High Tech and High Touch (HT2): Transforming Patient Engagement Through Portal Technology at the Bedside
Phase: NA
Conditions: Physician-Patient Relations, Inpatient Facility Diagnoses, Electronic Health Records, Outpatient
Sponsor: Ohio State University

 
 
High Tech and High Touch (HT2): Transforming patient engagement throughout 
the continuum of care by engaging patients with portal technology at the bedside 
NCT02943109 
 
Study Protocol 
 
Prepared By: 
 
Ann Scheck McAlearney, ScD, MS1,2,3,4; Daniel M. Walker, PhD, MPH1,2;  
Naleef Fareed, PhD, MBA2,3; Lindsey Sova, MPH2; Cynthia J. Sieck, PhD, MPH1,2; 
Timothy R. Huerta, PhD, MS1,2,3,4  
  
  
1 Department of Family and Community Medicine, College of Medicine, The Ohio 
State University. 
2 CATALYST, Center for the Advancement of Team Science, Analytics, and 
Systems Thinking in Health Services and Implementation Science Research, 
College of Medicine, The Ohio State University. 
3 Department of Biomedical Informatics, College of Medicine, The Ohio State 
University. 
4 Division of Health Services Management and Policy, College of Public Health, 
The Ohio State University. 
  
 
 
Version 2.0 (December 12, 2019): 
Final pre-analysis Protocol 
Version 2.1 (March 16, 2021): 
Updated to reflect request from external reviewer to 
include sensitivity analysis. 
  
 

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Table of Contents 
 
Section 1: Administrative information 
4 
1.1. 
Clinical trials registration 
4 
1.2 
Ethics approval 
4 
1.3 
Availability of data 
4 
1.4 
Competing interests 
4 
1.5 
Funding 
4 
1.6 
Roles and responsibilities 
4 
1.7 
Acknowledgements 
4 
1.8 
Protocol revisions 
5 
Section 2: Introduction 
9 
2.1 
Background and rationale 
9 
2.2 
Objectives 
9 
Section 3: Study methods 
11 
3.1 
Trial design 
11 
3.2 
Randomization 
14 
3.3 
Blinding 
14 
3.4 
Sample size 
15 
3.5 
Statistical interim analysis and stopping guidance 
15 
3.6 
Timing of final analysis 
15 
3.7 
Study flow 
15 
3.8 
Timing and mode of outcome assessment 
16 
Section 4: Statistical principles 
18 
4.1 
Confidence intervals and p-values 
18 
4.2 
Adherence and protocol deviations 
18 
4.3 
Analysis populations 
19 
Section 5: Trial population 
20 
5.1 
Screening and eligibility 
20 
5.2 
Recruitment 
21 
5.3 
Study withdrawal 
22 
5.4 
Baseline patient characteristics 
22 
Section 6: Data management 
23 

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6.1 
Data sources 
23 
6.2 
Data model 
23 
6.3 
Data processing 
23 
Section 7: References 
28 
 
 
 
 

High Tech and High Touch (HT2) 
 
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Section 1: Administrative information 
 
1.1. 
Clinical trials registration 
This study is registered with clinicaltrials.gov: NCT02943109.  
 
1.2 
Ethics approval 
The Institutional Review Board of The Ohio State University (OSU), College of Medicine 
(COM) approved the study. 
 
1.3 
Availability of data 
The data used in this study includes identifiable information, and per our consent 
approval we are not permitted to share study data. However, the data management 
protocol and analytic approach will be made publicly available via publication.  
 
1.4 
Competing interests 
The authors declare that they have no competing interests to report. 
 
1.5 
Funding 
This work was supported by the Agency for Healthcare Research and Quality (AHRQ) 
Grants R01HS024091, R21HS024767, P30HS024379. While this research was funded 
by AHRQ, the study sponsor had no involvement in the collection, analysis, or 
interpretation of data, in the writing of this article, or in the decision to submit the article 
for publication. 
   
1.6 
Roles and responsibilities 
ASM, TH, JH, CS, DW, AA, LS, MR, SMB designed the study, and with NF, SS, GD, 
SRM, and AG developed and approved the initially submitted version of this manuscript. 
DW and LS wrote the Protocol, and TH was the senior statistician responsible for the 
Protocol. ASM was the Principal Investigator of the study. All authors read and 
approved the final manuscript.  
 
1.7 
Acknowledgements 
The authors would like to thank the following individuals who were affiliated with the 
authors’ organization during the project for their assistance: 
Technical Support: Robert Taylor, Lakshmi Gupta 
Research Associates: Ayanna Scott, Jaclyn Volney, Toby Weinert, Alison Silverman, 
Danijela Cvijetinovic, Karen Alexander, Kimberly Karels 
Administrative: Pamela Thompson 
 
 
 

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1.8 
Protocol revisions 
Revision history of the protocol, including rationale, is provided in Table 1, sorted by date.  
 
Table 1: Amendments to the study protocol (sorted by date).  
 
Date 
 
Revision 
Rationale 
Section 
reference 
February 2016 
Low-Tech intervention: 
Changed from no tablet to Lite-Tech 
intervention with a tablet with a 
limited MyChart Bedside feature 
set.  
Independent of the study, OSUWMC 
decided to implement MyChart 
Bedside system-wide, resulting in it 
not being possible to not provide 
some patients a tablet. 
Section 3.1 
February 2016 
Study site: 
Changed study sites from six 
matched unit pairs to OSUWMC 
system-wide, including six hospitals. 
Independent of the study, OSUWMC 
decided to implement MyChart 
Bedside system-wide, resulting in it 
being feasible to expand the study 
sites across the OSUWMC.  
Section 3.4 
February 2016 
Focus on multiple chronic 
conditions: 
Changed from inclusion criteria of 
two or more chronic conditions to no 
disease restrictions. 
Independent of the study, OSUWMC 
decided to implement MyChart 
Bedside system-wide, resulting in it 
being infeasible to restrict the sample 
based on disease characteristics.  
Section 5.1 
February 2016 
Inclusion criteria: 
Criteria of patient admitted within 
last 24 hours and expected 
discharge in more than 72 hours 
removed.  
The expansion of the study from the 
six matched unit pairs to OSUWMC 
system-wide resulted in logistic 
challenges in being able to reaching 
all patients quickly. Additionally, 
OSUWMC does not store expected 
discharge in its Epic Clarity tables, 
making this criterion impossible to 
operationalize.  
Section 5.1 
February 2016 
Low-Touch intervention: Changed 
from active control where patients 
receive an in-person visit from a 
Technology Navigator (TN) to a 
passive control where patients were 
directed to self-guided learning 
materials built into MyChart 
Bedside. 
Independent of the study, OSUWMC 
decided to implement MyChart 
Bedside system-wide. This change 
increased the number of potentially 
eligible patients for TNs to visit, 
presenting a logistical challenge.  
Additionally, in the original protocol 
where patients assigned to the Low-

