doctor consultations. Laboratory results can be presented in different formats, but there is limited evidence regarding how these presentation formats impact patients' processing of the information. OBJECTIVE: This study aims to synthesize the evidence on effective formats for presenting numeric laboratory test results with a focus on outcomes related to patients' information processing, including affective perception, perceived magnitude, cognitive perception, perception of communication, decision, action, and memory. METHODS: The search was conducted in 3 databases (PubMed, Web of Science, and Embase) from inception until May 31, 2023. We included quantitative, qualitative, and mixed methods articles describing or comparing formats for presenting diagnostic laboratory test results to patients. Two reviewers independently extracted and synthesized the characteristics of the articles and presentation formats used. The quality of the included articles was assessed by 2 independent reviewers using the Mixed Methods Appraisal Tool. RESULTS: A total of 18 studies were included, which were heterogeneous in terms of study design and primary outcomes used. The quality of the articles ranged from poor to excellent. Most studies (n=16, 89%) used mock test results. The most frequently used presentation formats were numerical values with reference ranges (n=12), horizontal line bars with colored blocks (n=12), or a combination of horizontal line bars with numerical values (n=8). All studies examined perception as an outcome, while action and memory were studied in 1 and 3 articles, respectively. In general, participants' satisfaction and usability were the highest when test results were presented using horizontal line bars with colored blocks. Adding reference ranges or personalized information (eg, goal ranges) further increased participants' perception. Additionally, horizontal line bars significantly decreased participants' tendency to search for information or to contact their physician, compared with numerical values with reference ranges. CONCLUSIONS: In this review, we synthesized available evidence on effective presentation formats for laboratory test results. The use of horizontal line bars with reference ranges or personalized goal ranges increased participants' cognitive perception and perception of communication while decreasing participants' tendency to contact their physicians. Action and memory were less frequently studied, so no conclusion could be drawn about a single preferred format regarding these outcomes. Therefore, the use of horizontal line bars with reference ranges or personalized goal ranges is recommended to enhance patients' information processing of laboratory test results. Further research should focus on real-life settings and diverse presentation formats in combination with outcomes related to patients' information processing.

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BACKGROUND: Community health center (CHC) patients experience a disproportionately high prevalence of chronic conditions and barriers to accessing technologies that might support the management of these conditions. One such technology includes tools used for remote patient monitoring (RPM), the use of which surged during the COVID-19 pandemic. OBJECTIVE: The aim of this study was to assess how a CHC implemented an RPM program during the COVID-19 pandemic. METHODS: This retrospective case study used a mixed methods explanatory sequential design to evaluate a CHC's implementation of a suite of RPM tools during the COVID-19 pandemic. Analyses used electronic health record-extracted health outcomes data and semistructured interviews with the CHC's staff and patients participating in the RPM program. RESULTS: The CHC enrolled 147 patients in a hypertension RPM program. After 6 months of RPM use, mean systolic blood pressure (BP) was 13.4 mm Hg lower and mean diastolic BP 6.4 mm Hg lower, corresponding with an increase in hypertension control (BP<140/90 mm Hg) from 33.3% of patients to 81.5%. Considerable effort was dedicated to standing up the program, reinforced by organizational prioritization of chronic disease management, and by a clinician who championed program implementation. Noted barriers to implementation of the RPM program were limited initial training, lack of sustained support, and complexities related to the RPM device technology. CONCLUSIONS: While RPM technology holds promise for addressing chronic disease management, successful RPM program requires substantial investment in implementation support and technical assistance.

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The OurNotes movement aims to support patient collaboration and engagement in care through the implementation of pre-visit notes. By contributing to a pre-visit history or agenda, the patient voice is incorporated into the visit. While OurNotes has been successfully piloted in primary and acute care settings, its implementation in Canadian mental healthcare settings has been limited. In this study, we conducted semi-structured interviews with patients, care partners and mental health clinicians to identify implementation recommendations for OurNotes in Canadian mental health contexts. Six recommendations were identified. These recommendations can be adopted by organizations considering the implementation of OurNotes in mental health clinical settings.

