This study was conducted in three FQHCs in the New York area. This manuscript focuses on the pre-implementation qualitative phase of a broader randomized controlled trial (RCT). While the larger RCT aims to (1) promote enrollment in patient portals across the three FQHCs, and (2) compare different EHR-based smoking cessation referral strategies across them, the present paper reports only on the qualitative component conducted prior to the portal enrollment initiative to inform implementation planning (see Figure 1). The study received IRB approval from Columbia University under the number IRB-AAAU7659.

This study was conducted in three FQHCs affiliated with Clinical Directors Network, Inc. (CDN). CDN is a not-for-profit clinician membership organization, practice-based research network (PBRN) and AHRQ-designated Center of Excellence (P30) for Practice-based Research and Learning. CDN was founded as a clinician training organization to provide peer-initiated activities for clinicians practicing in low-income, minority, and other underserved communities (28). CDN's overall goal is to translate clinical research into clinical practice for the enhancement of health equity and improvement of public health (28).

Our project aimed to compare the effectiveness of two strategies to support enrollment in patient portals: education and patient navigation vs. patient navigation only. Three sites were randomized. The first center was the control site, where only patient education material was shared. The two intervention centers were provided with educational materials and patient navigation support.

As part of the pre-implementation phase (prior to randomization), we conducted interviews with stakeholders affiliated with the three participating FQHCs. Participants were recruited using convenience sampling. FQHC leadership distributed an open invitation to all clinical and administrative staff via internal email. Staff who found the study relevant and whose schedules permitted voluntarily contacted the research team to express interest in participating.

A total of 14 participants were interviewed, including 2 health information technology specialists, 2 nurses, 3 front desk assistants, 2 medical assistants, 2 health coaches, 2 clinical operations managers, and 1 medical director. After confirming interest, interviews were scheduled and conducted via Zoom. At the beginning of each interview, the study team reiterated the purpose of the study, explained the voluntary nature of participation, and obtained oral consent, including permission to audio-record the session. Interviews lasted between 25 and 40 min. Participants received a $50 gift card as a token of appreciation.

Interviews focused mainly on gathering information to (1) learn about the centers' existing processes to support patient portal enrollment, (2) co-develop patient engagement materials, and (3) establish the workflow of patient navigation implementation. The interview guide was developed following the EPIS framework (Exploration, Preparation, Implementation, and Sustainment) (29). EPIS includes four distinct phases: (1) Exploration: assessing current practices and identifying barriers and needs; (2) Preparation: planning and adapting strategies to the setting; (3) Implementation: executing and monitoring the intervention; and (4) Sustainment: promoting long-term integration into practice (30).

The framework also accounts for inner and outer contextual factors, innovation characteristics, and bridging elements between systems and organizations. Correspondingly, the interview guide included questions such as (see Appendix 1 for all the questions): -

Exploration (e.g., Please describe the current center's procedures for educating patients about patient portals in general. Are you educating them about how important they are to them?)

All interviews were audio-recorded, transcribed locally, and de-identified to ensure confidentiality. The analysis followed a qualitative thematic analysis using a hybrid deductive-inductive approach, guided by the EPIS framework and Braun and Clarke's (2012) six-phase method for thematic analysis (31). These six phases include: (1) familiarization with the data, (2) generation of initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the report.

Two coders independently analyzed the transcripts using a hybrid deductive-inductive coding strategy. An initial draft codebook was developed based on the interview guide, EPIS domains (Exploration, Preparation, Implementation, Sustainment), and key areas of inquiry relevant to the implementation goals of the study. After reviewing both transcripts and audio recordings, the coders expanded the codebook by identifying emergent themes not captured by the initial codes.

Iterative rounds of coding and discussion were conducted to refine the code definitions and structure. Coding was completed using Microsoft Excel, which was also used to document coding decisions, organize excerpts, and track the development of themes across interviews. Discrepancies in coding were addressed through a consensus-building process that involved repeated review and discussion of the transcript sections in question. Thematic saturation was determined by the recurrence of themes across sites and interviews.

Crosscutting themes were synthesized from the final code structure, capturing shared patterns as well as site-specific insights. The final themes were then used to inform the design of the navigator workflow, the development of tailored educational materials, and the implementation planning document. These themes included: (1) feedback about current enrollment procedures, (2) suggested improvements to the process, (3) optimal timing and location for enrollment support, (4) promotion strategies, (5) navigator challenges, (6) potential solutions, and (7) long-term sustainability considerations.

