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�The Impact of Increasing Patient Portal Enrollment and Utilization in Appointment No-Show Rates in Family Medicine Clinics�� Raziel Estornino� University of Mary��

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Acknowledgement

Jacalyn Luchsinger and mentors
SUNY Upstate Hospital and Upstate Family Medicine
Yowali Singh, Sarah Irish, and Dr. Greenwald for the opportunity, support, and approval
Amanda Doran for consistent support, patience, and unwavering direction.
Mary Whipple, Leanne Torres, nurses, front office staff, attending providers, and residents.
HIM for the data, Aaron P.
Friends, family, and God�

�

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Background of the Problem

What is a no-show?
Healthcare spending

- 19.7% Gross Domestic Product (GDP) (CMS.gov, 2021) / $12,530 per person

$150 billion a year (Ullah et al., 2018)
High no-show rate (15-20%)
Pending MyChart activation
Patient portal - MyChart
Workflow gap

-check-in, rooming, actual visit��

Image sources: https://www.bac2school.org/mobile/index.cfm?zone=/unionactive/view_article.cfm&homeID=537066

https://giphy.com/explore/happy-turtle

An appointment is a no-show when the patient fails to attend or reschedule an appointment without prior notification for at least 24-hours.

CMS (center for Medicaid-medicare services)

In 2020, U.S. health care spending grew 9.7%, reaching $4.1 trillion or $12,530 per person. Healthcare spending accounted for a 19.7% share of the nation's Gross Domestic Product (GDP) (CMS.gov, 2021). With the rising cost and demands on healthcare providers, it is more critical to efficiently use clinical resources, which have become even more limited due to the Covid-19 pandemic. No-shows are significant setbacks to cost-effective healthcare delivery because they may decrease generated revenue, waste human and space resources, and delay diagnosis and treatment.

��Missed appointments cost the U.S. healthcare system more than $150 billion a year (Ullah et al., 2018).

Show in next slide a chart for the last quarter of 2021

Show next slide: pie chart

�Enrollment is the primary step to patient engagement regarding patient portal utilization. Previously published studies showed that one of the effective ways to increase appointment adherence is utilizing the patient portal

SUNY has a well-designed patient portal called My Chart. However, a gap in the clinic's workflows that do not actively encourage or assist patients in signing up to MyChart or inform patients about its appointment management features.��

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Problem Statement

No-shows are significant setbacks to a cost-effective healthcare delivery; therefore, technology such as patient portals must be well utilized to improve patient appointment compliance, thus reducing expenditure.�

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Significance of the Problem

Focus: Family Medicine Community
No-shows

- productivity

- 1650 visits (residents)

- continuity of care

- space and human resources

- timely appointments

Image source: shorturl.at/hqAGM

The Family Medicine CC has identified an ongoing problem of a high no-show rate of about 15 to 20%. No-shows have directly and indirectly affected the productivity of the clinic and the providers, continuance of care, space and human resources, and future patients due to the unavailability of timely appointments

A 20-min visit is a single patient missed, and a 40-min visit is either one or two patients missed.

The department has done different measures to decrease the no-show rate, including automated reminder calls and texts and non-automated appointment reminder calls. The non-automated appointment reminder has been on hold due staffing shortage. Despite this, the high no-show rate continued. Furthermore, the check-in, rooming, and visit workflows and the patient visits do not actively involve encouraging or assisting patients to sign-up to MyChart and informing patients about its appointment management features.

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PICO(T) Question

Do process improvement and educational efforts with the family medicine community campus staff to increase patient portal enrollment and utilization affect the appointment no-show rates compared to the current workflows and processes of automated patient reminder calls and text over the summer?

��

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Purpose

Improve existing workflows

To increase MyChart enrollment and utilization

To find its impact on no-show rate

��

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Literature Review

National average no-show rate is 5%-7% (MGMA, 2017)
Clinic’s rate 15%-20%
Patient portal reduces no-shows

- increases patient engagement

Barriers and underutilization
Poor MyChart promotion
Promotion strategies

- Office visit as prime opportunity

According to the Medical Group Management Association (MGMA, 2017), the national average no-show rate is at 5%-7. Clinic rate Triple

likely to no-show are younger (18-49), has transportation issues, has no insurance, non-Caucasian, unmarried, chronic no-showers, Medicaid patients, non-English speakers, or whose primary language differs from the provider's, patients referred from the Emergency Department, acute visits, and patients with psychosocial problems (Johnson et al., 2007; Shah et al., 2019; Sobota & Vais, 2019).

different themes

One study to prove this was by Zhong et al. (2018), appointment no-show rate in the University of Florida Health, indicating improved patient engagement.

Davis (2021) conducted an integrative review of 20 published studies, patient portal reduce no-shows significantly by 5-10%

In a survey done by Goel et al. (2011), among the non-patient-portal users, 63% reported never attempting enrollment even if they received a sign-up invitation mainly due to lack of information or motivation,

Information Technology Patient Engagement Handbook (Health I.T., 2019), clinics should treat patient office visits as a prime opportunity for registration to facilitate portal enrollment. Patients are more likely to register in the office while getting support from staff and engaging in conversation about its benefits.