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BACKGROUND: German hospitals are legally obliged to implement digital patient portals within the next years. Systematic reviews show that the use of patient portals may be associated with improved patient-centeredness and workflows. However, mandatory digital healthcare innovations are sometimes not used by the target group as planned or even completely rejected. Based on Roger's theory of innovation diffusion, it can be assumed that the time factor is of particular importance for the adoption of the patient portal. The aim of the project is to assess determinants of patient portal adoption and to examine whether Roger's theory can be confirmed. METHODS: The project investigates the use of the patient portal in three different clinics of a large academic teaching hospital in Germany using a longitudinal study design with three cross-sectional time points (pre, post, post). Doctors and patients are surveyed about factors that predict the use of the patient portal and whether the strength of these factors changes over time. They are also interviewed about possible barriers they experience when using the patient portal or about the reasons why the patient portal is not used. Regression models and content analyses are used to answer the research questions. DISCUSSION: Determinants of patient portal use will be discussed under the light of the temporal component of Roger's theory. At the same time, it is expected that some determinants will remain unchanged over time. Identifying determinants independent of time allows targeting the groups, enabling specific communication strategies to empower these groups to use the patient portal, contributing to an equal health care system. TRIAL REGISTRATION: The study was prospectively registered in the German register of clinical trials (DRKS00033125) in May 2024.

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Patient portal messages often relate to specific clinical phenomena (e.g., patients undergoing treatment for breast cancer) and, as a result, have received increasing attention in biomedical research. These messages require natural language processing and, while word embedding models, such as word2vec, have the potential to extract meaningful signals from text, they are not readily applicable to patient portal messages. This is because embedding models typically require millions of training samples to sufficiently represent semantics, while the volume of patient portal messages associated with a particular clinical phenomenon is often relatively small. We introduce a novel adaptation of the word2vec model, PK-word2vec (where PK stands for prior knowledge), for small-scale messages. PK-word2vec incorporates the most similar terms for medical words (including problems, treatments, and tests) and non-medical words from two pre-trained embedding models as prior knowledge to improve the training process. We applied PK-word2vec in a case study of patient portal messages in the Vanderbilt University Medical Center electric health record system sent by patients diagnosed with breast cancer from December 2004 to November 2017. We evaluated the model through a set of 1000 tasks, each of which compared the relevance of a given word to a group of the five most similar words generated by PK-word2vec and a group of the five most similar words generated by the standard word2vec model. We recruited 200 Amazon Mechanical Turk (AMT) workers and 7 medical students to perform the tasks. The dataset was composed of 1389 patient records and included 137,554 messages with 10,683 unique words. Prior knowledge was available for 7981 non-medical and 1116 medical words. In over 90% of the tasks, both reviewers indicated PK-word2vec generated more similar words than standard word2vec (p = 0.01).The difference in the evaluation by AMT workers versus medical students was negligible for all comparisons of tasks' choices between the two groups of reviewers ( p = 0.774 under a paired t-test). PK-word2vec can effectively learn word representations from a small message corpus, marking a significant advancement in processing patient portal messages.

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BACKGROUND: Screening for health-related social needs (HRSN) has become more widespread but the best method of delivering the screening tool is not yet known. OBJECTIVE: Describe HRSN screening completion rate, specifically portal-based and in-person tablet-based screening. DESIGN: Cross-sectional retrospective observational study. PARTICIPANTS: Adults age 18 or older who had a non-acute primary care visit at one of three internal medicine primary care clinics at a large, urban, academic medical center between July 2022 and July 2023. MAIN MEASURES: We identified the proportion of individuals who were screened using the HRSN questionnaire, whether screening was completed by patient-portal or tablet, as well as the degree of burden of HRSN. Using the electronic health record, we explored associations between sociodemographic characteristics and HRSN attributes. KEY RESULTS: Our study included 24,597 patients, of whom 37% completed the HRSN questionnaire. A smaller proportion of Black/African American patients and those with Medicaid insurance completed the questionnaire, yet they comprised a greater percentage of those who screened positive for unmet HRSN (p ≤ 0.001). Most patients completed the questionnaire by patient-portal (86.1%) compared with in-office tablets (14.0%). A larger proportion of those who completed screening by tablet screened positive for HRSN. Of all patients screened, 21.8% were positive for an unmet HRSN and 11.5% had more than one unmet HRSN. CONCLUSIONS: A majority of patients are not being screened for HRSN and results illustrate disparities when screening patients for HRSN through portal-based compared with supplemental in-office tablet-based screening. Prevalence of unmet HRSN varied by demographics such as race and insurance status.

