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Implementing an Online Patient Portal Website in a Safety Net Healthcare System

Case Study by Courtney Lyles, PhD, Assistant Professor, UCSF, San Francisco and Urmimala Sarkar, MD, Associate Professor, UCSF, San Francisco

Courtney LyleCourtney Lyles, PhD is an Assistant Professor in the UCSF Division of General Internal Medicine at San Francisco General Hospital and the UCSF Center for Vulnerable Populations. A trained health services researcher, she uses quantitative and qualitative methods to examine quality of care, health behavior, and health outcomes. Her research focuses on harnessing health information technology to improve patient-provider communication for chronic disease self-management to ultimately reduce disparities in health and healthcare outcomes. She is currently on a career development award from the Agency for Healthcare Research and Quality to engage patients in using online patient portals for healthcare management, including leveraging user-centered design and implementation science principles to create as well as spread technologies that are relevant for diverse patient populations.

Urmimala SarkarUrmimala Sarkar MD, MPH is Associate Professor of Medicine at UCSF in the Division of General Internal Medicine and a primary care physician at San Francisco General Hospital’s Richard H. Fine People's Clinic. Dr. Sarkar’s research focuses on (1) patient safety in outpatient settings, including adverse drug events, missed and delayed diagnosis, and failures of treatment monitoring, (2) health information technology and social media to improve the safety and quality of outpatient care, and (3) implementation of evidence-based innovations in real-world, safety-net care settings. 

Dr. Sarkar is committed to enhancing health information technology approaches to improve primary care and ameliorate disparities in vulnerable populations, through the health-literacy-sensitive, patient-centered approaches such as co-development and usability testing, in partnership with technology development experts. Her current work applies design thinking and interdisciplinary, iterative approaches to characterize and address safety gaps in outpatient settings. 

She has conducted studies which explore the impact of health communication (health literacy, English proficiency) and health information technology on patient safety. Her prior studies on internet-based patient portals demonstrate digital disparities by race/ethnicity and health literacy. Her social media studies use mixed-methods approaches to understand patient perspectives about physician quality and about cancer screening behaviors. Her ongoing work employs varied health information technologies to detect and ameliorate adverse events among outpatient chronic disease populations. She is currently funded by the Agency for Healthcare Research and Quality (AHRQ) and the National Cancer Institute, with prior funding from the California Healthcare Foundation, and the Gordon and Betty Moore Foundation. 

This case study presents strategies being put in place in San Francisco to encourage patient engagement with an online patient portal designed to enhance communication between patients and healthcare providers whilst at the same time, meeting targets in patient-level engagement set on a National Level by the EHR Incentive Program. 

Please read the case study below and consider the following questions:

Both in the United States and internationally, there is a huge push to implement integrated electronic health records (EHRs). This adoption of health technology is viewed as critical to improving healthcare quality, and studies have shown that EHR implementation is linked to higher receipt of appropriate processes of care.(1,2) In the US, federal healthcare reform legislation jumpstarted this transition to EHRs, largely because providers in the fragmented healthcare marketplace did not have aligned financial incentives to modernize their medical records on their own. The US Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009 created the multi-billion-dollar EHR Incentive Program, the Meaningful Use program, which is managed by the Office of the National Coordinator for Health Information Technology (ONC). The Meaningful Use program has been very successful, with 94% of US hospitals receiving payment for EHR implementation and 77% of US office-based health professionals receiving payment.(3,4)

However, while primarily intended for system and provider implementation of EHRs, the Meaningful Use program also includes targeted metrics for patient-level engagement and use of electronic medical data, which is through websites linked to EHRs often called “online patient portals.” Despite the large amount of money on the table, many US healthcare systems are struggling with Meaningful Use patient portal metrics, which require that 50% of eligible patients be registered for portals and at least one patient per provider should be actively using a portal website.(5)  The struggles for patient engagement are particularly acute for healthcare systems serving vulnerable patient populations. Racial/ethnic minority groups and those with limited literacy have consistently been shown to be less likely to use Internet-based patient portals in healthcare systems that were early adopters of this technology.(6-8) Evidence suggests that this is not an issue of access or interest alone: almost all Americans have Internet access (across demographic subgroups such as income and race/ethnicity), and the vast majority of patients across healthcare settings are interested in Internet-based communication with providers or health systems.(9)

Case Presentation
Our system sought to focus on improving patient engagement with a newly launched online patient portal – to meet the Meaningful Use targets as well as to enhance communication between patients/caregivers and healthcare providers to ultimately improve health outcomes. 
The San Francisco Health Network is the public healthcare system for the city and county of San Francisco. The patients served in the Network are predominantly low-income patients with public insurance through Medicaid, and they are extremely racially/ethnically and linguistically diverse (32% Latino, 17% Black, 24% Asian; 45% speak a language other than English at home).  

