The effects of promoting patient access to medical records: a review

Impact of sharing electronic health records with patients on the quality and safety of care: a systematic review and narrative synthesis protocol

INTRODUCTION

Providing patients with access to electronic health records (EHRs) has emerged as a promising solution to improve quality of care and safety. As the efforts to develop and implement EHR-based data sharing platforms mature and scale up worldwide, there is a need to evaluate the impact of these interventions and to weigh their relative risks and benefits, in order to inform evidence-based health policies. The aim of this work is to systematically characterise and appraise the demonstrated benefits and risks of sharing EHR with patients, by mapping them across the six domains of quality of care of the Institute of Medicine (IOM) analytical framework (ie, patient-centredness, effectiveness, efficiency, timeliness, equity and safety).

METHODS AND ANALYSIS

CINAHL, Cochrane, Embase, HMIC, Medline/PubMed and PsycINFO databases will be searched from January 1997 to August 2017. Primary outcomes will include measures related with the six domains of quality of care of the IOM analytical framework. The quality of the studies will be assessed using the Cochrane Risk of Bias Tool, the ROBINS-I Tool and the Drummond's checklist. A narrative synthesis will be conducted for all included studies. Subgroup analysis will be performed by domain of quality of care domain and by time scale (ie, short-term, medium-term or long-term impact). The body of evidence will be summarised in a Summary of Findings table and its strength assessed according to the GRADE criteria.

ETHICS AND DISSEMINATION

This review does not require ethical approval as it will summarise published studies with non-identifiable data. This protocol complies with the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols guidelines. Findings will be disseminated widely through peer-reviewed publication and conference presentations, and patient partners will be included in summarising the research findings into lay summaries and reports.

PROSPERO REGISTRATION NUMBER

CRD42017070092.

Utilizing a Prototype Patient-Controlled Electronic Health Record in Germany: Qualitative Analysis of User-Reported Perceptions and Perspectives

Background

Personal electronic health records (PHR) are considered instrumental in improving health care quality and efficiency, enhancing communication between all parties involved and strengthening the patient’s role. Technical architectures, data privacy, and applicability issues have been discussed for many years. Nevertheless, nationwide implementation of a PHR is still pending in Germany despite legal regulations provided by the eHealth Act passed in 2015. Within the information technology for patient-oriented care project funded by the Federal Ministry of Education and Research (2012-2017), a Web-based personal electronic health record prototype (PEPA) was developed enabling patient-controlled information exchange across different care settings. Gastrointestinal cancer patients and general practitioners utilized PEPA during a 3-month trial period. Both patients and physicians authorized by them could view PEPA content online and upload or download files.

Objective

This paper aims to outline findings of the posttrial qualitative study carried out to evaluate user-reported experiences, perceptions, and perspectives, focusing on their interpretation of PEPA beyond technical usability and views on a future nationwide implementation.

Methods

Data were collected through semistructured guide-based interviews with 11 patients and 3 physicians (N=14). Participants were asked to share experiences, views of perceived implications, and perspectives towards nationwide implementation. Further data were generated through free-text fields in a subsequent study-specific patient questionnaire and researcher’s notes. Data were pseudonymized, audiotaped, and transcribed verbatim. Content analysis was performed through the Framework Analysis approach. All qualitative data were systemized by using MAXQDA Analytics PRO 12 (Rel.12.3.1). Additionally, participant characteristics were analyzed descriptively using IBM SPSS Statistics Version 24.

Results

Users interpreted PEPA as a central medium containing digital chronological health-related documentation that simplifies information sharing across care settings. While patients consider the implementation of PEPA in Germany in the near future, physicians are more hesitant. Both groups believe in PEPA’s concept, but share awareness of concerns about data privacy and older or impaired people’s abilities to manage online records. Patients perceive benefits for involvement in treatment processes and continuity of care but worry about financing and the implementation of functionally reduced versions. Physicians consider integration into primary systems critical for interoperability but anticipate technical challenges, as well as resistance from older patients and colleagues. They omit clear positioning regarding PEPA’s potential incremental value for health care organizations or the provider-patient relationship.

Conclusions

Digitalization in German health care will continue to bring change, both organizational and in the physician-patient relationship. Patients endorse and expect a nationwide PEPA implementation, anticipating various benefits. Decision makers and providers need to contribute to closing modernization gaps by committing to new concepts and by invigorating transformed roles.

Impact of patients' access to medical records in occupational medicine

Background

Information technologies offer new ways to engage with patients regarding their health, but no studies have been done in occupational health services (OHS).

Aims

To examine the advantages and disadvantages of providing written and oral medical information to patients in OHS.

