Screening for Chronic Conditions Using a Patient Internet Portal:

Recruitment for an Internet-based Primary Care Intervention

Suzanne G. Leveille, PhD, RN1,2, Annong Huang, MD1, Stephanie B. Tsai, MA1,
Saul N. Weingart, MD, PhD2,3, and Lisa I. Iezzoni, MD, MSc1,2,4
1
Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Brookline, MA, USA; 2Department of Medicine,
Harvard Medical School, Boston, MA, USA; 3Center for Patient Safety, Dana Farber Cancer Institute, Boston, MA, USA; 4Institute for Health
Policy, Massachusetts General Hospital, Boston, MA, USA.

BACKGROUND: Patient Internet portals have created considerable challenges setting priorities to address clinical
new opportunities for assessment and management of concerns. Information transmitted via secure patient Internet
chronic conditions. portals could allow identification of chronic problems before
scheduled visits.
OBJECTIVE: To conduct an online screening survey for
We developed an intervention conducted entirely through
a study recruitment using a secure patient Internet
PatientSite, a secure patient Internet portal, to coach primary
portal to identify primary care patients with untreated
care patients before office visits about communicating with
depression, chronic pain, or mobility difficulty before
their PCPs regarding 3 common conditions: depression,
nonurgent office visits.
chronic pain, and mobility difficulty. After providing informed
DESIGN: Internet-based screening survey for a ran- consent online, patients completed an electronic survey
domized trial. screening for these conditions and assessing study eligibility.
Participants randomized to the intervention received online
PARTICIPANTS: Patients who were registered portal
users who had scheduled primary care appointments. coaching from experienced nurses regarding communicating
effectively with their PCP about health concerns, specifically
APPROACH: Electronic study invitations via the portal their screened condition(s).
were sent to 4,047 patients with scheduled visits to 34 This paper describes our experiences recruiting study
primary care physicians participating in the study. After participants online. Although others have explored the use of
clicking on a link in the study invitation, patients were web-based screening tools,1–3 to our knowledge, this is the first
consecutively shown the study description, consent report about using an Internet portal-based screening survey
form, and lastly, the screening survey to determine final to identify patients with depression, chronic pain, or impaired
eligibility for study participation. mobility before scheduled PCP visits.
RESULTS: Of the 2,113 (52%) patients who opened the
study invitation, 1,001 consented online to join the
study and 981 (98%) of these completed the screening METHODS
survey. Of the respondents, 319 (33%) screened positive
for 1 or more of the 3 conditions. PatientSite was developed to permit secure electronic patient–
provider communication within Boston’s Beth Israel Deacon-
CONCLUSIONS: The online screening survey conducted ess Medical Center (BIDMC) and affiliated practices. Patients
through the patient portal was effective in identifying logon to PatientSite from any computer using personal IDs and
patients with chronic conditions in advance of sched- passwords. PatientSite allows e-mail messaging, prescription
uled primary care visits for participation in an inter- renewals, appointment and referral requests, and access to
vention study. sections of online medical records.4 PCPs must first register on
KEY WORDS: internet; ambulatory care; pain; screening; mobility.
PatientSite before their patients can enroll. Patients access
J Gen Intern Med 23(4):472–5 PatientSite most frequently to view laboratory or radiology
DOI: 10.1007/s11606-007-0443-6 reports and e-mail clinicians.4 To inform patients about new
© Society of General Internal Medicine 2007 PatientSite messages, PatientSite sends e-mail messages to
their external e-mail account saying they have new messages,
along with a link to the PatientSite logon webpage. Of the
estimated 80,000 patients within BIDMC and affiliates, 26,000
were registered PatientSite users when our project began in
INTRODUCTION
2005.
Online patient–doctor communication creates new opportuni-
ties for improving clinical care. Given the brevity of primary
Participant Recruitment
care physician (PCP) office visits, patients and physicians face
Our study first recruited PCPs registered on PatientSite from 2
hospital-based and 2 affiliated practices. Of 73 physicians, 57
met other eligibility requirements (electronic medical record

