Are Personal Health Records (PHRs) Facilitating Patient Safety? A Scoping Review

Personal Health Records (PHRs) are poised to improve patient safety, however the mechanism(s) in which they improve safety is not clear. To this end, we conducted a scoping review with the following objectives: 1) explore the extent of the evidence that PHRs improve patient safety, 2) determine where PHR research has been done per International Medical Informatics Association (IMIA) Represented Region [1], 3) to identify the PHR naming convention(s) used per IMIA Region [1]. The findings revealed that there is limited evidence that PHRs improve patient safety. The results also revealed heterogeneity in PHR nomenclature and how they were used in healthcare settings. However, the overarching theme of the study, was that future research is needed to ensure that PHRs are designed and used in a patient safety context with human factors and usability considerations.

Teaching Teledermatology: A Simulation Pilot for Health Professional Students

We developed a teledermatology simulation to give medical and physician assistant students practice with live videoconferencing and store-and-forward workflows. The simulation included (1) pre-session reading; (2) a brief teledermatology didactic; (3) a simulated encounter with a standardized patient; and (4) faculty-led debriefs. The faculty observed students during the simulation and distributed a post-session learner satisfaction survey. Although students had mixed feelings about the simulation, 88% said the workshop met or exceeded expectations.

A Telepsychiatry Simulation for Suicide Assessment: Teaching Telemedicine Safety Competencies

Educators must provide controlled scenarios for health professional students to develop patient safety competencies related to telemedicine, including when and how to escalate care. We developed a telepsychiatry workshop to give students experience with a high-stakes mental health condition. The workshop included (1) pre-session readings; (2) didactics on mood disorders and telepsychiatry; (3) a motivational interviewing exercise; (4) a simulated telemedicine encounter; and (5) a faculty-led group debrief. We evaluated teaching effectiveness using a competency assessment with three scales: (1) medical knowledge; (2) interpersonal and communication skills; and (3) telemedicine competencies. Between 0 and 59% of students were entrustable for each telemedicine competency. Our workshop demonstrates how to teach students about the safe use of telehealth technology and provides practice triaging mental health conditions commonly encountered in primary care and mental health telemedicine clinics.

Opportunities to Improve COVID-19 Dashboard Designs for the Public

Many organizations created COVID-19 dashboards to communicate epidemiologic statistics or community health capabilities with the public. In this paper we used dashboard heuristics to identify common violations observed in COVID-19 dashboards targeted to citizens. Many of the faults we identified likely stem from failing to include users in the design of these dashboards. We urge health information dashboard designers to implement design principles and test dashboards with representative users to ensure that their tools are satisfying user needs.

The Application of a Novel, Context Specific, Remote, Usability Assessment Tool to Conduct a Pre-Redesign and Post-Redesign Usability Comparison of a Telemedicine Website

The usability of telemedicine provider websites is an essential component of increasing the public's awareness of, understanding of, and safe and effective use of telemedicine. A newly developed usability data collection tool was used to conduct a usability assessment of the Teladoc website pre- and post- a redesign. The results suggest that the Teladoc website had better usability prior to the redesign. The Teladoc Website Usability Survey (TWUS) developed for the Teladoc website usability assessment can be modified and used in future usability studies of telemedicine provider interfaces. Usability research that takes place in specific context of use settings is more valuable to identify usability problems.

COVID-19 Vaccine Hesitancy in Canada: Content Analysis of Tweets Using the Theoretical Domains Framework

Background

With the approval of two COVID-19 vaccines in Canada, many people feel a sense of relief, as hope is on the horizon. However, only about 75% of people in Canada plan to receive one of the vaccines.

Objective

The purpose of this study is to determine the reasons why people in Canada feel hesitant toward receiving a COVID-19 vaccine.

Methods

We screened 3915 tweets from public Twitter profiles in Canada by using the search words “vaccine” and “COVID.” The tweets that met the inclusion criteria (ie, those about COVID-19 vaccine hesitancy) were coded via content analysis. Codes were then organized into themes and interpreted by using the Theoretical Domains Framework.

Results

Overall, 605 tweets were identified as those about COVID-19 vaccine hesitancy. Vaccine hesitancy stemmed from the following themes: concerns over safety, suspicion about political or economic forces driving the COVID-19 pandemic or vaccine development, a lack of knowledge about the vaccine, antivaccine or confusing messages from authority figures, and a lack of legal liability from vaccine companies. This study also examined mistrust toward the medical industry not due to hesitancy, but due to the legacy of communities marginalized by health care institutions. These themes were categorized into the following five Theoretical Domains Framework constructs: knowledge, beliefs about consequences, environmental context and resources, social influence, and emotion.