Methods

In this cross-sectional study, data were retrieved from patients visiting four different OHS during 2014-15 for a fitness for work evaluation. We built a semi-quantitative satisfaction questionnaire, with responses ranging on a Likert scale of 1-5 from very dissatisfied (1) to very satisfied (5).

Results

There were 287 questionnaires available for analysis. The number of patients who received detailed oral and written information, which included an explanation of their health condition and of the occupational physician's (OP's) decision, was higher in clinics 1 and 3 compared to clinics 2 and 4 (48 and 38% compared to 21 and 31% respectively, P < 0.05). When patients were provided with detailed oral and written information, they declared having a better understanding (4.3 and 4.4 compared to 3.8 respectively, P < 0.001), a higher level of confidence in their OP (4.4 and 4.3 compared to 3.7 and 4 respectively, P < 0.001), a higher level of satisfaction (4.3 and 4.4 compared to 3.8 respectively, P < 0.001) and a higher sense of control and ability to correct the record (1.8 compared to 1.4 respectively, P < 0.01), compared to patients who received partial information.

Conclusions

We recommend sharing detailed oral and written medical information with patients in OHS.

Same, same but different: Perceptions of patients’ online access to electronic health records among healthcare professionals

In this study, we explore how healthcare professionals in primary care and outpatient clinics perceive the outcomes of giving patients online access to their electronic health records. The study was carried out as a case study and included a workshop, six interviews and a survey that was answered by 146 healthcare professionals. The results indicate that professionals working in primary care perceive that an increase in information-sharing with patients can increase adherence, clarify important information to the patient and allow the patient to quality-control documented information. Professionals at outpatient clinics seem less convinced about the benefits of patient accessible electronic health records and have concerns about how patients manage the information that they are given access to. However, the patient accessible electronic health record has not led to a change in documentation procedures among the majority of the professionals. While the findings can be connected to the context of outpatient clinics and primary care units, other contextual factors might influence the results and more in-depth studies are therefore needed to clarify the concerns.

Open Notes in Teaching Clinics: A Multisite Survey of Residents to Identify Anticipated Attitudes and Guidance for Programs

BACKGROUND

Clinicians are increasingly sharing outpatient visit notes with patients through electronic portals. These open notes may bring about new educational opportunities as well as concerns to physicians-in-training and residency programs.

OBJECTIVE

We assessed anticipatory attitudes about open notes and explored factors influencing residents' propensity toward note transparency.

METHODS

Residents in primary care clinics at 4 teaching hospitals were surveyed prior to implementation of open notes. Main measures included resident attitudes toward open notes and the anticipated effect on patients, resident workload, and education. Data were stratified by site.

RESULTS

A total of 176 of 418 (42%) residents responded. Most residents indicated open notes would improve patient engagement, trust, and education but worried about overwhelming patients, residents being less candid, and workload. More than half of residents thought open notes were a good idea, and 32% (56 of 176) indicated they would encourage patients to read these notes. More than half wanted note-writing education and more feedback, and 72% (126 of 175) indicated patient feedback on residents' notes could improve communication skills. Attitudes about effects of open notes on safety, quality, trust, and medical education varied by site.

CONCLUSIONS

Residents reported mixed feelings about the anticipated effects of sharing clinical notes with patients. They advocate for patient feedback on notes, yet worry about workload, supervision, and errors. Training site was correlated with many attitudes, suggesting local culture drives resident support for open notes. Strategies that address resident concerns and promote teaching and feedback related to notes may be helpful.

ComprehENotes, an Instrument to Assess Patient Reading Comprehension of Electronic Health Record Notes: Development and Validation

BACKGROUND

Patient portals are widely adopted in the United States and allow millions of patients access to their electronic health records (EHRs), including their EHR clinical notes. A patient's ability to understand the information in the EHR is dependent on their overall health literacy. Although many tests of health literacy exist, none specifically focuses on EHR note comprehension.

OBJECTIVE

The aim of this paper was to develop an instrument to assess patients' EHR note comprehension.

METHODS

We identified 6 common diseases or conditions (heart failure, diabetes, cancer, hypertension, chronic obstructive pulmonary disease, and liver failure) and selected 5 representative EHR notes for each disease or condition. One note that did not contain natural language text was removed. Questions were generated from these notes using Sentence Verification Technique and were analyzed using item response theory (IRT) to identify a set of questions that represent a good test of ability for EHR note comprehension.