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Section 3.1 
Tech arm did not receive a tablet, it 
was not possible to deliver a passive 
control. However, when the protocol 
changed to all study participants 
receiving a Tablet (Full/Lite-Tech), a 
passive control arm was possible. 
This approach resolved the logistical 
challenges.   
December 2016 
Hypotheses: 
The primary and secondary 
hypotheses were revised and 
reduced from seven to four 
hypotheses.  
In the original proposed study, the 
plan was to execute it using 12 units 
and limit the study to chronic 
diseases. Additionally, participants 
were to be randomized to receive no 
technology or a full version of the 
MyChart Bedside application on the 
tablet. OSUWMC made several 
decisions that had an effect on the 
study design. In particular, 
OSUWMC determined that not 
providing a tablet was no longer an 
option; however, they made the units 
across the entire hospital system 
available for the study. The research 
team worked with OSUWMC to 
refine the hypotheses needed to 
reflect the more inclusive study. This 
resulted in dropping readmissions 
and comfort with technology as 
outcomes of interest, among other 
revisions.  
 
Section 2.2 
July 2017 
Improve enrollment yield: 
A research team member may visit 
the patient to remind them to 
complete the survey, limited to three 
visits per patient, once per day. 
Patients without completed surveys 
could also be visited on subsequent 
hospital admissions to complete 
their survey.   
Quality assurance testing of the data 
collection system identified a 
technical problem which caused an 
unusual pattern of missing 
responses. Inspection of 
completeness of questions identified 
a pattern of non-completion such that 
every 5-10 questions, a question 
would demonstrate a considerably 
lower percent missing than the 
questions asked immediately before 
and after it. This pattern was 
attributed to the display of the survey 
on Qualtrics that hid some questions 
from view. A reminder was added to 
the survey to inform respondents if 
they had left questions unanswered 
as they clicked the button to advance 
Section 4.2.1 

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the survey, still allowing them to 
advance if that was their preference.  
 
July 2017 
Study enrollment: 
A confirmation was added to each 
page of the survey to inform 
respondents when they had left 
questions unanswered on a page. 
They could continue to advance if 
that was their preference. 
 
Completion of the survey was found 
to limit the number of patients in the 
High-Touch study arm. This change 
represented a deviation from the 
original protocol which had required 
that the Admission survey be 
completed prior to intervention 
delivery. 
 
Section 4.2.1 
February 2018 
Study allocation: 
The allocation of individuals in arms 
were rebalanced to ensure sufficient 
numbers of participants in the High-
Touch treatment arm due to a 
significant number of patients 
becoming lost to follow-up. 
Quality monitoring of the study found 
a number of exogenous factors that 
were impacting the High-Touch 
intervention, including, but not limited 
to: patient discharges; patient moves 
to other rooms; patients not present 
during rounding; patients’ 
engagement with the care team; and 
tablet returns prior to receiving an 
intervention. This change was done 
to ensure that sufficient individuals 
were assigned to the High-Touch 
intervention to increase the number 
of patients who would be eligible to 
receive a High-Touch intervention. 
 
Section 3.1.3 
March 2018 
Intervention available after 
consent: 
TNs are allowed to make first 
contact for the High Touch 
intervention once the patient 
consented – no longer waiting for a 
complete Admission Survey. The 
TN should work with the patient to 
walk them through completing the 
survey during the intervention. 
 
As noted in Section 3.1.3 changes 
were made to the intervention 
protocol to facilitate greater 
engagement in the High-Touch arm. 
Specifically, prior to February 2018, 
participants assigned to the High-
Touch intervention group did not 
receive the intervention until after 
they had completed the Admission 
survey. Starting on February 22, 
2018, the research team modified the 
protocol to allow TNs to mark a 
survey as complete and allow the 
intervention team to perform the 
High-Touch intervention. In March 
2018, 22 days later, the protocol was 
once again changed to deliver the 
High-Touch intervention at first 
contact with the TN if they had been 
assigned to the High-Touch 
intervention.  
 
Section 4.2.1 

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July 2018 
Intervention assignment: 
Individuals that had activated a 
MyChart Bedside account prior to 
the study start or in a Full-Tech unit 
were manually assigned to the Full-
Tech intervention regardless of their 
MRN. Individuals who were found to 
have accessed both Full and Lite 
versions over the course of the 
study were excluded from the 
analysis for this study.  
 
Quality assurance testing of ongoing 
data collection of the MyChart 
Bedside usage data revealed that 
patients who were to have been 
assigned to Lite-Tech based on their 
MRN were, in fact, using functions 
only available on Full-Tech. 
Subsequent review also found the 
reverse to be true, participants that 
were assigned to Full-Tech were 
limiting their usage to those functions 
in Lite-Tech.  
 
The study team conferred with Epic–
the electronic health record (EHR) 
vendor that developed the code to 
assign patients to a particular arm of 
Tech status–and manually 
reconstructed Tech assignment 
using the original assignment code. 
A cohort of individuals were identified 
as not having received the intended 
Tech assignment. Through this 
process, the study team was able to 
secure the true Tech intervention 
status. Individuals that had activated 
a MyChart Bedside account or were 
in a Full-Tech unit prior to the study 
start were manually assigned to Full-
Tech regardless of their MRN. 
Additionally, individuals who were 
found to have accessed both Full 
and Lite versions over the course of 
the study were identified and 
subsequently excluded from the 
analysis for this study. This scenario 
may have occurred when a patient 
was assigned an MRN at admission 
but subsequent records review 
identified an existing MRN. In these 
cases, individuals unexpectedly 
transitioned between two Tech 
intervention states. 
 