Conclusions

With the World Health Organization stating that one of the worst threats to global health is vaccine hesitancy, it is important to have a comprehensive understanding of the reasons behind this reluctance. By using a behavioral science framework, this study adds to the emerging knowledge about vaccine hesitancy in relation to COVID-19 vaccines by analyzing public discourse in tweets in real time. Health care leaders and clinicians may use this knowledge to develop public health interventions that are responsive to the concerns of people who are hesitant to receive vaccines.

The Medium Is the Message: How Do Canadian University Students Want Digital Medication Information?

(1) Background: To facilitate optimal prescription medication benefits and safety, it is important that people are informed about their prescription medications. As we shift towards using the digital medium to communicate medication information, it is important to address the needs and preferences of different user groups so that they are more likely to read and use this information. In this study, we examined what digital medication information (DMI) format Canadian University students want and why. (2) Methods: This study was a qualitative investigation of young (aged 18-35) Canadian University students' (N = 36) preferences and rationale supporting these preferences with respect to three potential formats for providing DMI: email, a mobile application (app), and online. Reported advantages and disadvantages of each of the three DMI formats were identified and categorized into unique themes. (3) Results: Findings from this study suggest that Canadian University Students most want to receive DMI by email, followed by a mobile app, and finally they were least receptive to online DMI. Participants provided diverse themes of reasons supporting their preferences. (4) Conclusions: Different user groups may have different needs with respect to receiving DMI. The themes from this study suggest that using a formative evaluation framework for assessing different DMI formats may be useful in future research. Email may be the best way to share DMI with younger, generally healthy, Canadian University students who are on few medications. Further research is required to explore whether other mediums for DMI are more appropriate for users with other characteristics (e.g., older and less educated) and contexts (e.g., polypharmacy and complex conditions). Given the flexibility of digital information, DMI could plausibly be provided in multiple formats and could allow users to choose the option they like best and would be most likely to use.

Differences in Memory, Perceptions, and Preferences of Multimedia Consumer Medication Information: Experimental Performance and Self-Report Study

Background

Electronic health resources are becoming prevalent. However, consumer medication information (CMI) is still predominantly text based. Incorporating multimedia into CMI (eg, images, narration) may improve consumers’ memory of the information as well as their perceptions and preferences of these materials.

Objective

This study examined whether adding images and narration to CMI impacted patients’ (1) memory, (2) perceptions of comprehensibility, utility, or design quality, and (3) overall preferences.

Methods

We presented 36 participants with CMI in 3 formats: (1) text, (2) text + images, and (3) narration + images, and subsequently asked them to recall information. After seeing all 3 CMI formats, participants rated the formats in terms of comprehensibility, utility, and design quality, and ranked them from most to least favorite.

Results

Interestingly, no significant differences in memory were observed (F_2,70=0.1, P=0.901). Thus, this study did not find evidence to support multimedia or modality principles in the context of CMI. Despite the absence of effects on memory, the CMI format significantly impacted perceptions of the materials. Specifically, participants rated the text + images format highest in terms of comprehensibility (χ²₂=26.5, P<.001) and design quality (χ²₂=35.69, P<.001). Although the omnibus test suggested a difference in utility ratings as well (χ²₂=8.21, P=.016), no significant differences were found after correcting for multiple comparisons. Consistent with perception findings, the preference ranks yielded a significant difference (χ²₂=26.00, P<.001), whereby participants preferred the text + images format overall. Indeed, 75% (27/36) of participants chose the text + images format as their most favorite. Thus, although there were no objective memory differences between the formats, we observed subjective differences in comprehensibility, design quality, and overall preferences.

Conclusions

This study revealed that although multimedia did not appear to influence memory of CMI, it did impact participants’ opinions about the materials. The lack of observed differences in memory may have been due to ceiling effects, memory rather than understanding as an index of learning, the fragmented nature of the information in CMI itself, or the size or characteristics of the sample (ie, young, educated subjects with adequate health literacy skills). The differences in the subjective (ie, perceptions and preferences) and objective (ie, memory) results highlight the value of using both types of measures. Moreover, findings from this study could be used to inform future research on how CMI could be designed to better suit the preferences of consumers and potentially increase the likelihood that CMI is used. Additional research is warranted to explore whether multimedia impacts memory of CMI under different conditions (eg, older participants, subjects with lower levels of health literacy, more difficult stimuli, or extended time for decay).