The interviews informed us of the days and times it would be best to have a patient navigator in place. For instance, Mondays to Thursdays are the busiest days, and more patients would be in the centers between 10 AM and 4 PM, which would give the navigators a higher chance of finding eligible patients to enroll. In addition, waiting rooms were the areas that navigators should stay in to be close to the patients while waiting for their appointments.

We obtained the following results when asked about the possible challenges participants think navigators could face.

As shown in Figure 2, the patient navigator will try to contact the patients one day before their appointment. Once they arrive at the center, the patient checks in at the front desk and is oriented by the staff to sit in the waiting room where they expect the patient to be patient navigators. One of the navigators will then contact the patient and identify their eligibility. Eligible patients are adults who speak English or Spanish. The navigator will then ask if the patient has access to their portals. If yes, they will ask about usage and offer any support with the existing account as needed. Otherwise, the patient will be asked why they do not have access and whether they are interested in knowing more about it. If accepted, the navigator will start by sharing the flyer with the patient and using it as educational material to support their discussion on the benefits of the portal and how to navigate it. After educating them, the navigator will offer the patient their support in account creation. If the patient agrees, the patient will also be supported with the app downloading and initial setup. Ultimately, the patient will be offered a follow-up call to assist them if they have trouble accessing or navigating the application. All the steps and outcomes will be documented by the Patient Navigator in RedCap.

Although it is attractive for patients, we acknowledged that they may lack motivation to enroll in portals and to continue using them. Thus, we asked our participants about their opinions on making this process enjoyable and motivating their sustainability in portal usage.

The findings revealed significant variability in support and educational procedures across different centers. While one center employed dedicated patient navigators, others relied on front desk personnel or providers who faced challenges such as high workloads, time constraints, and limited training. Additionally, patient support was inconsistent, often restricted to essential technical assistance without comprehensive guidance.

Educational efforts lacked standardization, leading to reliance on patient initiative and suboptimal information dissemination. The variability in support structures suggests that dedicated staff, such as patient navigators, is crucial in facilitating effective patient portal enrollment and usage. Centers lacking such dedicated resources may struggle to provide comprehensive assistance due to overstretched front desk personnel and providers primarily focused on clinical duties. This inconsistency can lead to fragmented patient experiences, where some patients receive thorough guidance while others receive minimal support, potentially affecting their engagement with the patient portal.

Consistent with prior research (27, 32), our study underscores the importance of dedicated support staff in enhancing patient engagement with digital health tools, especially patient portals. Previous studies have shown that when patients receive comprehensive education and support, especially from patient navigators, they are more likely to engage actively with digital health tools, which would improve enrollment rates and patient satisfaction (27). However, unlike some studies that report minimal variability across centers, our findings indicate a substantial disparity, possibly reflecting differences in resource allocation and institutional priorities. Additionally, the observed reliance on patient initiative in some centers contrasts with some literature emphasizing proactive staff engagement as a critical facilitator for patient portal success (33). The inconsistency in educational efforts echoes concerns raised in earlier studies about the lack of standardized patient education protocols, which can lead to variable patient experiences and outcomes (34, 35).

These results helped us develop a manual of procedures that can help guide patient navigators in their efforts to enroll patients without disturbing the current workflows. The efforts implemented covered several strategic areas, including optimal scheduling and placement of patient navigators, customization of educational materials, efficient patient identification processes, early patient engagement, and effective coordination with other staff members. The interviews revealed that scheduling patient navigators during peak hours (Mondays to Thursdays, 10 AM to 4 PM) and positioning them in waiting rooms significantly increased the likelihood of enrolling eligible patients. Early engagement strategies, such as pre-appointment communications and in-lobby interactions, emphasize the importance of timing in patient support. By informing patients about the study and portal benefits before their visits, centers can foster a proactive mindset, allowing more time for consideration and decision-making, encouraging timely enrollment and sustained portal usage.

The strategic deployment of patient navigators during peak hours and their placement in high-traffic areas like waiting rooms suggests that visibility and accessibility are crucial for successful patient enrollment. By being present where patients are most likely to congregate, navigators can proactively engage with patients, reducing reliance on patient initiative and ensuring that support is readily available. The strategic placement and scheduling of navigators to coincide with peak patient flow times and locations have been suggested in earlier studies to maximize engagement (36).

