Adoption of a Portal for the Primary Care Management of Pediatric Asthma: A Mixed-Methods Implementation Study

Abstract

Background: Patient portals may improve communication between families of children with asthma and their primary care providers and improve outcomes. However, the feasibility of using portals to collect patient-reported outcomes from families and the barriers and facilitators of portal implementation across diverse pediatric primary care settings have not been established.

Objective: We evaluated the feasibility of using a patient portal for pediatric asthma in primary care, its impact on management, and barriers and facilitators of implementation success.

Methods: We conducted a mixed-methods implementation study in 20 practices (11 states). Using the portal, parents of children with asthma aged 6-12 years completed monthly surveys to communicate treatment concerns, treatment goals, symptom control, medication use, and side effects. We used logistic regression to evaluate the association of portal use with child characteristics and changes to asthma management. Ten clinician focus groups and 22 semistructured parent interviews explored barriers and facilitators of use in the context of an evidence-based implementation framework.

Results: We invited 9133 families to enroll and 237 (2.59%) used the portal (range by practice, 0.6%-13.6%). Children of parents or guardians who used the portal were significantly more likely than nonusers to be aged 6-9 years (vs 10-12, P=.02), have mild or moderate/severe persistent asthma (P=.009 and P=.04), have a prescription of a controller medication (P<.001), and have private insurance (P=.002). Portal users with uncontrolled asthma had significantly more medication changes and primary care asthma visits after using the portal relative to the year earlier (increases of 14% and 16%, respectively). Qualitative results revealed the importance of practice organization (coordinated workflows) as well as family (asthma severity) and innovation (facilitated communication and ease of use) characteristics for implementation success.

Conclusions: Although use was associated with higher treatment engagement, our results suggest that achieving widespread portal adoption is unlikely in the short term. Implementation efforts should include workflow redesign and prioritize enrollment of symptomatic children.

Clinicaltrial: Clinicaltrials.gov NCT01966068; https://ichgcp.net/clinical-trials-registry/NCT01966068 (Archived by WebCite at http://www.webcitation.org/6i9iSQkm3).

Keywords: asthma; electronic health records; health information technology.

Conflict of interest statement

Conflicts of Interest: Dr. Fiks and Dr. Grundmeier are the coinventors of the “Care Assistant” software that was used to implement the portal in the electronic medical record in this study. They hold no patent on the software and have earned no money from this invention. No licensing agreement exists. Dr. Pace has the following conflict of interest: He is the coinventor of the University of Colorado Patient Entered Electronic Recording System (PEERS), which was used as the underlying technology platform for the PROS MyAsthma portal. The remaining authors declare they have no conflicts of interest.

Figures

Figure 1

The MyAsthma Portal-PeRC Practices. In PeRC, MyAsthma was embedded in an existing patient portal (MyChart, Epic, Verona, WI, USA) already implemented by The Children’s Hospital of Philadelphia. ©2014 The Children’s Hospital of Philadelphia. All Rights Reserved.

Figure 2

The MyAsthma Portal-PROS Practices. In PROS, MyAsthma was available to families through Integrated Health Connect (IHealth Connect), a website developed by the University of Colorado. A test patient is shown.

Figure 3

Conceptual model of factors affecting the implementation of health innovations, adapted from [22].

Figure 4

Practice-level variability in portal adoption within 2 pediatric primary care networks. Range 0.6%-13.6%. CIs account for practice size (smaller practices have wider intervals).