472
JGIM Leveille et al.: Internet-based Primary Care Intervention 473

use); 34 (60%) consented, permitting us to invite their patients ated with physical performance in older populations.6 The SF-
to join the trial. 36 item regarding bodily pain in the past 4 weeks served as the
We recruited patient participants by electronically scanning initial screen for chronic musculoskeletal pain.7,8 This pain
PCPs’ appointment schedules for upcoming visits with patients measure correlates well with other pain rating scales.9,10 When
registered on PatientSite. Identified patients automatically patients reported pain, present for 3+ months in the past year,
received invitations via PatientSite 4 weeks prior to their they were asked whether their pain primarily involved “joints,
appointments. The e-mailed invitation listed “PatientSite” as bones, muscles, or back,” which confirmed a positive screen.
the sender and “invitation to participate” as the subject line. Depression screening comprised a 2-step process using the 8-
The text indicated their PCP was participating in a study, item Patient Health Questionnaire (known as PH-8 or PRIME-
briefly described the project, and provided an Internet link to a MD).11,12 Persons with positive responses to the first 2 items
webpage containing more information. The system sent 2 were shown the remaining 6 PH-8 items. We classified scores of
electronic reminders to invitees not responding within 2 and 10 or higher, the recommended cutpoint, as positive for
5 days, respectively, to the invitation. When invitees declined depression.
participation, the system stopped sending them messages. The Persons who reported not receiving specialist care for their
study webpage contained an embedded link to an online screened condition were eligible for the study and automati-
consent form. cally randomized to treatment groups. Physicians received
The consent form’s first window contained a table of PatientSite messages indicating when their patients joined
contents with 16 links allowing patients to select sections or the study, specifying the screened condition(s). Intervention
scroll through the form. At the end of the form, patients could subjects received access to the intervention web site (Fig. 1b),
click buttons accepting or declining participation. Consenting automated nurse e-coaching messages via PatientSite to
patients were immediately shown the online screening survey promote communicating with their PCP, and individualized
and were sent a PatientSite message with a link to reaccess the help planning their PCP visit. Control subjects received a
screening survey if needed. BIDMC’s Institutional Review message containing links to U.S. government web sites with
Board approved all study procedures. general health information.

Screening Procedures Analysis

The screening survey included questions about demographics, Our focus here is the online recruitment and screening. We
general health, and targeted conditions: mobility difficulty, present descriptive statistics characterizing screening survey
chronic pain, and depression (Fig. 1a). With skip patterns, the respondents. Chi-square tests compared persons who screened
survey ranged from 25 to 52 items and required 6 to 7 minutes positive to those who screened negative for all 3 targeted
to complete, on average. Reports of any difficulty walking one- conditions. We conducted a brief qualitative evaluation of all
half mile or climbing 10 steps without help from assistive incidental (i.e., not specifically related to coaching interactions)
devices or another person screened positive for mobility e-mail correspondence sent to the study team by potential
difficulties.5 This 2-item mobility measure is strongly associ- participants.

Figure 1. (a) E-Health study survey window. (b) E-Health study intervention webpage. Graphics used in the webpage were freely available
from Microsoft Office Online.
474 Leveille et al.: Internet-based Primary Care Intervention JGIM