RESULTS

Using Sentence Verification Technique, 154 questions were generated from the 29 EHR notes initially obtained. Of these, 83 were manually selected for inclusion in the Amazon Mechanical Turk crowdsourcing tasks and 55 were ultimately retained following IRT analysis. A follow-up validation with a second Amazon Mechanical Turk task and IRT analysis confirmed that the 55 questions test a latent ability dimension for EHR note comprehension. A short test of 14 items was created along with the 55-item test.

CONCLUSIONS

We developed ComprehENotes, an instrument for assessing EHR note comprehension from existing EHR notes, gathered responses using crowdsourcing, and used IRT to analyze those responses, thus resulting in a set of questions to measure EHR note comprehension. Crowdsourced responses from Amazon Mechanical Turk can be used to estimate item parameters and select a subset of items for inclusion in the test set using IRT. The final set of questions is the first test of EHR note comprehension.

The Effectiveness of Health Care Information Technologies: Evaluation of Trust, Security Beliefs, and Privacy as Determinants of Health Care Outcomes

Background

The diffusion of health information technologies (HITs) within the health care sector continues to grow. However, there is no theory explaining how success of HITs influences patient care outcomes. With the increase in data breaches, HITs’ success now hinges on the effectiveness of data protection solutions. Still, empirical research has only addressed privacy concerns, with little regard for other factors of information assurance.

Objective

The objective of this study was to study the effectiveness of HITs using the DeLone and McLean Information Systems Success Model (DMISSM). We examined the role of information assurance constructs (ie, the role of information security beliefs, privacy concerns, and trust in health information) as measures of HIT effectiveness. We also investigated the relationships between information assurance and three aspects of system success: attitude toward health information exchange (HIE), patient access to health records, and perceived patient care quality.

Methods

Using structural equation modeling, we analyzed the data from a sample of 3677 cancer patients from a public dataset. We used R software (R Project for Statistical Computing) and the Lavaan package to test the hypothesized relationships.

Results

Our extension of the DMISSM to health care was supported. We found that increased privacy concerns reduce the frequency of patient access to health records use, positive attitudes toward HIE, and perceptions of patient care quality. Also, belief in the effectiveness of information security increases the frequency of patient access to health records and positive attitude toward HIE. Trust in health information had a positive association with attitudes toward HIE and perceived patient care quality. Trust in health information had no direct effect on patient access to health records; however, it had an indirect relationship through privacy concerns.

Conclusions

Trust in health information and belief in the effectiveness of information security safeguards increases perceptions of patient care quality. Privacy concerns reduce patients’ frequency of accessing health records, patients’ positive attitudes toward HIE exchange, and overall perceived patient care quality. Health care organizations are encouraged to implement security safeguards to increase trust, the frequency of health record use, and reduce privacy concerns, consequently increasing patient care quality.

Enhancing NICU parent engagement and empowerment

Within the neonatal intensive care unit (NICU), parent engagement and empowerment are of critical importance, particularly when infants are at risk of developing severe complications, such as necrotizing enterocolitis (NEC). Stakeholders within the NICU, including the fragile patients, families, clinicians, staff, and administration, benefit when parents are a valued member of their baby's care team. The 2017 NEC Symposium explored the experiences of families whose infants were impacted by NEC, the barriers to effective partnership, and promising solutions. Parents want to participate in their baby's care, and crave honest, timely, comprehensive information regarding their baby's health and potential outcomes. Clinicians and staff should implement a specific set of Family-Centered Care policies and practices within the NICU to foster a culture of collaboration with parents of premature and fragile infants.

Patient portals and personal health information online: perception, access, and use by US adults

Background

Access to online patient portals is key to improving care, but we have limited understanding of patient perceptions of online portals and the characteristics of people who use them.

Methods

Using a national survey of 3677 respondents, we describe perceptions and utilization of online personal health information (PHI) portals.

Results

Most respondents (92%) considered online PHI access important, yet only 34% were offered access to online PHI by a health care provider, and just 28% accessed online PHI in the past year. While there were no differences across race or ethnicity in importance of access, black and Hispanic respondents were significantly less likely to be offered access ( P  = .006 and <.001, respectively) and less likely to access their online PHI ( P  = .041 and <.001, respectively) compared to white and non-Hispanic respondents.

Conclusion

Health care providers are crucial to the adoption and use of online patient portals and should be encouraged to offer consistent access regardless of patient race and ethnicity.

"Why Do They Need to Check Me?" Patient Participation Through eHealth and the Doctor-Patient Relationship: Qualitative Study

BACKGROUND

Roles in the doctor-patient relationship are changing and patient participation in health care is increasingly emphasized. Electronic health (eHealth) services such as patient accessible electronic health records (PAEHRs) have been implemented to support patient participation. Little is known about practical use of PAEHR and its effect on roles of doctors and patients.