Additionally, customizing educational materials to meet each center's unique and specific population needs, including language-specific versions, indicates the importance of culturally and contextually relevant information in enhancing patient understanding and portal utilization, which resonates with previous literature on the effectiveness of tailored health communication in improving patient outcomes (37). This customization ensures that educational efforts resonate with diverse patient demographics in FQHCs, improving engagement, as shown in previous studies (38, 39).

The study also identified the need for granting patient navigators direct access to EHR systems, which addresses a significant systems-level barrier to promptly identifying eligible patients. Granting navigators access enables them to engage with patients in real-time, including those who walk in without prior appointments, ensuring comprehensive coverage and minimizing missed opportunities for enrollment. This approach may differ from some existing models where navigators rely on printed lists or manual referrals, highlighting an area for potential improvement in workflow integration (40). Finally, effective coordination with front desk staff and medical assistants underscores the necessity of an integrated support system. By leveraging the roles of existing staff members, centers can create a seamless referral process that enhances patient support without overburdening any single group.

In addition to identifying existing gaps in support and education, the study explored potential challenges faced by patient navigators and the strategies implemented to mitigate them. Several anticipated challenges were identified. Patient reluctance and language barriers emerged as significant potential hurdles in patient portal enrollment. Patients' discomfort with technology and difficulty remembering passwords can impede their willingness to use digital health tools. By incorporating credential sections into educational materials and providing multilingual resources, centers have taken proactive steps to alleviate these barriers, fostering a more inclusive and supportive environment. Studies have shown that addressing language barriers through multilingual educational materials improves portal enrollment among diverse patient populations (41). Additionally, operational challenges during peak hours have been identified in previous studies, highlighting the need for streamlined workflows and adequate staffing (42). However, adding credential sections to educational flyers to assist with password management is a novel approach, potentially offering a straightforward solution to a common barrier.

Another challenge identified was operational coordination, particularly during peak hours. This highlighted the need for efficient workflow management to ensure that navigators can reach eligible patients without overwhelming existing staff. The recommendation to grant navigators direct access to Electronic Health Records (EHR) systems facilitates timely identification of eligible patients, including walk-ins and unscheduled visits, thereby enhancing enrollment rates. In addition, we identified patient frustration and engagement problems as possible issues. This stems from patients being preoccupied with other health-related concerns, underscoring the importance of empathetic and respectful interactions. Navigators are encouraged to approach patients thoughtfully, recognizing their emotional states and providing support without adding to their stress.

This study's results shed light on suggestions for improving the continuous use of portals among patients. One of the strategies suggested includes emphasizing the portal's convenience and time-saving benefits. Navigators can communicate the practical benefits that resonate with patients' daily lives, increasing their intrinsic motivation to engage with the portal. These findings are consistent with prior research emphasizing the importance of user-friendly design and continuous support in promoting patient portal adoption (43). Studies have also shown that highlighting the practical benefits of patient portals, such as easy access to medical records and lab results, significantly increases patient engagement (44).

Additionally, the use of visual aids and hands-on demonstrations has been identified as an effective method to reduce technological anxiety and improve portal usability (45). However, the specific emphasis on social media promotion represents an innovative approach that is less extensively covered in existing literature. This strategy may offer new avenues for increasing portal visibility and facilitating patient education interactively and engagingly.

Finally, it was advised to implement long-term feedback mechanisms to enable healthcare centers to continuously adapt their strategies based on patient needs and preferences, ensuring that the portal remains relevant and satisfying to patients' needs. Gathering patient feedback continuously allows healthcare centers to identify and address issues promptly, tailoring support and educational materials to meet patients' preferences better and overcome challenges. This iterative process fosters a patient-centered approach, enhancing the portal's usability and relevance and increasing its sustained use. These findings align with existing literature emphasizing the importance of continuous feedback mechanisms for understanding user experiences and making necessary improvements to enhance portal usability (46).

Based on the findings presented, several practical implications emerge, highlighting actionable strategies and considerations for healthcare organizations to enhance patient portal enrollment and sustained usage, particularly among low-income populations receiving care in Federally Qualified Health Centers (FQHCs). First, the study underscores the critical role of dedicated patient navigators in facilitating effective patient portal enrollment and usage. Healthcare organizations should consider allocating resources to hire and train dedicated patient navigators. These navigators can provide specialized assistance, ensuring patients receive thorough guidance and support, improving enrollment rates and patient satisfaction.

Standardizing patient education protocols is essential as it ensures that all patients receive uniform information and support, reducing portal enrollment and usage disparities. This can involve creating comprehensive training programs for navigators and other staff members to deliver consistent educational content. In addition, healthcare centers should strategically schedule navigators when patient traffic is highest and place them in visible, accessible locations. This approach maximizes opportunities for patient-navigator interactions, facilitating timely enrollment and support without disrupting existing workflows.