Online Medication Information for Citizens: A Comparison of Demands on eHealth Literacy

Many people take prescription medications and need information about the risks and benefits associated with taking them. Citizens are increasingly turning to the internet for health information and medication information is no exception. There are a variety of websites that offer Online Medication Information for Citizens (OMIC). This study compared six such websites using the Health Literacy Online (HLO) Checklist as a framework. Additionally, we conducted a detailed analysis of the individual content in each OMIC for three different medications. We identified several strengths and weaknesses of the different websites in terms of how they were designed and written and their appropriateness for users with limited eHealth literacy.

User Experience Theories, Models, and Frameworks: A Focused Review of the Healthcare Literature

User experience (UX) theories, models, and frameworks (TMFs) help scope user-centered design activities, aid in the selection of constructs and measures, and contextualize findings within a larger knowledge base. However, the fragmentation of literature across disciplines and the inconsistent use of TMFs makes integrating concepts and selecting UX tools challenging. Therefore, we conducted a focused review of the healthcare literature to identify a succinct list of UX-specific TMFs for academic UX researchers and industry practitioners alike.

Narratives and Stories: Novel Approaches to Improving Patient-Facing Information Resources and Patient Engagement

Patient-centered healthcare requires development of materials for health consumers that increase health literacy, enrich the provider-patient dialog, empower shared decision-making, and improve downstream outcomes. Unfortunately, evidence suggests current methods of communication, including print and electronic media, are inadequate. The Narrative Theory of Learning is grounded in the premise that humans define their experiences and form cognitive structures (e.g., new learning, novel concepts) within the context of narratives. Simply put, humans remember stories better than fragmented bits of information. Therefore, we propose leveraging the power of narratives and stories to improve the efficacy and impact of consumer health applications. We describe several examples of future technologies that could incorporate narrative techniques and present a call to action for future research and development.

We Built It, But They Are Not Coming: Exploring Deterrents to Consumer Medication Information Use

Given the prevalence of prescription medication use, it is important that consumers are aware of the benefits and risks of taking their prescribed medications. One approach to informing consumers in North America is to provide them with Consumer Medication Information (CMI), the paper leaflets given to consumers when they fill a prescription for the first time. Unfortunately, reported use rates of written medication information are quite low. As part of a broader study investigating memory, perceptions, preferences and information needs around CMI, this study specifically examined reported deterrents to CMI use. Findings from this study revealed three areas that appear to influence CMI use: 1) Documentation, how CMI is designed and what it contains; 2) Provision, how and when CMI is given to consumers; and 3) Context, what the individual's characteristics and experiences are. These three factors warrant further investigation to reveal more of their unique facets and their relative influences on CMI use. That is, some aspects may be more influential than others.

Development of a Video Coding Scheme for Understanding Human-Computer Interaction and Clinical Decision Making

The usability of healthcare information technology has become a major issue in health informatics. There have been many reports of systems that have been deemed unusable by end users such as clinicians and a growing body of usability studies have been reported in the literature. The issue of how to fruitfully analyze and code usability study data in a meaningful way that can lead to optimized and more efficient systems has remained to be fully detailed. In this paper we describe our work in developing and organizing a principled video coding scheme that builds from our previous work in a couple of areas. We include video coding categories we have developed for understanding problems and issues with human-computer interaction. In addition, we integrate this coding scheme with categories we have used to characterize human cognition, such as clinical reasoning and decision making, in isolation of technology use. The resultant new scheme thus incorporates coding categories that can used to evaluate both usability issues (applying categories from human-computer interaction) and human cognition, in order to assess the impact of technology on clinical reasoning and decision making.

Putting Guidelines in the Hands of Patients: A Heuristic Evaluation of a Consumer Mobile Application

Preventive clinical practice guidelines are valuable. However, they are often difficult for primary care providers to implement in the time sensitive primary care setting and alternate approaches warrant exploration. An app called CANBeWell was developed in an effort to allow consumers to identify appropriate guidelines for themselves. Two investigators conducted a heuristic evaluation to identify potential eHealth literacy and usability issues. Several recommendations were made to make CANBeWell easier for consumers to use and understand. CANBeWell is a promising app for deploying preventive guidelines directly to health consumers. Usability testing is planned for the next iteration to ensure that this app meets the needs and capabilities of health consumers.