Patient Feedback and Technical Issues

During the 1-year recruitment, we received 287 PatientSite
messages from invitees, including several multiple e-mail
exchanges with individuals. We received 121 messages from
people replying to the invitation, either to decline or accept
participation—unnecessary messages because the consent
form contained buttons clearly marked “decline” and “accept.”
Thirteen messages expressed anger or annoyance about
receiving study invitations. Patients reporting technical pro-
blems sent 74 messages. Although technical adjustments fixed
most problems, we could not resolve some browser incompat-
ibility difficulties: Macintosh computer users appeared to have
more problems than PC users in accessing forms. Nonetheless,
8% of respondents used Macintosh computers. A dozen cases
required telephone conversations to troubleshoot technical
issues or resolve concerns about the informed consent.
Figure 2. E-Health study recruitment flow chart. In the final 3 months of recruitment, we added questions to
the screening survey asking about experiences with online
recruitment processes. Only 4 of 76 respondents reported
technical difficulties. However, patients with significant tech-
RESULTS nical problems may have been unable to complete these
From August 2005 to September 2006, the computerized questions located at the end of the electronic form.
system automatically e-mailed study invitations to 4,047
patients. Figure 2 shows screening and enrollment results,
while Table 1 summarizes respondents’ characteristics. The
DISCUSSION
most common screened condition was chronic pain (n=273;
28%), followed by mobility difficulty (n=93; 10%) and depres- PatientSite, an Internet patient portal, served as a useful
sion (n=56; 6%); 25% (81 of 319) had 2 or more conditions. venue for recruiting and screening primary care patients for a
Patients screening positive were older and had less education randomized trial. More than half of invitees opened their e-
than those screening negative. Survey respondents were older mailed invitations—perhaps not surprising because, unlike
than BIDMC primary care patients in general (81% vs 64% age ordinary e-mail, PatientSite inboxes almost exclusively involve
40+, respectively); more were white (92% vs 65%, respectively). communication between patients and providers. Some invitees
Women comprised 61% of both groups. may not have opened invitation messages because they
assumed them to be standard appointment reminders. Nearly
all patients (92%) sent invitations logged onto PatientSite
before their visits. An earlier PatientSite study indicated that
Table 1. Baseline Characteristics of Survey Respondents of the
patients use the portal for viewing laboratory and radiology
E-Health Study
reports more often than messaging.4
Characteristics Screened Screened All respondents During early recruitment, direct telephone availability proved
negative positive (n=981) n (%)* essential, primarily to give technical assistance. Telephone calls
(n=662) (n=319) to study staff decreased markedly following initial technical
n (%)* n (%)*
adjustments. Many patients sent specific reply messages to
Age (years) invitation e-mails in addition to pressing automated enrollment
20–39 141 (21.3) 50 (15.7) 191 (19.5) buttons on the informed consent. The large number of messages
40–59 394 (59.5) 179 (56.1) 573 (58.4) accepting or declining participation may have occurred because
≥60 127 (19.2) 90 (28.2) 217 (22.1)
the invitation message did not state that it was unnecessary to
Women 404 (61.0) 190 (59.6) 594 (60.5)
White race 604 (91.9) 285 (90.5) 889 (91.5) reply to the message. Also, the standard “reply” button at the top
Education of each PatientSite message may have inadvertently encouraged
High school 16 (2.4) 22 (7.0) 38 (3.9) replies.
or less This study had important limitations. We could not deter-
Not college 88 (13.3) 89 (28.2) 177 (18.1)
mine reasons invitees chose not to complete informed consents
graduate
College 556 (84.2) 205 (64.9) 761 (78.0) of screening surveys, such as not having – or fear of stigma for
graduate having – a screened condition. Our results suggest that many
Married/ 480 (72.6) 203 (64.2) 683 (69.9) people were willing to report health problems in a portal-based
partnered
screen. We would have expected that patients interested in
Employed 543 (82.5) 213 (67.2) 756 (77.5)
Self-rated health previsit coaching might have more health problems (i.e.,
Good to 629 (95.0) 236 (74.0) 865 (88.2) selection bias), but reliance on PatientSite may have intro-
excellent duced instead a healthy volunteer bias in our recruitment.4,13
Fair to poor 33 (5.0) 83 (26.0) 116 (11.8) Also, well-educated, Internet-savvy patients may have less
*Percents were based on nonmissing information. There were <2% need for coaching to promote productive interaction with their
missing for all measures PCPs than persons with fewer personal resources.
JGIM Leveille et al.: Internet-based Primary Care Intervention 475

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Johnson Foundation Health e-Technologies Initiative grant # 051757. performance battery. J Gerontol. 2000;55:M221–31.
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