Furthermore, developing culturally and linguistically appropriate educational materials is crucial for addressing diverse patient needs. Customization ensures that information is relevant and understandable, enhancing patient understanding and willingness to engage with the portal. Our findings also highlight a tension between the need for standardization and the importance of personalization in patient education. While standardizing the navigator workflow and core educational materials can promote consistency and make implementation more feasible for staff, the interviews underscored that rigid protocols may not adequately address patients' diverse needs.

Several participants suggested that standardization and customization are not mutually exclusive. Instead, they recommended creating a core protocol with built-in flexibility, such as optional scripts, multilingual materials, or adaptable engagement strategies, allowing navigators to tailor their approach based on each patient's language, health literacy, or comfort with technology. This hybrid approach ensures consistent delivery while allowing for responsiveness at the point of care, thus supporting both implementation fidelity and person-centeredness.

Moreover, integrating navigators into the EHR system workflow can streamline the enrollment process. This integration enables navigators to identify and engage eligible patients promptly, reducing missed opportunities and improving overall enrollment rates. It is also noteworthy that implementing proactive engagement strategies may ensure that patients are informed about the portal and its benefits before their visits. This proactive approach can foster a mindset geared towards timely enrollment and sustained usage, enhancing overall patient engagement. Patient reluctance, technological discomfort, and language barriers were significant hurdles. Providing comprehensive support to address these barriers is essential. This includes offering multilingual educational materials, incorporating password management assistance into educational resources, and conducting hands-on demonstrations to reduce technological anxiety. Such measures create a more inclusive and supportive environment for all patients. Healthcare centers should optimize workflow processes to accommodate navigator activities seamlessly. This might involve redefining roles, enhancing staff collaboration, and ensuring that navigators have the necessary tools, such as digital tablets for real-time enrollment, and support to perform their duties efficiently.

Finally, establishing ongoing feedback loops enables centers to monitor patient experiences, identify emerging issues, and make data-driven adjustments to their enrollment and support strategies. This iterative process ensures the patient portal remains relevant, user-friendly, and aligned with patient expectations and maximizes the potential for sustainability.

Although the findings reflect the experiences of a small number of FQHCs in New York City, the challenges and facilitators identified, such as the need for navigator support, tailored educational materials, and workflow integration, are likely relevant to many safety-net settings. However, variability in structural readiness may influence scalability. Differences in staffing resources, digital health maturity, leadership engagement, and the specific patient populations served could impact the feasibility of implementing similar navigator-led interventions elsewhere. For instance, clinics with limited EHR functionality or no established patient portal may require more foundational investments before such strategies can be adopted.

While this study offers important insights into the use of patient navigators and educational strategies to enhance patient portal enrollment among low-income populations in FQHCs, several limitations must be acknowledged. First, this study involved interviews with only 14 stakeholders across three FQHCs in New York. This limited sample size may not capture diverse experiences and perspectives in healthcare settings. Consequently, the findings may not be relevant to other FQHCs and safety net practices with varying structures, patient demographics, or resource levels. Also, the qualitative data reflect only the perspectives of staff and stakeholders; direct input from patients was not included in this phase of the study. Although staff insights offer valuable operational and contextual understanding, patient perspectives could have enriched the findings by shedding light on end-user barriers, motivations, and experiences with portal enrollment. Future work should prioritize incorporating patient voices to strengthen intervention design and ensure alignment with patient needs.

Second, the intervention centers utilized different patient portal systems (Healow), while the control center used NextGen. This variation introduces a potential confounding variable, as differences in portal functionality, user interface, and integration with Electronic Health Records (EHR) systems could impact enrollment and usage rates independently of the navigational and educational interventions, although working across multiple EHRs enhances generalizability.

Third, we gathered feedback from healthcare staff and stakeholders, excluding direct input from patients. As a result, the perspectives of the end-users (patients) on barriers to enrollment and portal usage were not directly captured. Including patient voices in future research could provide a more comprehensive understanding of the challenges and facilitators from the user's standpoint. Finally, this research was conducted during the pre-implementation phase, focusing on training, preliminary results, and lessons learned. Consequently, the study does not assess the long-term effectiveness or sustainability of the implemented strategies. Follow-up studies are necessary to evaluate the impact of patient navigators and educational interventions on patient portal enrollment and usage over time.