Usability and eHealth Literacy Evaluation of a Mobile Health Application Prototype to Track Diagnostic Imaging Examinations

In the absence of a pan-Canadian electronic health record, unnecessary duplicate diagnostic imaging (DI) examinations are sometimes ordered when a physician is not aware of prior DI or prior DI is not available. Research suggests that physicians may ask their patient to recall their DI history; however, patient recall of DI can be unreliable. As a potential solution, a patient-facing mobile health application (app) prototype was developed for users to record their DI. The app was designed to be usable and inclusive to users of all health literacy levels. The aim of this paper is to demonstrate how eHealth literacy and usability heuristics can be used during the design phases of app development.

Are Health Literacy and eHealth Literacy the Same or Different?

Many researchers assume that there is a relationship between health literacy and eHealth literacy, yet it is not clear whether the literature supports this assumption. The purpose of this study was to determine if there was a relationship between health and eHealth literacy. To this end, participants' (n = 36) scores on the Newest Vital Sign (NVS, a health literacy measure) were correlated with the eHealth Literacy Scale (eHEALS, an eHealth literacy measure). This analysis revealed no relationship (r = -.041, p = .81) between the two variables. This finding suggests that eHealth Literacy and health literacy are dissimilar. Several possible explanations of the pattern of results are proposed. Currently, it does not seem prudent to use the eHEALS as the sole measure of eHealth literacy, but rather researchers should continue to complement it with a validated health literacy screening tool.

All Consumer Medication Information Is Not Created Equal: Implications for Medication Safety

Many Canadians take prescription medications. These medications often have both benefits and potential consequences associated with their use. Additionally, instructions for how to administer some medications (e.g., inhalers, eye drops) maybe be critical in maximizing the beneficial effects of using medications. This study examined the Consumer Medication Information (CMI) from a leading Canadian pharmacy and revealed none of the 10 CMI contained information about allergic reactions, overdoses, or drug interactions. This lack of information may come at the expense patient safety. Additionally, much of the content identified as important was not readily differentiable from the surrounding text. Further, inhalers were the only category of medication that did not have specific use instructions but instead directed consumers to consult other resources. Thus, there are opportunities to augment CMI to improve the safe and effective use of medications. The shortcomings of CMI identified in this study represent important considerations for CMI as it is currently delivered (printed text) and opportunities to improve upon CMI as it is beginning to be offered online.

Consumer Medication Information: Similarities and Differences Between Three Canadian Pharmacies

Prescription medication use is prevalent. When a new prescription medication is dispensed, Consumer Medication Information (CMI) is provided to communicate various important aspects of the medication (e.g., benefits, administration instructions, potential side effects). However, CMI is not regulated and differs from pharmacy to pharmacy. This study explores the similarities and differences between the CMI from three pharmacies (two paper print outs and one online source) for a single medication. The three CMI were assessed in terms of readability and utility. This evaluation revealed drastic differences in the length of the CMI (Range = 453 to 2 337 words). The online CMI was longer, described more topics and provided more detail than the print versions. Although online CMI has the advantage of interactivity to expedite navigation to specific topics of interest (e.g., heading links) and searching for key words, this CMI was not layered but rather presented as one long continuous page. Consumers with lower eHealth literacy skills may be deterred by the length of the document. As CMI makes the shift to online presentation an improved understanding of optimal information organization and media presentation will be needed.

A Comparison of Danish and Canadian Consumer Medication Information

Many people around the world use prescription medications. Consumers often require information about their medications to support taking them safely and effectively. One source of such information is Consumer Medication Information (CMI). Canadians typically receive printed CMI when a new prescription is filled whereas Danes have the online resource min.medicin.dk. This study compared the content and design of Danish and Canadian CMI. Danish CMI satisfied seven of the 11 content utility criteria (developed in previous work) identified as supporting the safe and effective medication use. However, Danish CMI provided a more information about how frequently possible side effects occur and multimedia (e.g., images, videos) directions for some medications. This study examined some of the similarities and differences between how Canadians and Danes are informed about medications. However, further research is required to determine what content and methods of delivery are most beneficial in supporting safe and effective medication use.

