title: Barriers and Facilitators to Online Portal Use Among Patients and Caregivers in a Safety Net Health Care System: A Qualitative Study.
abstract: BACKGROUND
  Patient portals have the potential to support self-management for chronic diseases and improve health outcomes. With the rapid rise in adoption of patient portals spurred by meaningful use incentives among safety net health systems (a health system or hospital providing a significant level of care to low-income, uninsured, and vulnerable populations), it is important to understand the readiness and willingness of patients and caregivers in safety net settings to access their personal health records online.
  
  
  OBJECTIVE
  To explore patient and caregiver perspectives on online patient portal use before its implementation at San Francisco General Hospital, a safety net hospital.
  
  
  METHODS
  We conducted 16 in-depth interviews with chronic disease patients and caregivers who expressed interest in using the Internet to manage their health. Discussions focused on health care experiences, technology use, and interest in using an online portal to manage health tasks. We used open coding to categorize all the barriers and facilitators to portal use, followed by a second round of coding that compared the categories to previously published findings. In secondary analyses, we also examined specific barriers among 2 subgroups: those with limited health literacy and caregivers.
  
  
  RESULTS
  We interviewed 11 patients and 5 caregivers. Patients were predominantly male (82%, 9/11) and African American (45%, 5/11). All patients had been diagnosed with diabetes and the majority had limited health literacy (73%, 8/11). The majority of caregivers were female (80%, 4/5), African American (60%, 3/5), caregivers of individuals with diabetes (60%, 3/5), and had adequate health literacy (60%, 3/5). A total of 88% (14/16) of participants reported interest in using the portal after viewing a prototype. Major perceived barriers included security concerns, lack of technical skills/interest, and preference for in-person communication. Facilitators to portal use included convenience, health monitoring, and improvements in patient-provider communication. Participants with limited health literacy discussed more fundamental barriers to portal use, including challenges with reading and typing, personal experience with online security breaches/viruses, and distrust of potential security measures. Caregivers expressed high interest in portal use to support their roles in interpreting health information, advocating for quality care, and managing health behaviors and medical care.
  
  
  CONCLUSIONS
  Despite concerns about security, difficulty understanding medical information, and satisfaction with current communication processes, respondents generally expressed enthusiasm about portal use. Our findings suggest a strong need for training and support to assist vulnerable patients with portal registration and use, particularly those with limited health literacy. Efforts to encourage portal use among vulnerable patients should directly address health literacy and security/privacy issues and support access for caregivers.
authors.affiliation: Division of General Internal Medicine, University of California, San Francisco, San Francisco, CA, United States. Lina.Tieu@ucsf.edu.
authors.forename: Lina
authors.identifier: http://orcid.org/0000-0002-9980-0774
authors.initials: L
authors.lastname: Tieu
authors.forename: Urmimala
authors.identifier: http://orcid.org/0000-0003-4213-4405
authors.initials: U
authors.lastname: Sarkar
authors.forename: Dean
authors.identifier: http://orcid.org/0000-0002-7221-7327
authors.initials: D
authors.lastname: Schillinger
authors.forename: James D
authors.identifier: http://orcid.org/0000-0001-6317-7987
authors.initials: JD
authors.lastname: Ralston
authors.forename: Neda
authors.identifier: http://orcid.org/0000-0001-9944-6923
authors.initials: N
authors.lastname: Ratanawongsa
authors.forename: Rena
authors.identifier: http://orcid.org/0000-0002-3322-6626
authors.initials: R
authors.lastname: Pasick
authors.forename: Courtney R
authors.identifier: http://orcid.org/0000-0002-1111-8595
authors.initials: CR
authors.lastname: Lyles
mesh_terms: D017028:Caregivers; D003695:Delivery of Health Care; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D005260:Female; D057220:Health Literacy / Q000379:methods*; D055991:Health Records, Personal; D006801:Humans; D020407:Internet / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D036301:Qualitative Research
keywords: caregivers; chronic disease; electronic health records; health literacy; personal health records; safety-net providers