A study by Athena Health revealed that among 973,000 patients who are offered to sign-up to the portal during their office visit, 57% effectively signed up using a kiosk or a tablet, 53% used the registrar computer, and 23% enrolled after receiving a text. The at-home registration was lower, showing only 12% signed up after getting an email at check-in, 4% after automated monthly email, and less than 1% via marketing campaign invitation (Health I.T., 2019).

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Recommendations

Include MyChart in the workflow
Providers to promote MyChart
MyChart Brochures
Staff Training
Pending Activation and Proxy accounts
Enable Text Alert
MyChart Go-To Person
Staff incentives��

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Implementation Plan

1. Focus – Family Medicine Community

2. Timeline

Month	Activity
May	Implementation, staff training/presentation (May 12th) Changes: May 28^{th ;} Jun 23^rd
June	Implementation Delay: 2 month data
July	Data gathering 1^st week; Analysis; Written report
August	Written report; final presentation

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Implementation Plan

Staff Education and Training

Staff meeting

Tip sheet, PowerPoint, ways to enroll in Epic, pending accounts, proxy access, utilization (cancel via MyChart)
One-on-one training
Go-to person, time-constraints
Rewards program
Brochures

Changes: two staff trainings

Brochures at nurse station VS MyChart posters

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Measurement Plan

SlicerDicer and WorkBench

Project Outcome
Total sign-up (rewards program)
MyChart rate from IT
Oct-Dec 2021 data vs post-implementation rate

Post-project (Nov-Dec 2021 vs Jun-Jul 2022); trend

The measuring tools to be used are Epic SlicerDicer and Reporting WorkBench. Epic SlicerDicer is a self-service reporting tool that provides intuitive and customizable data exploration abilities; thus, it generates the percentage of population or number of patients by MyChart Status. Reporting Workbench (RWB) is a Business Intelligence tool within Epic that shows the no-show rate for each month. Reports from the I.T. department on the monthly MyChart sign-up will also be used. The total number of patients from the rewards program will also be utilized.

��The project's objective is to acquire an increase in the MyChart monthly enrollment, a decrease in the monthly no-show rate, an increase in the activated MyChart rate, and a drop in the pending MyChart accounts. For outcome measurement, the monthly no-show rate, MyChart status, and monthly MyChart sign-up of the last quarter of 2021 will be compared with the post-evaluation monthly rate.

�Q4 2021 – 194 sign ups, 76% activated account (1705/2233), 23.6% no Mychart (528/2233)�

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Human Subject Protection

No consent form required
No identifiable information
Confidentiality agreement
No consent from staff (organizational support)
IRB proposal (school IRB chair) – approved on 4/13/22

Image source: https://www.presentermedia.com/powerpoint-animation/business-meeting-shaking-hands-pid-7558

The project does not require consent to inform patients of risk or expose them to any risk. No identifiable patient information during baseline data gathering and post-intervention analysis will be used in the project. The project leader signed a confidentiality agreement with the organization's manager noting that all information that the healthcare organization has provided will be kept confidential and will not be shared outside of the educational requirements of this project. Since this project is an organizational initiative supported by its leaders, the staff and providers are expected to participate; therefore, consent is not required. An IRB proposal will be submitted to the University of Mary IRB Chair during the spring semester to gain approval to proceed with this proposed project.

�

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Implementation and Measurement

1. Delay

😐 outcome - 2 month data (Jun-Jul 2022)

😃 Two trainings

- May 28^th (8 nurse/clerical office)

- Jun 23^rd(35-45 attendees)

2. Powerpoint presentation revision

😃 targeted to attendees

3. Brochures

🙁 to track next time

😃 Kept at front office instead of nurse station

😃 MyChart posters

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4. Record sheet

😐 Mix – some recorded, some forget, or few participated

Future: simplify by IT tracking

😃 Incentive program winner

Lisa, Congrats!

5. Time constraints

🙁 Fails to take advantage of resources

😐 New residents started July

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Project Outcome Measurements

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In-office MyChart Assistance�(Incentive program)

Participants: 7 total (nurses and front office)

Providers - none

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IT-generated MyChart Activation Rate

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IT-generated MyChart Activation Rate

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Organizational Hand-off

Project leader

Continue to lead/support person
Follow up kiosk/tablet

Providers

encourage MyChart
MyChart presentation to 1^st years
Incentive program (providers vs other staff)

Leadership meeting

funding and support
Elevate the project
Continuous tracking/feedback; retrospective study

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Conclusions

Improved MyChart status; NO impact to no-shows
National average specific
Minimal workflow change
Positive impact
Results should not hinder MyChart utilization
Positive > Negative feedback
TIME Constraints
Keep workflow change