Section 4.2.1 
 
 

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Section 2: Introduction 
 
2.1 
Background and rationale 
For patients with complex care needs, engagement in disease management 
activities is particularly critical.1-4 The human cost of chronic illnesses touches almost 
every person in the US. These costs are real, personal and pervasive.5 In response, 
patients often seek out tools to help them manage their health. Patient portals–a 
Personal Health Record (PHR) tethered to an Electronic Health Record (EHR)–show 
promise as tools that patients accept and value and that can improve health.6-10 
Although patient portals currently focus on the outpatient experience, the Ohio State 
University Wexner Medical Center (OSUWMC) has deployed a portal designed 
specifically for the inpatient experience that is connected to the ambulatory patient 
portal available after discharge. While this inpatient technology is in active use at only 
one other hospital in the US, healthcare facilities are currently investing in the 
infrastructure necessary to support large-scale deployment.11 
Times of acute crisis such as hospitalization may increase a patient’s focus on 
his/her health, a factor that has been linked in other areas to a greater awareness of 
health risks and increased focus on health behaviors.12-14 During this time, patients may 
be more engaged with their care and therefore particularly interested in the potential for 
using tools to manage their health after discharge. Evidence shows that enhanced 
patient self-management can lead to better control of chronic illness,1,15,16 and patient 
portals may serve as a mechanism to facilitate increased engagement.17-19 
Our proposed four-year study used a mixed-methods approach to evaluate a 
pragmatic randomized controlled trial (RCT) studying the effectiveness of a High-Tech 
Intervention (MyChart Bedside, the inpatient portal), and an accompanying High-Touch 
Intervention (training patients to use the portal to manage their care and conditions) in a 
sample of hospitalized patients. This study measured how a patient portal tailored to the 
inpatient stay could improve patient experience and increase patient engagement by 1) 
improving patients’ perceptions of the process of care while in the hospital, 2) increasing 
patients’ self-efficacy for managing their health and health care, and 3) facilitating 
continued use of a patient portal for care management activities after discharge. In 
addition, we aimed to enhance patients’ use of the patient portal available to 
outpatients, MyChart, once they were discharged. 
 
2.2 
Objectives 
The High Tech and High Touch (HT2): Transforming patient engagement 
throughout the continuum of care by engaging patients with portal technology at 
the bedside study at OSU Wexner Medical Center (OSUWMC) sought to study how the 
deployment of a commercial (i.e., Epic Systems) inpatient portal, MyChart Bedside, 
impacted identified patient outcomes. To evaluate the impact of function set and training 

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on inpatient (i.e., MyChart Bedside) and outpatient (i.e., MyChart) portal use, the HT2 
Study20 was designed as a large-scale, pragmatic randomized controlled trial across six 
hospitals in a healthcare system.  
Using a two-by-two factorial design, HT2 simultaneously examined the effects of two 
approaches to portal training with two versions of the inpatient portal. HT2 was 
designed to test four study hypotheses: 
Hypotheses related to primary outcomes: 
H1: Patients assigned to the High intervention levels for Tech and Touch will 
demonstrate higher use of MyChart Bedside. 
 
H2: Patients assigned to the High intervention levels for Tech and Touch will 
demonstrate higher levels of satisfaction with (H2a) and involvement in (H2b) 
their care experience. 
 
Hypotheses related to secondary outcomes: 
H3: Patients assigned to the High intervention levels for Tech and Touch will 
demonstrate higher rates of outpatient portal adoption (i.e., of Epic’s MyChart) for 
those admitted without prior outpatient portal use (H3a), and higher use of 
MyChart for those admitted who had previously used the outpatient portal (H3b). 
 
H4: Patients assigned to the High intervention levels for Tech and Touch will 
demonstrate higher levels of self-efficacy. 
 
To prevent outcome reporting bias and data-driven analysis of results, we produced this 
detailed statistical analysis plan. The plan was originally developed and drafted prior to 
examination of the data, and in the absence of randomization knowledge. The plan has 
been revised as the analysis has proceeded.   
 
 
 

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Section 3: Study methods 
 
3.1 
Trial design 
This study was designed as a pragmatic factorial randomized controlled trial of two 
concurrent patient portal-related interventions. 
 
3.1.1 Intervention description: Tech - Full/Lite 
The Full-Tech intervention consisted of the standard build of the MyChart Bedside 
product as delivered from Epic and augmented by OSUWMC at the start of the study. 
The application was served by a Home landing page that displays events scheduled for 
the day and recent health updates and included access to 10 additional functions 
located in tabs along the side of the inpatient portal image: 
 
1. Home: presented events scheduled for the day and data on patient vitals, 
including last blood pressure reading, current pulse and other patient vital signs 
refreshed from the Electronic Health Record (EHR) once every 5 minutesi 
2. Bedside Tutorial: tutorial materials for the use of MyChart Bedside, including an 
11-minute video explaining how to use MyChart Bedside and access to PDF 
versions of tutorial materials 
3. Dining on Demand: food ordering service  
4. To Learn: educational resources for the patient based on their treatment plan 
5. Happening Soon: a timeline for the care activities that the patient could expect for 
the day 
6. Taking Care of Me: information detailing members of the patient’s care team 
7. Messages: non-urgent secure messaging with the patient’s care team 
8. My Health: recent vital signs and lab test results 
9. Notes: write/record reminders and notes 
10. I Would Like: non-urgent requests from pastoral care or gift shop 
11. OSU MyChart: allowed the patient to access MyChart, including creating a new 
account 
 
In addition to the Home landing page, the Lite-Tech version of MyChart Bedside 
consisted of the 3 functions: Bedside Tutorial, Dining on Demand, and To Learn. 
  
3.1.2 Intervention description: Touch - High/Low 
The education and training intervention, referred to as Touch, was performed by trained 
Technology Navigators (TNs) who deliver training tailored to both the version of 
 
i This function was automatic, so was not considered selectable and not included in the count of functions 
for either the Full- or Lite-Tech versions. 

