Screening for Chronic Conditions Using a Patient Internet Portal: Recruitment for an Internet-based Primary Care Intervention

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 use); 34 (60%) consented, permitting us to invite their patients to join the trial.

We recruited patient participants by electronically scanning PCPs’ appointment schedules for upcoming visits with patients registered on PatientSite. Identified patients automatically received invitations via PatientSite 4 weeks prior to their appointments. The e-mailed invitation listed “PatientSite” as the sender and “invitation to participate” as the subject line. The text indicated their PCP was participating in a study, briefly described the project, and provided an Internet link to a webpage containing more information. The system sent 2 electronic reminders to invitees not responding within 2 and 5 days, respectively, to the invitation. When invitees declined participation, the system stopped sending them messages. The study webpage contained an embedded link to an online consent form.

The consent form’s first window contained a table of contents with 16 links allowing patients to select sections or scroll through the form. At the end of the form, patients could click buttons accepting or declining participation. Consenting patients were immediately shown the online screening survey and were sent a PatientSite message with a link to reaccess the screening survey if needed. BIDMC’s Institutional Review Board approved all study procedures.

The screening survey included questions about demographics, general health, and targeted conditions: mobility difficulty, chronic pain, and depression (Fig. 1a). With skip patterns, the survey ranged from 25 to 52 items and required 6 to 7 minutes to complete, on average. Reports of any difficulty walking one-half mile or climbing 10 steps without help from assistive devices or another person screened positive for mobility difficulties.5 This 2-item mobility measure is strongly associated with physical performance in older populations.6 The SF-36 item regarding bodily pain in the past 4 weeks served as the initial screen for chronic musculoskeletal pain.7,8 This pain measure correlates well with other pain rating scales.9,10 When patients reported pain, present for 3+ months in the past year, they were asked whether their pain primarily involved “joints, bones, muscles, or back,” which confirmed a positive screen. Depression screening comprised a 2-step process using the 8-item Patient Health Questionnaire (known as PH-8 or PRIME-MD).11,12 Persons with positive responses to the first 2 items were shown the remaining 6 PH-8 items. We classified scores of 10 or higher, the recommended cutpoint, as positive for depression.

Persons who reported not receiving specialist care for their screened condition were eligible for the study and automatically randomized to treatment groups. Physicians received PatientSite messages indicating when their patients joined the study, specifying the screened condition(s). Intervention subjects received access to the intervention web site (Fig. 1b), automated nurse e-coaching messages via PatientSite to promote communicating with their PCP, and individualized help planning their PCP visit. Control subjects received a message containing links to U.S. government web sites with general health information.

Our focus here is the online recruitment and screening. We present descriptive statistics characterizing screening survey respondents. Chi-square tests compared persons who screened positive to those who screened negative for all 3 targeted conditions. We conducted a brief qualitative evaluation of all incidental (i.e., not specifically related to coaching interactions) e-mail correspondence sent to the study team by potential participants.

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 problems sent 74 messages. Although technical adjustments fixed most problems, we could not resolve some browser incompatibility 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.

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 technical problems may have been unable to complete these questions located at the end of the electronic form.