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


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.


CONCLUSIONS
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.


CONCLUSIONS
We found a mismatch between MU-based metrics of patient engagement and the priorities and needs of safety net patient populations.
Department of Social and Behavioral Sciences, University of California, San Francisco, CA, USA.
Sara L
SL
Ackerman
Department of Medicine, Zuckerberg San Francisco General Hospital and University of California, San Francisco, CA, USA.
Urmimala
U
Sarkar
Department of Medicine, Zuckerberg San Francisco General Hospital and University of California, San Francisco, CA, USA.
Lina
L
Tieu
Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.
Margaret A
MA
Handley
Department of Medicine, Zuckerberg San Francisco General Hospital and University of California, San Francisco, CA, USA.
Dean
D
Schillinger
Department of Medicine, Zuckerberg San Francisco General Hospital and University of California, San Francisco, CA, USA.
Kenneth
K
Hahn
Department of Medicine, Zuckerberg San Francisco General Hospital and University of California, San Francisco, CA, USA.
Mekhala
M
Hoskote
Department of Medicine, Zuckerberg San Francisco General Hospital and University of California, San Francisco, CA, USA.
Gato
G
Gourley
Department of Medicine, Zuckerberg San Francisco General Hospital and University of California, San Francisco, CA, USA.
Courtney
C
Lyles
D000884:Anthropology, Cultural; D002140:California; D003151:Community Health Centers; D057286:Electronic Health Records; D006284:Health Plan Implementation; D006801:Humans; D007407:Interviews as Topic; D062527:Meaningful Use; D000072638:Patient Portals; D064876:Safety-net Providers
electronic health records; health disparities; meaningful use; patient access to records; safety net providers