BackgroundPatient 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.ObjectiveTo explore patient and caregiver perspectives on online patient portal use before its implementation at San Francisco General Hospital, a safety net hospital.MethodsWe 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.ResultsWe 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.ConclusionsDespite 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.

BACKGROUND:Mobile applications or 'apps' intended to help people manage their health and chronic conditions are widespread and gaining in popularity. However, little is known about their acceptability and usability for lowincome, racially/ethnically diverse populations who experience a disproportionate burden of chronic disease and its complications. OBJECTIVE: The objective of this study was to investigate the usability of existing mobile health applications ("apps") for diabetes, depression, and caregiving, in order to facilitate development and tailoring of patient-facing apps for diverse populations. DESIGN: Usability testing, a mixed-methods approach that includes interviewing and direct observation of participant technology use, was conducted with participants (n = 9 caregivers; n = 10 patients with depression; and n = 10 patients with diabetes) on a total of 11 of the most popular health apps (four diabetes apps, four depression apps, and three caregiver apps) on both iPad and Android tablets. PARTICIPANTS: The participants were diverse: 15 (58 %) African Americans, seven (27 %) Whites, two (8 %) Asians, two (8 %) Latinos with either diabetes, depression, or who were caregivers. MAIN MEASURES: Participants were given conditionspecific tasks, such as entering a blood glucose value into a diabetes app. Participant interviews were video recorded and were coded using standard methods to evaluate attempts and completions of tasks. We performed inductive coding of participant comments to identify emergent themes. KEY RESULTS: Participants completed 79 of 185 (43 %) tasks across 11 apps without assistance. Three themes emerged from participant comments: lack of confidence with technology, frustration with design features and navigation, and interest in having technology to support their self-management.CONCLUSIONS: App developers should employ participatory design strategies in order to have an impact on chronic conditions such as diabetes and depression that disproportionately affect vulnerable populations. While patients express interest in using technologies for selfmanagement, current tools are not consistently usable for diverse patients.

Geriatric conditions were common among older homeless adults living in diverse environments, and the prevalence of these conditions was higher than that seen in housed adults 20 years older. Services that address geriatric conditions are needed for older homeless adults living across varied environments.

Our findings suggest a strong need for tailored and accessible training and support to assist all vulnerable patients and/or caregivers with portal registration and use. Measuring the health literacy of a patient population might serve as a strong proxy for identifying patients who need the most support in using health technologies.

Background. The feasibility of digital health programs to prevent and manage diabetes in low-income patients has not been adequately explored. Methods. Researchers collaborated with a digital health company to adapt a diabetes prevention program for low-income prediabetes patients at a large safety net clinic. We conducted focus groups to assess patient perspectives, revised lessons for improved readability and cultural relevance to low-income and Hispanic patients, conducted a feasibility study of the adapted program in English and Spanish speaking cohorts, and implemented real-time adaptations to the program for commercial use and for a larger trial of in multiple safety net clinics. Results. The majority of focus group participants were receptive to the program. We modified the curriculum to a 5th-grade reading level and adapted content based on patient feedback. In the feasibility study, 54% of eligible contacted patients expressed interest in enrolling (n = 23). Although some participants' computer access and literacy made registration challenging, they were highly satisfied and engaged (80% logged in at least once/week). Conclusions. Underserved prediabetic patients displayed high engagement and satisfaction with a digital diabetes prevention program despite lower digital literacy skills. The collaboration between researchers and a digital health company enabled iterative improvements in technology implementation to address challenges in low-income populations.

Little is known about pathways to homelessness among older adults. We identified life course experiences associated with earlier versus later onset of homelessness in older homeless adults and examined current health and functional status by age at first homelessness. We interviewed 350 homeless adults, aged 50 and older, recruited via population-based sampling. Participants reported age at first episode of adult homelessness and their life experiences during 3 time periods: childhood (<18 years), young adulthood (ages 18–25), and middle adulthood (ages 26–49). We used a structured modeling approach to identify experiences associated with first adult homelessness before age 50 versus at age 50 or older. Participants reported current health and functional status, including recent mental health and substance use problems. Older homeless adults who first became homeless before 50 had more adverse life experiences (i.e., mental health and substance use problems, imprisonment) and lower attainment of adult milestones (i.e., marriage, full-time employment) compared to individuals with later onset. After multivariable adjustment, adverse experiences were independently associated with experiencing a first episode of homelessness before age 50. Individuals who first became homeless before age 50 had higher prevalence of recent mental health and substance use problems and more difficulty performing instrumental activities of daily living. Life course experiences and current vulnerabilities of older homeless adults with first homelessness before age 50 differed from those with later onset of homelessness. Prevention and service interventions should be adapted to meet different needs.