OBJECTIVE

This qualitative study aimed to investigate how physicians view the idea of patient participation, in particular in relation to the PAEHR system. Hereby, the paper aims to contribute to a deeper understanding of physicians' constructions of PAEHR, roles in the doctor-patient relationship, and levels and limits of involvement.

METHODS

A total of 12 semistructured interviews were conducted with physicians in different fields. Interviews were transcribed, translated, and a theoretically informed thematic analysis was performed.

RESULTS

Two important aspects were identified that are related to the doctor-patient relationship: roles and involvement. The physicians viewed their role as being the ones to take on the responsibility, determining treatment options, and to be someone who should be trusted. In relation to the patient's role, lack of skills (technical or regarding medical jargon), motives to read, and patients' characteristics were aspects identified in the interviews. Patients were often referred to as static entities disregarding their potential to develop skills and knowledge over time. Involvement captures aspects that support or hinder patients to take an active role in their care.

CONCLUSIONS

Literature of at least two decades suggests an overall agreement that the paternalistic approach in health care is inappropriate, and a collaborative process with patients should be adopted. Although the physicians in this study stated that they, in principle, were in favor of patient participation, the analysis found little support in their descriptions of their daily practice that participation is actualized. As seen from the results, paternalistic practices are still present, even if professionals might not be aware of this. This can create a conflict between patients who strive to become more informed and their questions being interpreted as signs of critique and mistrust toward the physician. We thus believe that the full potential of PAEHRs is not reached yet and argue that the concept of patient empowerment is problematic as it triggers an interpretation of "power" in health care as a zero-sum, which is not helpful for the maintenance of the relationship between the actors. Patient involvement is often discussed merely in relation to decision making; however, this study emphasizes the need to include also sensemaking and learning activities. This would provide an alternative understanding of patients asking questions, not in terms of "monitoring the doctor" but to make sense of the situation.

Managing patients' information in a community mental health team

Aims and Method

To explore current practice in offering patients copies of correspondence, we audited the documentation of 422 patients of a community mental health team.

Results

Discussion about copying letters was documented in 194 case notes (46%); older patients and those with medically unexplained physical symptoms were less likely to be offered copies. There were 159 patients (82%) that wanted to receive copies of letters; male gender was associated with declining this option. In 167 (87%) instances the professional completing the form was a psychiatrist.

Clinical Implications

Older patients need to be offered the opportunity to receive correspondence. Clinicians should record and substantiate their decision not to offer copies of letters to some patients. Professionals other than psychiatrists should be encouraged to discuss copying letters with patients.

Amplified hearing device use in acute care settings for patients with hearing loss: A feasibility study

The objective of this study was to assess the feasibility of using amplified hearing devices (AHD) in acute care settings for patients with hearing loss. Secondary objectives include patient and nurse satisfaction, and nursing perceived productivity. Twenty-five adult hard of hearing patients and 15 nurses were evaluated. Patients with a perceived hearing handicap were identified through the Hearing Handicap for the Elderly Screening Version. Patient and staff nurse surveys were used to assess for satisfaction with using the AHD. Nurses were surveyed to evaluate whether they felt the AHD made patient communication more efficient and effective. Twenty-four patients expressed satisfaction with the AHD and would use it in future hospitalizations. Nurses also reported satisfaction, perceived improvement of patient communication and decreased time spent communicating with patients. Results demonstrate the feasibility of using an AHD in acute care inpatient settings where elderly hard of hearing patients are common.

Supporting Lung Cancer Patients With an Interactive Patient Portal: Feasibility Study

BACKGROUND

MyAVL is an interactive portal for cancer patients that aims to support lung cancer patients.

OBJECTIVE

We aimed to evaluate the feasibility and usability of the patient portal and generate preliminary evidence on its impact.

METHODS

Lung cancer patients currently or recently treated with curative intent could use MyAVL noncommittally for 4 months. Feasibility, usability, and preliminary impact (ie, patient activation, quality of life, and physical activity) were studied by means of questionnaires, a focus group, and analysis of user log data.

RESULTS

We included 37 of 123 eligible patients (mean age 59.6 years). The majority of responses (82%) were positive about using MyAVL, 69% saw it as a valuable addition to care, and 56% perceived increased control over their health. No positive effects could be substantiated on the impact measures.

CONCLUSIONS

MyAVL appears to be a feasible and user-friendly, multifunctional eHealth program for a selected group of lung cancer patients. However, it needs further improvements to positively impact patient outcomes.