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MyChart Bedside installed on their tablet (both Full- and Lite-Tech) and the perceived 
capacity of the patient. 
 
Patients assigned to the Low-Touch intervention received an intervention focused on 
providing them with resources to conduct self-guided learning of MyChart Bedside.  
Specifically, TNs directed patients to the tutorial videos integrated in the MyChart 
Bedside application that explained the portal’s functions.  
 
In contrast, patients assigned to the High-Touch intervention would systematically 
review each of the functions of MyChart Bedside with the TN who would discuss how 
and when they are appropriately used. Patients were encouraged to use their tablet and 
follow along with the training as the TN moved through each function and ask the TN 
questions about their records during the presentation. The TNs tailored their 
presentation based on a patient’s demonstrated knowledge of the technology to 
minimize patient participation burden while focusing on explaining the value of each 
function within the application. Patients unavailable after three intervention attempts 
were converted to Low-Touch.  
 
3.1.3 Allocation ratio 
The Tech intervention contrasted two function sets–Lite-Tech (40% allocation), which 
was a minimalistic toolset focused on providing basic data to the patient, and Full-Tech 
(60% allocation), a more expansive toolset. The Touch intervention contrasted two 
training approaches–Low-Touch, a self-guided approach where patients could view 
built-in tutorials, and High-Touch (initially 50% allocation), where patients receive in-
person guided training with the technology. The realized allocation ratios are presented 
in Table 2. 
 
 
 

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Table 2.  Realized allocation ratio. 
Tech Allocation 
Touch Allocation 
 
High 
Low 
Total 
Full 
    Frequency 
    Row % 
    Column % 
    Overall % 
 
624 
29.1% 
69.3% 
21.6% 
 
1,523 
70.9% 
76.5% 
52.7% 
 
2,147 
100.0% 
74.2% 
74.2% 
Lite 
    Frequency 
    Row % 
    Column % 
    Overall % 
 
277 
37.2% 
30.7% 
9.6% 
 
468 
62.8% 
23.5% 
16.2% 
 
745 
100.0% 
25.8% 
25.8% 
Total 
    Frequency 
    Row % 
    Column % 
    Overall % 
 
901 
31.2% 
100.0% 
31.1% 
 
1,991 
68.8% 
100.0% 
68.8% 
 
2,892 
100.0% 
100.0% 
100.0% 
 
The assignment protocol used three phases where the Touch allocation ratio was 
changed by the research team. 
1. In Phase 1, patients received the High-Touch intervention only after consenting 
to the study and submitting their Admission survey (see Section 3.8.2). Low-
Touch patients could view the tutorial at any point and were not required to 
complete the Admission survey. Phase 1 assigned patients to High/Low-Touch in 
a 1:1 ratio.   
2. In Phase 2, beginning in February 2018, the study shifted to a 3:1 ratio of 
High/Low-Touch. This change was done to ensure that sufficient individuals were 
assigned to the High-Touch intervention due to under-enrollment. Quality 
monitoring of the study found a number of exogenous factors that were impacting 
the High-Touch intervention, including, but not limited to: patient discharges; 
patient moved to other rooms; patient not present during TN rounding; patient 
was engaged with the care team and unable to work with the TN; and tablet 
returned prior to receiving an intervention. This change in the ratio was intended 
to increase the number of patients who would be eligible to receive a High-Touch 
intervention while maintaining the per protocol approach in that these exceptions 
were considered a component of the Protocol. 
3. Phase 3 began in March 2018 and lasted through the end of the study in 
September, 2018. This phase maintained the 3:1 split, but removed the 
requirement that patients complete the Admission survey prior to receiving the 
High-Touch intervention. Completion of the survey was found to limit the number 
of patients in the High-Touch study arm. This change represented a deviation 

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from the original protocol which had required that the Admission survey be 
completed prior to intervention delivery (see Section 4.2.1). 
 
3.2 
Randomization 
Participants were randomized into each arm of each intervention, Tech and Touch, in 
separate processes. 
 
3.2.1 Tech randomization 
Tech randomization was accomplished using a 4-digit random number table generated 
using Stata version 14.0 which was used as a comparison table against the last four 
digits of the patient’s Medical Record Number (MRN) which was assigned prior to study 
assignment. A preliminary simulation analysis found that random assignment using this 
model created appropriately sized groups of 40% and 60%. 
 
Individuals who had access to the Full version of MyChart Bedside prior to enrollment in 
the study (i.e., those patients who were admitted to the Cancer Center, which was not 
included as a site, or patients who had used MyChart Bedside during the pilot phase of 
implementation in which only Full-Tech was available) maintained their Full-Tech status 
and were excluded from randomization if they were transferred to a unit included in the 
study.  
 
3.2.2 Touch randomization 
The study protocol included a series of robust approaches to randomization. Generally, 
Touch randomization occurred at consent using the randomizer function in Qualtrics 
which was used for both consent and survey data collection. The Protocol included a 
procedure for the assignment of Touch in cases where the patient was checked in after 
daily census and was not included in the Qualtrics randomization (i.e., due to timing of 
reconciliation between report pulls and the start of the work day). In those cases, a 
predefined randomization table was used to assign Touch status.  
 
3.3 
Blinding 
Both the standard and alternate processes for Touch assignment occurred prior to study 
consent and therefore the TN, the patient, and the care team were blind to their study 
assignment at consent. Additionally, at the time of provisioning, both the patient and the 
nurse that assigned the patient the tablet were blind to Tech assignment. TNs providing 
the intervention were blind to Tech assignment prior to consent, but not prior to study 
eligibility assessment. 
 

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3.4 
Sample size 
The study did not adopt a sampling frame and represented a census approach to the 
implementation. The Consort Diagram (see Figure 1), provides information on the 
pragmatic factors that limited enrollment. 
 
The original protocol calculated power based on 2016 Hospital Consumer Assessment 
of Healthcare Provider and Systems (HCAHPS) patient satisfaction scores as a 
baseline for outcome measures using G*Power 3.1 software. An expected enrollment of 
3,872 was planned with the design expected to be sensitive enough to identify changes 
of between 2.2% and 3.8% across the panel of HCAHPS patient satisfaction scores. 
 