BackgroundThe median age of single homeless adults is approximately 50 years. Older homeless adults have poor social support and experience a high prevalence of chronic disease, depression, and substance use disorders. Access to mobile phones and the internet could help lower the barriers to social support, social services, and medical care; however, little is known about access to and use of these by older homeless adults.ObjectiveThis study aimed to describe the access to and use of mobile phones, computers, and internet among a cohort of 350 homeless adults over the age of 50 years.MethodsWe recruited 350 participants who were homeless and older than 50 years in Oakland, California. We interviewed participants at 6-month intervals about their health status, residential history, social support, substance use, depressive symptomology, and activities of daily living (ADLs) using validated tools. We performed clinical assessments of cognitive function. During the 6-month follow-up interview, study staff administered questions about internet and mobile technology use. We assessed participants’ comfort with and use of multiple functions associated with these technologies.ResultsOf the 343 participants alive at the 6-month follow-up, 87.5% (300/343) completed the mobile phone and internet questionnaire. The median age of participants was 57.5 years (interquartile range 54-61). Of these, 74.7% (224/300) were male, and 81.0% (243/300) were black. Approximately one-fourth (24.3%, 73/300) of the participants had cognitive impairment and slightly over one-third (33.6%, 100/300) had impairments in executive function. Most (72.3%, 217/300) participants currently owned or had access to a mobile phone. Of those, most had feature phones, rather than smartphones (89, 32.1%), and did not hold annual contracts (261, 94.2%). Just over half (164, 55%) had ever accessed the internet. Participants used phones and internet to communicate with medical personnel (179, 64.6%), search for housing and employment (85, 30.7%), and to contact their families (228, 82.3%). Those who regained housing were significantly more likely to have mobile phone access (adjusted odds ratio [AOR] 3.81, 95% CI 1.77-8.21). Those with ADL (AOR 0.53, 95% CI 0.31-0.92) and executive function impairment (AOR 0.49; 95% CI 0.28-0.86) were significantly less likely to have mobile phones. Moderate to high risk amphetamine use was associated with reduced access to mobile phones (AOR 0.27, 95% CI 0.10-0.72).ConclusionsOlder homeless adults could benefit from portable internet and phone access. However, participants had a lower prevalence of smartphone and internet access than adults aged over 65 years in the general public or low-income adults. Participants faced barriers to mobile phone and internet use, including financial barriers and functional and cognitive impairments. Expanding access to these basic technologies could result in improved outcomes.

BackgroundDespite the widespread implementation of electronic health records (EHRs), there is growing evidence that racial/ethnic minority patients do not use portals as frequently as non-Hispanic whites to access their EHR information online. This differential portal use could be problematic for health care disparities since early evidence links portal use to better outcomes.ObjectiveWe sought to understand specific barriers to portal use among African American and Latino patients at Kaiser Permanente, which has had a portal in place for over a decade, and broad uptake among the patient population at large.MethodsWe conducted 10 focus groups with 87 participants in 2012 and 2013 among African American and Latino Kaiser Permanente members in the mid-Atlantic, Georgia, and Southern California regions. Members were eligible to participate if they were not registered for portal access. Focus groups were conducted within each racial/ethnic group, and each included individuals who were older, had a chronic disease, or were parents (as these are the three biggest users of the portal at Kaiser Permanente overall). We videotaped each focus group and transcribed the discussion for analysis. We used general inductive coding to develop themes for major barriers to portal use, overall and separately by racial/ethnic group.ResultsWe found that lack of support was a key barrier to initiating portal use in our sample—both in terms of technical assistance as well as the fear of the portal eroding existing personal relationships with health care providers. This held true across a range of focus groups representing a mix of age, income, health conditions, and geographic regions.ConclusionsOur study was among the first qualitative explorations of barriers to portal use among racial/ethnic subgroups. Our findings suggest that uniform adoption of portal use across diverse patient groups requires more usable and personalized websites, which may be particularly important for reducing health care disparities. This work is particularly important as all health care systems continue to offer and promote more health care features online via portals.