Management and outcomes
We are currently launching a two-part engagement strategy for patient portal uptake within our healthcare system, using both volunteers and a broad educational training approach.  We have relied on a multidisciplinary patient engagement workgroup that included the following stakeholders: staff, clinicians, medical library, information technology, and researchers, with outreach to patient advisory boards. This group developed a comprehensive enrollment workflow and training strategy to improve hospitalized patient engagement in a resource-poor setting while also meeting Meaningful Use metrics.

Volunteer-led outreach
Our campus-based library coordinated groups of 2-5 local university students as volunteer Health Technology Educators for a 100-hour, 8-week rotation to educate and enroll patients, including facilitated first logins. In October 2015, inpatient nursing integrated into the admission workflow a 1-item assessment of portal interest to enhance patient engagement through clinical care team support. 

Since February 2015, volunteers have approached 2128 total patients, spending an average of 8.5 minutes with each interested patient who was available to enroll immediately and issued 645 (30%) patients electronic access.  Of those 645, 277 (43%) logged into the portal. Not all patients could be approached during their hospital stay due to clinical interruptions or lack of an available volunteer.  This intensive outreach required 1540 volunteer hours and 0.5 FTE of library staff.

Educational training 
We also developed patient brochures in English, Spanish, Chinese, Russian, Vietnamese, and Tagalog (the major languages of our system) and dedicated a section of our healthcare system website to explain the purpose of the portal and outline the steps for signing up.  In early 2016, we will be completing a tailored, in-depth online training curriculum to provide additional support for patients in using the portal website. These training materials will include step-by-step guides for creating an account, logging onto the website, and viewing all the available sections of the portal website, as well as information about receiving additional resources for technical support and/or building basic computer skills.  The training has been iteratively created with the support of a dedicated patient advisory board as well as community-based partnerships with the public library and several non-profit organizations who work on building digital literacy skills of vulnerable individuals throughout the San Francisco Bay Area.   Currently, the in-depth training content will only be available in English, as our portal is only offered from our EHR vendor in English at this time.

To date, we have learned that getting patients enrolled and engaged in using online patient portals in our safety net healthcare system takes far greater time and staffing needs than in other healthcare organizations.10 The portal websites that we are able to offer our patient population are often not extremely usable,11 cannot be customized for the needs of our target audience, and are often not available in multiple languages or at an appropriate reading level.  

Despite these challenges, we have leveraged our community resources in a number of important ways, such as through volunteer-led enrollment as well as community- and library-based partnerships to enhance the overall digital literacy skills of the patients we serve.   


1. In your setting, how would you ideally adapt patient-facing technology for your population of interests? (200 words)

2. What would be key partnerships for implementing patient-facing technology for you? How would you establish such partnerships? (200 words)

3. What staffing requirements do you anticipate for your technology implementation? What existing resources could you access? (200 words)


1. Herrin J, da Graca B, Nicewander D, et al. The effectiveness of implementing an electronic health record on diabetes care and outcomes. Health services research. 2012;47(4):1522-1540.

2. Tenforde M, Nowacki A, Jain A, Hickner J. The association between personal health record use and diabetes quality measures. Journal of general internal medicine. 2012;27(4):420-424.

3. Centers for Medicare and Medicaid Services. Office-based Health Care Professional Participation in the CMS EHR Incentive Programs. http://dashboard.healthit.gov/quickstats/pages/FIG-Health-Care-Professionals-EHR-Incentive-Programs.php (Accessed 5/14/15). 2014.

4. Centers for Medicare and Medicaid Services. Meaningul Use Definitions and Objectives. http://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives (Accessed 5/14/15). 2015.

5. New CMS rule allows flexibility in certified EHR technology for 2014 [press release]. Washington, DC http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-08-29.html (Accessed 12/30/14).  2014.

6. Lyles CR, Harris LT, Jordan L, et al. Patient race/ethnicity and shared medical record use among diabetes patients. Medical care. 2012;50(5):434-440.

7. Sarkar U, Karter AJ, Liu JY, et al. The literacy divide: health literacy and the use of an internet-based patient portal in an integrated health system-results from the diabetes study of northern California (DISTANCE). Journal of health communication. 2010;15 Suppl 2(Journal Article):183-196.

8. Sarkar U, Karter AJ, Liu JY, et al. Social disparities in internet patient portal use in diabetes: evidence that the digital divide extends beyond access. Journal of the American Medical Informatics Association : JAMIA. 2011;18(3):318-321.

9. Schickedanz A, Huang D, Lopez A, et al. Access, Interest, and Attitudes Toward Electronic Communication for Health Care Among Patients in the Medical Safety Net. Journal of general internal medicine. 2013.

10. Pearl R. Kaiser Permanente Northern California: current experiences with internet, mobile, and video technologies. Health affairs. 2014;33(2):251-257.

11. Taha J, Sharit J, Czaja SJ. The impact of numeracy ability and technology skills on older adults' performance of health management tasks using a patient portal. Journal of applied gerontology : the official journal of the Southern Gerontological Society. 2014;33(4):416-436.