3.5 
Statistical interim analysis and stopping guidance 
No interim analyses were planned or conducted for our study. Since HT2 posed minimal 
risk, stopping guidance was not applicable.  
 
3.6 
Timing of final analysis 
HT2 was a minimal risk study, and as a result, final outcomes and their association with 
the interventions were reviewed only upon study completion.  
 
3.7 
Study flow 
Patient participation in the study followed the CONSORT diagram shown in Figure 1. 
 
 
 
  
16,110: Study eligible patients
2,944: Declined study participation
9,384: Other exclusions
3,782: Enrolled study 
participants 
1,242: Randomized to High-Touch
     624: Received intended treatment
623: Admission survey responses
154: 15-day Post-discharge survey 
responses
150: 6-month Post-discharge 
survey responses
905: Randomized to Low-Touch
     1,523: Received intended 
treatment
1,480: Admission survey responses
187: 15-day Post-discharge survey 
responses
346: 6-month Post-discharge survey 
responses
470: Randomized to High-Touch
     277: Received intended 
treatment
276: Admission survey responses
58: 15-day Post-discharge survey 
responses
82: 6-month Post-discharge survey 
responses
275: Randomized to Low-Touch
     468: Received intended 
treatment
456: Admission survey responses
60: 15-day Post-discharge survey 
responses
95: 6-month Post-discharge survey 
responses
Hospital protocol for tablet eligibility for 
available units
620: To Full-Tech/ Low-Touch 
per protocol
194: To Lite-Tech/ Low-Touch 
per protocol
Data processing exclusions:
734: Enrollment admission <3 days
 17: No MyChart Bedside use
139: Switched tech assignment
2,147: Randomized to Full-Tech 
745: Randomized to Lite-Tech 
1: To Lite-Tech/ High-Touch per 
protocol
2: To Full-Tech/ High-Touch per 
protocol
Figure 1. CONSORT diagram.  

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3.8 
Timing and mode of outcome assessment 
The outcomes for this study included measures of use of both the inpatient and 
outpatient portal as well as measures of satisfaction and self-efficacy. 
 
3.8.1 Portal usage 
MyChart Bedside and MyChart usage was determined through the use of log file 
analysis (LFA). The methods associated with LFA have been extensively discussed in 
methods papers published by the research team. Log files provided the date, time, and 
type of interaction with each of the functions in both of the patient portals. The log file 
data that was available included: 
 
1. Login date and time 
2. Functions accessed 
3. Activity notes 
  
Log files were linked to the patient MRN within the Epic Clarity clinical data record. 
MyChart Bedside and MyChart log files were obtained in an identified form for study 
participants for purposes of matching this data to Admission and Post-discharge 
surveys and follow-up interviews (see Section 6 - Data Management). 
 
3.8.2 Satisfaction and self-efficacy 
Data on satisfaction and self-efficacy were collected via survey at enrollment (referred 
to as the Admission survey), between 10 and 21 days post-discharge (referred to as the 
15-day Post-discharge survey) and, finally, at six months post-discharge (referred to as 
the 6-month Post-discharge survey). The three surveys each gathered data on the 
outcomes to allow for comparisons at different time points. 
 
The Admission survey included questions related to self-efficacy, hospital satisfaction, 
and patient experience. The Admission survey was administered in two modes: a paper 
form and electronically. The electronic survey was created and collected using Qualtrics 
online survey software. Patients accessed the survey via the MyChart Bedside portal. 
The default administration mode was electronic; paper forms were only given if the 
patient requested it or encountered a technical issue with the hospital-issued tablet that 
affected their ability to complete the survey electronically.  
 
3.8.3 Post-discharge survey administration 
Both the 15-day and 6-month Post-discharge surveys were administered based on the 
communication preference of the participant. During the consent process, participants 
were asked to identify a communication preference–email or phone–through which they 

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would be contacted for the follow-up surveys. The study team developed a robust 
communication approach that would initiate contact based on stated preference, allow 
for participants to change their preference throughout the study, and would leverage 
alternate approaches if the participant could not be reached using their preferred 
approach. When email was used, the research team would send the participant an 
invitation and a link to the Qualtrics online survey and up to three reminders. When a 
phone call was used, the research team would attempt up to three calls. 
Communication efforts for Post-discharge surveys began 10 days post-discharge from 
the enrollment admission and 24 weeks post-discharge from the enrollment admission. 
 
 
 
 

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Section 4: Statistical principles 
 
4.1 
Confidence intervals and p-values 
For all statistical tests, a p-value of 0.05 was used to assess significance and 95% 
confidence intervals were reported. No adjustments were made for multiple hypothesis 
testing.  
 
4.2 
Adherence and protocol deviations 
The HT2 study was designed as a pragmatic study with the interventions conducted 
using a per protocol approach. 
 
Protocol deviations 
Protocol deviations may have occurred if: 
1. a participant consented to participate in the study but subsequently requested a 
change in Tech status to the OSUWMC; 
2. a participant was admitted to the OSUWMC, was assigned to the Lite 
intervention, and was subsequently admitted to a unit that always received the 
Full version of MyChart Bedside. 
 
In these cases, the individual was removed from the study. 
 
4.2.1 Operational protocol amendments 
Operational protocol amendment 1: Improve enrollment yield (Jan 2017) 
A research team member could visit the patient to remind them to complete the survey, 
limited to three visits per patient, once per day. Patients without completed surveys 
could also be visited on subsequent hospital admissions to complete their survey.   
 
Operational protocol amendment 2: Improve data quality (Jul 2017) 
A confirmation was added to each page of the survey to inform respondents when they 
had left questions unanswered on a page. They could continue to advance if that was 
their preference. 
 
Operational protocol amendment 3: Intervention available after consent (Feb 2018) 
TNs were allowed to make first contact for the High-Touch intervention once the patient 
consented–no longer waiting for a complete Admission survey. The TN should work 
with the patient to walk them through completing the survey during the intervention. 
 
Operational protocol amendment 4: Intervention assignment (Mar 2018) 
Individuals that had activated a MyChart Bedside account or were in a Full-Tech unit 
prior to the study start were manually assigned Full-Tech regardless of their MRN. 