Patient-centric medical notes: Identifying areas for improvement in the age of open medical records

OBJECTIVE

Patients are increasingly provided facilitated access to their medical notes. Physicians have reported concerns that patients will find notes confusing and offensive, and that typographical errors will appear unprofessional. This exploratory study quantifies the prevalence of potentially confusing or offensive medical language and typographic errors within notes.

METHODS

The authors performed a retrospective, cross-sectional review of 400 inpatient History and Physical notes from a tertiary care center. All notes were from admissions to general internal medicine services. Words and phrases of interest were codified into five pre-established categories and subdivisions.

RESULTS

Of 400 notes, 337 notes written by residents and hospitalists were analyzed. The most prevalent characteristics identified per note were General Medical Acronyms (99.1%), Medical Jargon (96.7%), and Typographical Errors (49%). Residents used a greater number of acronyms and abbreviations (p<0.01). All subdivisions within Subjective Descriptors and Mental and Personal Health appeared in less than 20% of notes.

CONCLUSION

While the place of medical shorthand, jargon, and sensitive history in the note is unlikely to change in the near future, this study identifies typographical errors as a modifiable area for improvement. The examination of medical note language may prove beneficial to the patient-physician relationship in the digital era.

The patient perspective on the effects of medical record accessibility: a systematic review

BACKGROUND

Health care is shifting from a paternalistic to a participatory model, with increasing patient involvement. Medical record accessibility to patients may contribute significantly to patient comanagement.

OBJECTIVES

To systematically review the literature on the patient perspective of effects of personal medical record accessibility on the individual patient, patient-physician relationship and quality of medical care.

METHODS

Screening of PubMed, Web of Science, Cinahl, and Cochrane Library on the keywords 'medical record', 'patient record', 'communication', 'patient participation', 'doctor-patient relationship', 'physician-patient relationship' between 1 January 2002 and 31 January 2016; systematic review after assessment for methodological quality.

RESULTS

Out of 557 papers screened, only 12 studies qualified for the systematic review. Only a minority of patients spontaneously request access to their medical file, in contrast to frequent awareness of this patient right and the fact that patients in general have a positive view on open visit notes. The majority of those who have actually consulted their file are positive about this experience. Access to personal files improves adequacy and efficiency of communication between physician and patient, in turn facilitating decision-making and self-management. Increased documentation through patient involvement and feedback on the medical file reduces medical errors, in turn increasing satisfaction and quality of care. Information improvement through personal medical file accessibility increased reassurance and a sense of involvement and responsibility.

CONCLUSION

From the patient perspective medical record accessibility contributes to co-management of personal health care.

Maternal care quality in near miss and maternal mortality in an academic public tertiary hospital in Yogyakarta, Indonesia: a retrospective cohort study

Background

Reducing maternal mortality remains a major challenge for health care systems worldwide. The factors related to maternal mortality were extensively researched, and maternal death clusters around labour, delivery and the immediate postpartum period. Studies on the quality of maternal care in academic medical centre settings in low income countries are uncommon.

Methods

A retrospective cohort study of maternal deaths was conducted in an academic public tertiary hospital in Yogyakarta, and maternal near misses were used as controls. Data were obtained from medical records from February 1, 2011 to September 30, 2012. Three groups of variables were measured: (1) timeliness of care, (2) adherence to a standard of process indicators, and (3) associated extraneous variables. Variables were analysed using logistic regression to explore their effects on maternal mortality.

Results

The mean of triage response time and obstetric resident response time were longer in maternal deaths (8 ± 3.59 and 36.17 ± 23.48 min respectively) compared to near misses (1.29 ± 0.24 and 18.78 ± 4.85 min respectively). Near misses more frequently received oxytocin treatment than the maternal deaths (OR 0.13; 95%CI 0.02–0.77). Magnesium sulfate treatment in severe-preeclampsia or eclampsia was less given in maternal deaths although insignificant statistically (OR 0.19; 95% CI 0.03–1.47). Prophylactic antibiotic was also more frequently given in near misses than in maternal deaths though insignificant statistically (OR 0.3; 95% CI 0.06–1.56). Extraneous variables, such as caesarean sections were less performed in maternal deaths (OR 0.15; 95% CI 0.04–0.51), vaginal deliveries were more frequent in maternal deaths (OR 3.47; 95% CI 1.05–11.54), and more women in near misses were referred from other health care facilities (OR 0.09; 95% CI 0.01–0.91).

Conclusions

The near misses had relatively received better quality of care compared to the maternal deaths. The near misses had received faster response time and better treatments. Timely referral systems enabled benefits to prevent maternal death.

