Meaningful use in the safety net: a rapid ethnography of patient portal implementation at five community health centers in California

Abstract

Objective: US health care institutions are implementing secure websites (patient portals) to achieve federal Meaningful Use (MU) certification. We sought to understand efforts to implement portals in "safety net" health care systems that provide services for low-income populations.

Materials and methods: Our rapid ethnography involved visits at 4 California safety net health systems and in-depth interviews at a fifth. Visits included interviews with clinicians and executives ( n = 12), informal focus groups with front-line staff ( n = 35), observations of patient portal sign-up procedures and clinic work, review of marketing materials and portal use data, and a brief survey ( n = 45).

Results: Our findings demonstrate that the health systems devoted considerable effort to enlisting staff support for portal adoption and integrating portal-related work into clinic routines. Although all health systems had achieved, or were close to achieving, MU benchmarks, patients faced numerous barriers to portal use and our participants were uncertain how to achieve and sustain "meaningful use" as defined by and for their patients.

Discussion: Health systems' efforts to achieve MU certification united clinic staff under a shared ethos of improved quality of care. However, MU's assumptions about patients' demand for electronic access to health information and ability to make use of it directed clinics' attention to enrollment and message routing rather than to the relevance and usability of a tool that is minimally adaptable to the safety net context.

Conclusion: We found a mismatch between MU-based metrics of patient engagement and the priorities and needs of safety net patient populations.

Keywords: electronic health records; health disparities; meaningful use; patient access to records; safety net providers.

Figure 1.

Health IT readiness assessment survey results (n = 45; all sites combined). We modified the American Medical Association’s Health Information Technology Readiness Survey by removing 3 questions focused on provider-facing EHR functions (documentation of patient care, retrieval of patient information, and ePrescribing) and adding a question focused on provider willingness to communicate with patients through the EHR.