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References

Berg, B. P., Murr, M., Chermak, D., Woodall, J., Pignone, M., Sandler, R. S., & Denton, B. T. (2013). Estimating the cost of no-shows and evaluating the effects of mitigation strategies. Medical Decision Making : An International Journal of the Society for Medical Decision Making, 33(8), 976–985. https://doi-org.ezproxy.umary.edu/10.1177/0272989X13478194
CMS.gov. (2021). National Health Expenditure Data. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical
Fabrizio, N. (2017). Automated Appointment Reminders Lead to Fewer No-Shows. https://www.mgma.com/data/data-stories/automated-appointment-reminders-lead-to-fewer-no-s
GAO. (2017). Health Information Technology: HHS Should Assess the Effectiveness of Its Efforts to Enhance Patient Access to and Use of Electronic Health Information. https://www.gao.gov/products/gao-17-305#
Goel, M.S., Brown, T. L., Williams, A., Cooper, A. J., Hasnain-Wynia, R., & Baker, D. W. (2011). Patient reported barriers to enrolling in a patient portal. Journal of the American Medical Informatics Association, 18, i8–i12. https://doi-org.ezproxy.umary.edu/10.1136/amiajnl-2011-000473
Graham, T. A. D., Ali, S., Avdagovska, M., & Ballermann, M. (2020). Effects of a Web-Based Patient Portal on Patient Satisfaction and Missed Appointment Rates: Survey Study. Journal of Medical Internet Research, 22(5), e17955. https://doi-org.ezproxy.umary.edu/10.2196/17955
Horvath, M., Levy, J., L’Engle, P., Carlson, B., Ahmad, A., & Ferranti, J. (2011). Impact of health portal enrollment with email reminders on adherence to clinic appointments: a pilot study. Journal of Medical Internet Research, 13(2), e41. https://doi-org.ezproxy.umary.edu/10.2196/jmir.1702
Johnson, B. J., Mold, J. W., & Pontious, J. M. (2007). Reduction and Management of No-Shows by Family Medicine Residency Practice Exemplars. Annals of Family Medicine, 5(6), 534–539. https://doi-org.ezproxy.umary.edu/10.1370/afm.752
MGMA. (2017). Doing everything possible to prevent patient no-shows. https://www.mgma.com/data/data-stories/doing-everything-possible-to-prevent-patient-no-sh

�

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References

Miller, D. P., Jr, Latulipe, C., Melius, K. A., Quandt, S. A., & Arcury, T. A. (2016). Primary Care Providers’ Views of Patient Portals: Interview Study of Perceived Benefits and Consequences. Journal of Medical Internet Research, 18(1), e8. https://doi-org.ezproxy.umary.edu/10.2196/jmir.4953
Mohammadi, I., Wu, H., Turkcan, A., Toscos, T., & Doebbeling, B. N. (2018). Data Analytics and Modeling for Appointment No-show in Community Health Centers. Journal of primary care & community health, 9, 2150132718811692. https://doi.org/10.1177/2150132718811692
Plimpton, E. (2020). A Quality Improvement Project to Increase Patient Portal Enrollment and Utilization in Women Living With HIV at Risk for Disengagement in Care. The Journal of the Association of Nurses in AIDS Care : JANAC, 31(1), 60–65. https://doi-org.ezproxy.umary.edu/10.1097/JNC.0000000000000153
Ronda, M. C., Dijkhorst-Oei, L.-T., & Rutten, G. E. (2014). Reasons and Barriers for Using a Patient Portal: Survey Among Patients With Diabetes Mellitus. Journal of Medical Internet Research, 16(11), 1. https://doi-org.ezproxy.umary.edu/10.2196/jmir.3457
Sobota, A., & Vais, S. (2019). Our Sickle Cell Clinic Was Struggling With No-Shows. So We Called an Uber. https://healthcity.bmc.org/population-health/our-clinic-was-struggling-no-shows-so-we-called-uber
Shah, K., Alshammaa, A., Affan, M., Schultz, L., Walbert, T., & Zaman, I. (2019). Education Research: Electronic patient portal enrollment and no-show rates within a neurology resident clinic. Neurology, 92(1), 50–54. https://doi-org.ezproxy.umary.edu/10.1212/WNL.0000000000006685
Ullah S, Rajan S, Liu T, Demagistris E, Jahrstorfer R, et al. (2018). Why do Patients Miss their Ap- pointments at Primary Care Clinics?. J Fam Med Dis Prev 4:090. doi.org/10.23937/2469-5793/1510090
Zhong, X., Liang, M., Sanchez, R., Yu, M., Budd, P. R., Sprague, J. L., & Dewar, M. A. (2018). On the effect of electronic patient portal on primary care utilization and appointment adherence. BMC Medical Informatics and Decision Making, 18(1), 84. https://doi-org.ezproxy.umary.edu/10.1186/s12911-018-0669-8��