Shared Decision-Making and Patient Empowerment in Preventive Cardiology

Shared decision-making, central to evidence-based medicine and good patient care, begins and ends with the patient. It is the process by which a clinician and a patient jointly make a health decision after discussing options, potential benefits and harms, and considering the patient's values and preferences. Patient empowerment is crucial to shared decision-making and occurs when a patient accepts responsibility for his or her health. They can then learn to solve their own problems with information and support from professionals. Patient empowerment begins with the provider acknowledging that patients are ultimately in control of their care and aims to increase a patient's capacity to think critically and make autonomous, informed decisions about their health. This article explores the various components of shared decision-making in scenarios such as hypertension and hyperlipidemia, heart failure, and diabetes. It explores barriers and the potential for improving medication adherence, disease awareness, and self-management of chronic disease.

Supporting Families in Reviewing and Communicating about Radiology Imaging Studies

Diagnostic radiology reports are increasingly being made available to patients and their family members. However, these reports are not typically comprehensible to lay recipients, impeding effective communication about report findings. In this paper, we present three studies informing the design of a prototype to foster patient-clinician communication about radiology report content. First, analysis of questions posted in online health forums helped us identify patients' information needs. Findings from an elicitation study with seven radiologists provided necessary domain knowledge to guide prototype design. Finally, a clinical field study with 14 pediatric patients, their parents and clinicians, revealed positive responses of each stakeholder when using the prototype to interact with and discuss the patient's current CT or MRI report and allowed us to distill three use cases: co-located communication, preparing for the consultation, and reviewing radiology data. We draw on our findings to discuss design considerations for supporting each of these use cases.

Design, Implementation, and Evaluation of Self-Describing Diabetes Medical Records: A Pilot Study

Background

Each patient’s medical record consists of data specific to that patient and is therefore an appropriate source to adapt educational information content.

Objectives

This study aimed to design and implement an information provision system based on the medical records of diabetic patients and to investigate the attitudes of users toward using this product.

Methods

The study was organized into three phases: need analysis, design and implementation, and final evaluation. The aim of the need analysis phase was to investigate the questioning behavior of the patient in the real-world context. The design and implementation phase consisted of four stages: determining the minimum dataset for diabetes medical records, collecting and validating content, designing and implementing a diabetes electronic medical record system, and data entry. Evaluating the final system was done based on the constructs of the technology acceptance model in the two dimensions of perceived usefulness and perceived ease of use. A semistructured interview was used for this purpose.

Results

Three main categories were extracted for the patient’s perceived usefulness of the system: raising the self-awareness and knowledge of patients, improving their self-care, and improving doctor-patient interaction. Both patients and physicians perceived the personalized sense of information as a unique feature of the application and believed that this feature could have a positive effect on the patient’s motivation for learning and using information in practice. Specialists believed that providing personal feedback on the patient’s lab test results along with general explanations encourages the patients to read the content more precisely. Moreover, accessing medical records and helpful notes was a new and useful experience for the patients.

Conclusions

One of the key perceived benefits of providing tailored information in the context of medical records was raising patient awareness and knowledge. The results obtained from field observations and interviews have shown that patients were ready to accept the system and had a positive attitude when it was put into practice. The findings related to user attitude can be used as a guideline to design the next phase of the research (ie, investigation of system effectiveness on patient outcomes).

Trust in Mental Health Clinicians Among Patients Who Access Clinical Notes Online

OBJECTIVE

This study explored patient perspectives of how online access to clinical notes (OpenNotes) within the Veterans Affairs (VA) health care system may affect patients' relationships with their mental health clinicians.

METHODS

Semistructured qualitative interviews were conducted with 28 patients receiving VA mental health care who had accessed OpenNotes. Transcripts were coded and analyzed with a constant comparative approach.

RESULTS

Respondents consistently reported that patient-clinician relationships-feelings of trust in particular-are critical to the therapeutic process and that reading clinical notes strengthens or strains patients' trust in mental health clinicians. Perceptions of transparency and respect as conveyed in notes were central to maintaining trust.

CONCLUSIONS

Findings suggest that ensuring consistency between what occurs during appointments and what appears in clinical notes, as well as highlighting patient individuality and strengths in notes, may help engender patient trust and avoid negative consequences of OpenNotes in mental health care.