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Individuals who were found to have accessed both Full and Lite versions over the 
course of the study were to be excluded from the analysis for this study.  
 
4.3 
Analysis populations 
The analytic population of the study used a per protocol approach. Using this paradigm, 
study participants assigned to the High-Touch group that did not receive the High-Touch 
intervention were reassigned to the Low-Touch group. In rare instances (n=3) where a 
patient was assigned to the Low-Touch group but received the training intervention due 
to patient request, they were reassigned to the High-Touch group. 
 
 

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Section 5: Trial population 
 
5.1 
Screening and eligibility 
All admitted patients were screened at admission by nursing staff for eligibility to use a 
standardized tablet and the associated MyChart Bedside application based on the 
following protocol, developed by OSUWMC: 
 
1. Patients must have been admitted to a hospital in the OSUWMC system where 
MyChart Bedside has been deployed. 
2. Patients must have been capable of accepting the tablet terms of service. 
3. Patients must not have had an excluded status, which were: 
a. less than 18 years old; 
b. legally blind; 
c. cannot speak and/or read English; 
d. involuntarily confined or detained; or, 
e. be considered as having a diminished decision-making capacity. 
 
Nursing staff used their judgement in terms of whether a patient may have had an 
additional reason for exclusion and documented those reasons in the EHR. Acceptable 
reasons for exclusion included that the patient declined to use a tablet or the patient 
was not coherent at the time the nursing staff was rounding for the purpose of providing 
tablets. Patients were provided Android tablets by the medical center for use during 
their stay. The provisioning process defined the patient population and was outside of 
the scope of the study. 
 
5.1.1 Inclusion criteria 
Study inclusion criteria were as follows: 
1. patient accepted tablet and use of MyChart Bedside; 
2. patient was available in their room; and,  
3. patient was capable of informed consent. 
 
Only patients who were provisioned with MyChart Bedside were included in the study.  
 
5.1.2 Exclusion criteria 
Study exclusion criteria were as follows: 
1. the patient was less than 18 years of age. 
 
The inclusion criteria, by design, means that family and proxy users were excluded from 
the study. 
 

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5.2 
Recruitment 
The AMC Epic Clarity tables were used to develop a fully identified custom Census 
Report which provided information on all patients who met the inclusion criteria present 
in the hospital at midnight of each day. The research team integrated this report with the 
study database to create a daily list of individuals that had consented, refused, not been 
provided a tablet, or were eligible for being visited by a TN during TN rounding. This 
information was used to set up a rounding schedule to visit the rooms of these patients 
to follow up about study participation as follows: 
1. In cases where a patient had not been provisioned and there were no clinical 
notes detailing a rationale for the withholding of access, members of the research 
team would approach the nursing team and ask them to make a formal 
determination about the appropriateness of the tablet for the patient. 
2. In cases where a patient was provisioned, the study team would put the patient 
on the rounding schedule and attempt to recruit them to the study. 
 
5.2.1 Study enrollment, participation, and remuneration 
Eligible identified patients were invited to participate in the study via a link in MyChart 
Bedside which presented an electronic combined HIPAA authorization and consent 
form approved by the AMC’s Institutional Review Board (IRB) for patients to sign to 
authorize extraction of identified clinical data. Study staff approached eligible patients to 
identify their interest in participation. Interested patients were guided to the tab within 
MyChart Bedside that explained that participation included the following tasks and 
consent: 
1. a survey to be taken immediately upon completing consent (the Admission 
survey); 
2. two surveys that would be taken by phone or via an emailed link; 
a. The 15-day Post-discharge survey 
b. The 6-month Post-discharge survey 
3. additionally, patients were notified that they may be contacted for up to two 
telephone interviews: within 21 days of discharge and at approximately 6 months 
post-discharge. Not all individuals would be invited to participate in these 
interviews; 
4. consent to share their clinical data, including the log files associated with their 
use of patient portals. 
 
Upon completion of each survey, participants had the option to enter contact information 
on a separate page for a raffle of a $100 gift card and for future follow-up for additional 
surveys and interviews. One gift card was raffled off each week throughout data 
collection.  
 

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Participants were provided the option to request a paper combined HIPAA authorization 
and consent form to sign, delivered by a study team member. Participants received an 
electronic copy of the signed combined HIPAA authorization and consent form or a 
paper version from a study team member within 24 hours. If the patient had been 
discharged, a paper version was mailed to the address on file. 
 
5.3 
Study withdrawal 
All data collected during the period as study participants was included in the analysis. 
Individuals who chose to withdraw were, in effect, refusing to contribute further data, 
including the following: 
1. Patients who removed themselves from the study prior to discharge in the 
admission in which they are enrolled had no data about them included in the 
study. 
2. Patients who removed themselves from the study after discharge in the 
admission in which they are enrolled had the Admission survey data and 
MyChart Bedside use data about them included in the study, but depending on 
when they withdrew, may not have any data about them included as part of either 
of the Post-discharge surveys. 
3. Patients who were not reachable after discharge for the 15-day Post-discharge 
survey were not considered lost to follow-up, and contact was attempted for the 
6-month Post-discharge survey. 
 
5.4 
Baseline patient characteristics 
Baseline characteristics were summarized, including age (median), gender (male, 
female percentages), race (White, Black, Other percentages), length of stay (days), and 
the Charlson comorbidity index (median, treated as a continuous score). Baseline 
characteristics were compared using analysis of variance (ANOVA) or t-tests, as 
appropriate, to examine equivalence between the four study arms.  
 
 
 
 

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Section 6: Data management 
 
6.1 
Data sources 
Data for this study was merged from two sources–one delivered from surveys 
promulgated by Qualtrics, a cloud-based survey system, and the other from the 
OSUWMC Epic Clarity tables. Data was kept in separate tables in accordance with the 
study data model. 
6.2 
Data model 
Five tables were used in the data model used for this study. Figure 2 illustrates the 
entity data diagram for each table in the data model and their relationship. 
 