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BACKGROUND: The National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends the paper-based or computerized Alcohol Symptom Checklist to assess alcohol use disorder (AUD) symptoms in routine care when patients report high-risk drinking. However, it is unknown whether Alcohol Symptom Checklist response characteristics differ when it is administered online (eg, remotely via an online electronic health record [EHR] patient portal before an appointment) versus in clinic (eg, on paper after appointment check-in). OBJECTIVE: This study evaluated the psychometric performance of the Alcohol Symptom Checklist when completed online versus in clinic during routine clinical care. METHODS: This cross-sectional, psychometric study obtained EHR data from the Alcohol Symptom Checklist completed by adult patients from an integrated health system in Washington state. The sample included patients who had a primary care visit in 2021 at 1 of 32 primary care practices, were due for annual behavioral health screening, and reported high-risk drinking on the behavioral health screen (Alcohol Use Disorder Identification Test-Consumption score ≥7). After screening, patients with high-risk drinking were typically asked to complete the Alcohol Symptom Checklist-an 11-item questionnaire on which patients self-report whether they had experienced each of the 11 AUD criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) over a past-year timeframe. Patients could complete the Alcohol Symptom Checklist online (eg, on a computer, smartphone, or tablet from any location) or in clinic (eg, on paper as part of the rooming process at clinical appointments). We examined sample and measurement characteristics and conducted differential item functioning analyses using item response theory to examine measurement consistency across these 2 assessment modalities. RESULTS: Among 3243 patients meeting eligibility criteria for this secondary analysis (2313/3243, 71% male; 2271/3243, 70% White; and 2014/3243, 62% non-Hispanic), 1640 (51%) completed the Alcohol Symptom Checklist online while 1603 (49%) completed it in clinic. Approximately 46% (752/1640) and 48% (764/1603) reported ≥2 AUD criteria (the threshold for AUD diagnosis) online and in clinic (P=.37), respectively. A small degree of differential item functioning was observed for 4 of 11 items. This differential item functioning produced only minimal impact on total scores used clinically to assess AUD severity, affecting total criteria count by a maximum of 0.13 criteria (on a scale ranging from 0 to 11). CONCLUSIONS: Completing the Alcohol Symptom Checklist online, typically prior to patient check-in, performed similarly to an in-clinic modality typically administered on paper by a medical assistant at the time of the appointment. Findings have implications for using online AUD symptom assessments to streamline workflows, reduce staff burden, reduce stigma, and potentially assess patients who do not receive in-person care. Whether modality of DSM-5 assessment of AUD differentially impacts treatment is unknown.

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OBJECTIVE: Assessing asthma control is an essential part of the outpatient management of children with asthma and can be performed through validated questionnaires such as the Asthma Control Test (ACT). Systematic approaches to incorporating the ACT in outpatient visits are often lacking, contributing to inconsistent completion rates. We conducted a quality improvement initiative to increase the proportion of visits where the ACT is completed for children with asthma in our multi-site pediatric pulmonary clinic network. METHODS: We developed an intervention of sending the ACT questionnaire to patients and caregivers through the electronic patient portal to complete prior to their visits. This strategy was first piloted at one clinic beginning in July 2020 and then expanded to 5 other clinics in the network in October 2020. Our outcome measure was average monthly proportion of visits with a completed ACT, tracked using statistical process control charts. The process measure was method of ACT completion tracked using run charts. RESULTS: At the pilot clinic, average monthly completion rate rose within 3 months of the intervention from 27% to 72% and was sustained more than 22 months. Completion across all clinics increased from 57% pre-intervention to 76% post-intervention. Importantly, the intervention did not rely on clinic staff to administer the questionnaire and did not interfere with existing clinic flow. CONCLUSION: An intervention of delivering the ACT electronically to patients and caregivers for completion prior to visits led to a rapid and sustained improvement in ACT completion rates across a large, pediatric pulmonary clinic network.