Exploring patients' perceptions of accessing electronic health records: Innovation in healthcare

The more widespread implementation of electronic health records has led to new ways of providing access to healthcare information, allowing patients to view their medical notes, test results, medicines and so on. In this article, we explore how patients perceive the possibility to access their electronic health record online and whether this influences patient involvement. The study includes interviews with nine patients and a survey answered by 56 patients. Our results show that patients perceive healthcare information to be more accessible and that electronic health record accessibility improves recall, understanding and patient involvement. However, to achieve the goal of involving patients as active decision-makers in their own treatment, electronic health records need to be fully available and test results, referrals and information on drug interactions need to be offered. As patient access to electronic health records spreads, it is important to gain a deeper understanding of how documentation practices can be changed to serve healthcare professionals and patients.

Toward a patient-centered ambulatory after-visit summary: Identifying primary care patients' information needs

OBJECTIVE

The purpose of this study was to determine the information needs of primary care patients as they review clinic visit notes to inform information that should be contained in an after-visit summary (AVS).

METHOD

We collected data from 15 patients with an acute illness and 14 patients with a chronic disease using semi-structured interviews. The acute patients reviewed seven major sections, and chronic patients reviewed eight major sections of a simulated, but realistic visit note to identify relevant information needs for their AVS.

RESULTS

Patients in the acute illness group identified the Plan, Assessment and History of Present Illness the most as important note sections, while patients in the chronic care group identified Significant Lab Data, Plan, and Assessment the most as important note sections.

DISCUSSION

This study was able to identify primary care patients' information needs after clinic visit. Primary care patients have information needs pertaining to diagnosis and treatment, which may be the reason why both patient groups identified Plan and Assessment as important note sections. Future research should also develop and assess an AVS based on the information gathered in this study and evaluate its usefulness among primary care patients.

PRACTICE IMPLICATIONS

The results of this study can be used to inform the development of an after-visit summary that assists patients to fully understand their treatment plan, which may improve treatment adherence.

Patient web portals, disease management, and primary prevention

BACKGROUND

Efforts aimed at health care reform and continued advances in information technologies have prompted interest among providers and researchers in patient web portals. Patient web portals are password-protected online websites that offer the patients 24-hour access to personal health information from anywhere with an Internet connection.

METHODS

This article, which is based upon bibliographic searches in PubMed, reviews important developments in web portals for primary and secondary disease prevention, including patient web portals tethered to electronic medical records, disease-specific portals, health disparities, and health-related community web portals.

RESULTS

Although findings have not been uniformly positive, several studies of the effectiveness of health care system patient portals in chronic disease management have shown promising results with regard to patient outcomes. Patient web portals have also shown promising results in increasing adherence with screening recommendations. Racial and ethnic minorities, younger persons, and patients who are less educated or have lower health literacy have been found to be less likely to use patient portals.

CONCLUSION

Additional studies are needed of the utility and effectiveness of different elements of web portals for different patient populations. This should include additional diseases and health topics such as smoking cessation and weight management.

Factors that impact Patient Web Portal Readiness (PWPR) among the underserved

OBJECTIVE

Healthcare organizations in the US are increasingly using Patient Portals as a means to provide patients with partial access to their health records and thereby comply with the 'meaningful use' of Health Information Technology policy issued by the US federal government. Patient portals are used to not only provide access to parts of the health records such as lab results but also offer services such as customized educational materials and appointment scheduling. While prior studies examining the adoption rates of these patient portals have not offered consistent findings, many of the studies have reported limited adoption and use [1] of patient portals, especially among the underserved population. This study explores the factors behind the reduced adoption rate of patient portals among the underserved by focusing on their Patient Web Portal Readiness (PWPR).

DESIGN

The study empirically evaluates the impact of three important variables on PWPR among the underserved: (a) Personal Health Information Management (PHIM) activities, (b) patient attitude toward personal health record keeping; and (c) use of Internet for health information seeking. The study also incorporates three other factors: (d) access to Internet; (e) demographics; and (f) presence of chronic illness.

MEASUREMENTS

Data were collected through a survey from 132 patients from the underserved population who visited 5 free clinics in the Northern Virginia area in the US. The paper-based survey was administered to the patients who visited these free clinics for care.

RESULTS

The study findings show support for the hypotheses related to the impact of the two key factors - Personal Health Information Management (PHIM) activities and attitude toward personal health record keeping - on PWPR. The findings also indicate that the use of Internet for health information seeking has relatively more impact than patient's Internet access on PWPR. Overall, the findings imply the critical importance of complementary activities - e.g., PHIM activities, Internet-based health information seeking - to enhance PWPR among the underserved population.