 
 
 
Data Tables 1 and 2 provided data related to the participant. Intervention data was 
written into Qualtrics records from the EHR via a passthrough using a secure 
application programming interface (API). Data Tables 3 and 4 provided data about the 
patient’s encounter history during the study period as well as their use of the inpatient 
portal for each visit. Data Table 5 provided data about the use of the outpatient portal, 
which therefore meant it was not related to a specific encounter. Where possible, the 
original data in the associated Epic Clarity tables were delivered to the research team, 
including the Admission/Discharge/Transfer (ADT) table. This approach was used to 
ensure that joins were completed by the research team as opposed to an intermediate 
data broker and ensure data quality. 
 
6.3 
Data processing 
As noted in Section 6.2, data from the original Epic Clarity tables were provided to the 
research team. This process was deemed necessary, as quality testing of the data 
found a number of join errors that created issues when using the study and EHR 
Figure 2. Entity data diagram.   

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derived data. We detailed ten specific data quality issues that were found and resolved 
in the data quality assurance testing. 
 
6.3.1 Multiple MRNs 
MRNs were used as primary identifiers by both the hospital and in the context of the 
study. Moreover, MRNs were used throughout data processing to associate data with a 
unique patient. Typically, each unique patient had a single, unique MRN. In rare cases, 
for instance when a patient presented in the emergency room and was unable to 
provide identification, a patient may have been temporarily issued an MRN. While 
hospital records are adjusted to ensure a single, unique MRN at a later time, data was 
written to the log files with the temporary MRN. Patients with multiple MRNs were 
identified, along with their duplicate MRNs, and the identifiers were recoded to a 
“primary” MRN in the processed data. 
 
6.3.2 Combining hospital encounters 
In preliminary data processing, it was discovered that the ADT report contained both 
overlapping admissions as well as two separate admissions within close time proximity. 
These scenarios commonly occurred when an individual moved facilities for diagnosis 
and treatment; for instance, in the case of an individual in the general hospital moving to 
the heart hospital for testing. To resolve these issues, data analysts merged admissions 
within 4 hours of each other, as well as overlapping admissions, and considered them a 
single admission. Data quality tests found that approximately 9% of discharge-
subsequent admission and overlaps were resolved by this threshold. In cases where a 
discharge was recorded and a subsequent admission was recorded more than four 
hours later, that admission was deemed to be a new, separate admission. 
 
6.3.3 Matching admission surveys to a patient encounter 
Both the MRN and the date and time of the start of the Admission survey was used to 
match an Admission survey to a specific patient encounter in the ADT table. However, 
Admission surveys were collected using two modalities–electronic and paper–the latter 
of which did not produce an electronic timestamp for survey start. In the first case, 
electronic data capture via the Qualtrics-hosted survey, MRN, and survey start/stop 
times were written to Data Table 2, however in cases where paper surveys were used, 
no such recording of start/ stop time was automatically recorded. In this latter case, the 
date and estimated time the survey was delivered was recorded in a separate 
administrative data system that included study team notes, which was merged into Data 
Table 2 after study completion. Given that dates, but not time, were used for merging, 
there was high confidence in this merging approach. Subsequent data checks provided 
quality assurance of this approach. 
 

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6.3.4 Merging use with encounters 
There was no existing unique key to match MyChart Bedside use to hospital encounter 
data. To merge inpatient encounters with MyChart Bedside usage data, the merged 
encounter data discussed in 6.3.2 was used to establish admission and discharge dates 
and times. In these cases, the timestamp on the MyChart Bedside audit files was 
matched and used to link a user action to a specific encounter. Some user actions, 
approximately 1.5% of the raw MyChart Bedside log files, fell outside the encounter 
periods defined using the ADT record. Any actions that occurred outside an encounter 
period were dropped from further analyses.  
 
6.3.5 MyChart Bedside user actions 
MyChart Bedside log file data included 58 total actions that a user could perform. These 
actions could be classified into two categories: active and passive actions. Active 
actions were user initiated, required user engagement, and had exclusive and reliable 
representation in the log file across the entire study time frame. For example, sending a 
message action only occurred when an individual initiated a message send in MyChart 
Bedside. Passive actions occurred automatically, were non-exclusive, and were 
unreliable. For example, every five minutes the tablet refreshed telemetry data through 
no action of the patient. As a result, the research team sought to identify all active 
actions and associated them with one of the 10 functions offered in MyChart Bedside.  
 
6.3.6 Survey data cleaning 
Occasionally, respondents to the paper survey chose multiple responses to single 
response question. Such responder error was treated as non-response.  
 
6.3.7 Merging billing data with encounters 
Patient encounters and billing data may not have merged uniquely, as a single hospital 
charge record often incorporated multiple hospital encounters. Approximately 4.6% of 
the encounter dataset had billing data associated with multiple encounters. Additionally, 
because of the processing choice to merge close and overlapping encounters, multiple 
charges could have been associated with a single encounter. While the billing data was 
neither reported nor associated with a primary or secondary outcome, the study team 
thought it important to disclose its existence as part of this protocol document, as 
subsequent exploratory data analysis in other papers may refer to this data. 
 
6.3.8 Additional exclusions 
Several cases were identified post-hoc that created additional exclusions: 
1. A negligible number of patients were enrolled in the study and in a subsequent 
visit were admitted as prisoners. In these cases, the enrolled participants were 
dropped from the analysis. 

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2. Study participants were dropped from the data if they withdrew from the study 
and were enrolled for less than three days. The study team determined that in 
these cases, the patient effectively indicated the intent to not be part of the study, 
despite originally agreeing to participate in the research. 
3. Study participants with a length of stay less than three days were also dropped 
from the analysis. In prior work, it was determined that provisioning of tablets was 
not consistent for patients with length of stay less than three days.20  
4. Study participants with no MyChart Bedside use in their enrollment admission 
were excluded from analysis. These cases may have occurred because an 
individual was enrolled into the study using a paper survey, but then never 
received their tablet. 
 
6.3.9 Multiple surveys 
Initial survey data processing revealed that some patients began multiple Admission 
surveys. Specifically, 322 patients had more than one survey, with a total of 719 
multiple surveys. These cases were commonly related to technical issues with the 
Qualtrics survey system experienced by the patient, for example in the case of a loss of 
wireless connectivity. In these cases, patients would frequently log back into the system 
and attempt to complete the survey again. The research team developed a set of 
heuristics to determine which survey responses to keep (see Table 3).  
 