Isolating the Effects of a Mobile Phone on the Usability and Safety of eHealth Software Applications

Mobile phones are used in conjunction with mobile eHealth software applications. These mobile software applications can be used to access, review and document clinical information. The objective of this research was to explore the relationship between mobile phones, usability and safety. Clinical simulations and semi-structured interviews were used to investigate this relationship. The findings revealed that mobile phones may lead to specific types of usability issues that may introduce some types of errors.

How to Present Evidence-Based Usability Design Principles Dedicated to Medication-Related Alerting Systems to Designers and Evaluators? Results from a Workshop

Medication alerting system use errors and lack of adoption are often attributed to usability issues. Previous work has used evidence from the literature to reveal usability principles specific to medication alerting systems and identify potential consequences of violating these principles. The current study sought to explore how best to convey these principles to designers and evaluators of these systems to facilitate their work. To this aim, a workshop with 19 participants was used to generate ideas and opinions on how to deliver these topic-specific design principles in a way that would be most helpful for them. Participants generated ideas for how (e.g., a collaborative, continuously updated forum) and what (e.g., illustrations, checklists, evidence sources and strength, consequences of violations) information is most useful to disseminate usability principles for medication alerting systems. Participants, especially designers, expressed desire to use these principles in practice and avoid previously documented mistakes and therefore make design and evaluation of these systems more effective and efficient. Those insights are discussed in terms of feasibility and logistical challenges to developing the proposed documentation). To move this work forward, a more collaborative approach of Human Factors specialists in medical informatics is necessary.

InformedTogether: Usability Evaluation of a Web-Based Decision Aid to Facilitate Shared Advance Care Planning for Severe Chronic Obstructive Pulmonary Disease

Background

Advance care planning may help patients receive treatments that better align with their goals for care. We developed a Web-based decision aid called InformedTogether to facilitate shared advance care planning between chronic obstructive pulmonary disease (COPD) patients and their doctors.

Objective

Our objective was to assess the usability of the InformedTogether decision aid, including whether users could interact with the decision aid to engage in tasks required for shared decision making, whether users found the decision aid acceptable, and implications for redesign.

Methods

We conducted an observational study with 15 patients and 8 doctors at two ethnically and socioeconomically diverse outpatient clinics. Data included quantitative and qualitative observations of patients and doctors using the decision aid on tablet or laptop computers and data from semistructured interviews. Patients were shown the decision aid by a researcher acting as the doctor. Pulmonary doctors were observed using the decision aid independently and asked to think aloud (ie, verbalize their thoughts). A thematic analysis was implemented to explore key issues related to decision aid usability.

Results

Although patients and doctors found InformedTogether acceptable and would recommend that doctors use the decision aid with COPD patients, many patients had difficulty understanding the icon arrays that were used to communicate estimated prognoses and could not articulate the definitions of the two treatment choices—Full Code and Do Not Resuscitate (DNR). Minor usability problems regarding content, links, layout, and consistency were also identified and corresponding recommendations were outlined. In particular, participants suggested including more information about potential changes in quality of life resulting from the alternative advance directives. Some doctor participants thought the decision aid was too long and some thought it may cause nervousness among patients due to the topic area.

Conclusions

A decision aid for shared advance care planning for severe COPD was found acceptable to most COPD patients and their doctors. However, many patient participants did not demonstrate understanding of the treatment options or prognostic estimates. Many participants endorsed the use of the decision aid between doctors and their patients with COPD, although they desired more information about quality of life. The design must optimize comprehensibility, including revising the presentation of statistical information in the icon array, and feasibility of integration into clinical workflow, including shortening the decision aid.

Using personal health records to scaffold perceived self-efficacy for health promotion

According to Bandura (1977), believing in one's ability to achieve a goal is one of the best predictors that a goal will be accomplished. Given its predictive power, the concept of belief in one's ability to succeed, or perceived self-efficacy, is well researched for its influence on health promotion. It has been argued that a paradigm shift must occur away from illness treatment towards illness prevention and health promotion, for healthcare to accommodate the needs of the population. Personal Health Records (PHRs) may be a tool to help facilitate this paradigm shift. PHRs are repositories of information that individuals can use to access, manage, and share their personal health information. An extension of Bandura's model of self-efficacy will be presented here which identifies opportunities for PHRs to enhance perceived self-efficacy through mastery, social modeling, social persuasion, and physiological state. Bolstering self-efficacy through PHR tools will expand the utility of PHRs beyond self-management to also facilitate health promotion and illness prevention and gains in self-efficacy are also likely to transcend into other areas of consumers' lives.