 

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Table 3. Multiple survey heuristics. 
Rule 
Cause 
Description 
Potential reason 
Number 
of 
surveys 
dropped 
1 
Empty 
surveys 
If a patient had 
multiple surveys and 
at least one was non-
empty, the empty 
surveys were 
dropped. 
Loss of connectivity could 
have created multiple empty 
survey records. 
228 
2 
Paper 
surveys 
When a patient had 
both electronic and 
paper survey, the 
electronic survey was 
dropped. 
Patients started an 
electronic survey and then 
changed their preference 
and asked for paper. 
94 
3 
Intervention 
check 
When a patient had 
more than one survey 
attempt, the survey 
attempt that occurred 
in the same admission 
as the study 
intervention or 
interaction with the 
study team was kept. 
Patients were discharged 
before the study team was 
able to perform an 
intervention. Subsequently, 
they were readmitted, 
attempted a new survey, 
and received an intervention 
or interacted with the study 
team. The first survey was 
discarded. 
11 
4 
Recent 
admission 
When a patient had 
more than one survey, 
the survey attempt 
from the most recent 
admission was kept. 
Patients with multiple 
admissions and multiple 
survey attempts that did not 
receive an intervention or 
interaction with the study.  
4 
5 
Completion 
rate 
For patients who still 
had more than one 
survey attempt, only 
surveys with greater 
than 60% completion 
rate were kept. 
Patients with multiple 
survey attempts within a 
single admission.  
5 
 
 
In the 71 cases where a participant completed more than one survey at greater than 
60%, the research team adopted the following question level heuristic to identify the 
patient’s answer: 
           

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1.    If a question was completed in only one survey attempt, that response was kept 
2.    If a question was the same in all survey attempts, that response was kept 
3.    If a question response was ever in conflict, that response was treated as missing 
 
6.3.10 Missing Touch intervention date 
The date of receipt of a High-Touch intervention was supposed to be recorded for each 
patient in Qualtrics in an administrative data system. In rare instances, this date was 
missing. For these instances, intervention delivery date was identified from study notes 
made by the TNs about patient visits that included dates and details of encounters and 
was entered manually. 
 
Section 7: References 
 
1.  Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of 
chronic disease in primary care. JAMA 2002;288:2469-75. 
2.  Coleman MT, Newton KS. Supporting self-management in patients with chronic 
illness. Am Fam Physician 2005;72:1503-10. 
3.  Smith SM, Soubhi H, Fortin M, Hudon C, O'Dowd T. Managing patients with 
multimorbidity: systematic review of interventions in primary care and community 
settings. BMJ 2012;345:e5205. 
4.  US Department of Health Human Services. Multiple chronic conditions–a strategic 
framework: optimum health and quality of life for individuals with multiple chronic 
conditions. Washington, DC: US Department of Health and Human Services 
2010;2. 
5.  Wu S, Green A. Projection of chronic illness prevalence and cost inflation. Santa 
Monica, CA: RAND Health; 2000. 
6.  Demiris G, Afrin LB, Speedie S, et al. Patient-centered applications: use of 
information technology to promote disease management and wellness. A white 
paper by the AMIA knowledge in motion working group. J Am Med Inform Assoc 
2008;15:8-13. 
7.  Halamka JD, Mandl KD, Tang PC. Early experiences with personal health records. 
J Am Med Inform Assoc 2008;15:1-7. 
8.  Hess R, Bryce CL, Paone S, et al. Exploring challenges and potentials of personal 
health records in diabetes self-management: implementation and initial 
assessment. Telemed J E Health 2007;13:509-17. 
9.  Kaelber DC, Jha AK, Johnston D, Middleton B, Bates DW. A research agenda for 
personal health records (PHRs). J Am Med Inform Assoc 2008;15:729-36. 
10. Wald JS, Middleton B, Bloom A, et al. A patient-controlled journal for an electronic 
medical record: issues and challenges. Stud Health Technol Inform 2004;107:1166-
70. 
11. Agarwal R, Anderson C, Zarate J, Ward C. If we offer it, will they accept? Factors 
affecting patient use intentions of personal health records and secure messaging. J 
Med Internet Res 2013;15:e43. 

High Tech and High Touch (HT2) 
 
NCT02943109 
29 
12. Holtrop JS, Corser W, Jones G, Brooks G, Holmes-Rovner M, Stommel M. Health 
behavior goals of cardiac patients after hospitalization. Am J Health Behav 
2006;30:387-99. 
13. Lau K, Freyer-Adam J, Gaertner B, Rumpf HJ, John U, Hapke U. Motivation to 
change risky drinking and motivation to seek help for alcohol risk drinking among 
general hospital inpatients with problem drinking and alcohol-related diseases. Gen 
Hosp Psychiatry 2010;32:86-93. 
14. Sieck CJ, Heirich M, Major C. Alcohol counseling as part of general wellness 
counseling. Public Health Nurs 2004;21:137-43. 
15.  Chodosh J, Morton SC, Mojica W, et al. Meta-analysis: chronic disease self-
management programs for older adults. Ann Intern Med 2005;143:427-38. 
16.  Warsi A, Wang PS, LaValley MP, Avorn J, Solomon DH. Self-management 
education programs in chronic disease: a systematic review and methodological 
critique of the literature. Arch Intern Med 2004;164:1641-9. 
17.  Adler-Milstein J, Sarma N, Woskie LR, Jha AK. A comparison of how four countries 
use health IT to support care for people with chronic conditions. Health Aff 
2014;33:1559-66. 
18.  Archer N, Fevrier-Thomas U, Lokker C, McKibbon KA, Straus SE. Personal health 
records: a scoping review. J Am Med Inform Assoc 2011;18:515-22. 
19.  Or CK, Tao D. Does the use of consumer health information technology improve 
outcomes in the patient self-management of diabetes? A meta-analysis and 
narrative review of randomized controlled trials. Int J Med Inform 2014;83:320-9. 
20.  McAlearney AS, Sieck CJ, Hefner JL, et al. High touch and high tech (HT2) 
proposal: transforming patient engagement throughout the continuum of care by 
engaging patients with portal technology at the bedside. JMIR Res Protoc 
2016;5:e221.