Writing the patient down and out: the construal of the patient in medical certificates of disability

We analysed a set of medical certificates to investigate how GPs portray patients who seek disability benefits in Norway, focusing on patient centredness, agency and involvement. We performed a qualitative linguistic analysis of 33 medical certificates collected throughout Norway that were strategically selected based on the patients' sex, age and diagnosis. We found that patients were represented as passive carriers of symptoms, in whom agency was low, failed, conditional or non-existing, or as passive objects of the actions of impersonalised others. Conversely, symptoms were foregrounded as independent and powerful actors. The patient's experience of illness was sometimes reported, but the perspective of the GP tended to be doctor oriented, rather than patient centred. The policy of the social services, which emphasises patient involvement, patient centredness and work, rather than social benefits, was almost completely absent from these medical certificates. If medical certificates are to be a valid basis for decisions within the social services, we suggest that doctor paternalism in these documents must give way to considering the patient as an involved and co-responsible individual in the processes of disability assessment.

Increase in Cancer Center Staff Effort Related to Electronic Patient Portal Use

PURPOSE

Electronic portals provide patients with real-time access to personal health records. Use of this technology by individuals with cancer is particularly intensive. We therefore examined patterns of use of electronic portals by clinic staff at a National Cancer Institute-designated comprehensive cancer center.

METHODS

We identified and characterized cancer center providers and clinic staff who performed electronic activities related to MyChart, the institution's personal health records portal, from 2009 to 2014. Total MyChart actions and messages received were quantified and characterized according to type, timing, and staff category.

RESULTS

Two hundred eighty-nine employees were included in our analysis: 85 nurses (29%), 79 ancillary staff (27%), 49 clerical/managerial staff (17%), 47 physicians (16%), and 29 advanced practice providers (10%). These individuals performed 740,613 MyChart actions and received 117,799 messages. Seventy-seven percent of actions were performed by nurses, 11% by ancillary staff, 6% by advanced practice providers, 5% by physicians, and 1% by clerical/managerial staff. From 2011 to 2014, staff MyChart activity increased approximately 10-fold. On average, 6.3 staff MyChart actions were performed per patient-initiated message. In 2014, nurses performed an average of 3,838 MyChart actions and received an average of 589 messages, compared with 591 actions and 87 messages in 2011 ( P < .001). Sixteen percent of all actions occurred outside clinic hours.

CONCLUSION

Cancer center employee effort related to an electronic patient portal has increased markedly over time, particularly among nursing staff. Because further uptake of this technology is expected, it is critical to consider potential effects on clinical resources, employee and patient satisfaction, and patient safety.

Communication of laboratory data and diagnostic test results to hospitalized patients: a study of preferences and recall

OBJECTIVE

To assess patients' preferences with respect to different methods of receiving test results while they were hospitalized and to determine whether the different modes of communication of the test results were associated with better recall.

METHODS

Five discrete test results were shared with adult inpatients on general medicine service (blood pressure, white blood cell count, hematocrit, creatinine, and chest X-ray). The information was delivered by a physician in one of three ways: 1) verbally, 2) explained with a print out of the results, or 3) described while showing results on a computer monitor (electronic). The same physician returned within 3 hours to assess recall and satisfaction with the way patients received their results.

RESULTS

All the patients (100%) receiving their results in written format were satisfied with the mode of communication as compared to electronic format (86%) or verbally (79%) (P=0.02). Fifty percent of patients in the computer format group could recall four or more test results at the follow-up, as compared to 43% in printed group and 24% who were informed of their results verbally (P=0.35).

CONCLUSION

Patients most appreciated receiving test results in written form while in the hospital, and this delivery method was as good as any other method with respect to recall.

Cancer patients' attitudes and experiences of online access to their electronic medical records: A qualitative study

Patients' access to their online medical records serves as one of the cornerstones in the efforts to increase patient engagement and improve healthcare outcomes. The aim of this article is to provide in-depth understanding of cancer patients' attitudes and experiences of online medical records, as well as an increased understanding of the complexities of developing and launching e-Health services. The study result confirms that online access can help patients prepare for doctor visits and to understand their medical issues. In contrast to the fears of many physicians, the study shows that online access to medical records did not generate substantial anxiety, concerns or increased phone calls to the hospital.

Electronic Release of Pathology and Radiology Results to Patients: Opinions and Experiences of Oncologists

PURPOSE

There is an emerging standard to provide patients rapid electronic access to elements of their medical records. Although surveys of patients generally support it, this practice is controversial among oncologists, because few empiric data are available for scenarios of potentially life-threatening conditions like cancer. We report the views of oncologists about patient electronic access to radiology and pathology results that could potentially indicate disease progression.

METHODS

Four months before oncologists were surveyed, final results of radiology/pathology reports were routinely made available to patients online through a secure portal after a 7-day, hold to provide clinicians time to review and communicate results with the patients. Mixed methods were used to assess physician attitudes and experiences toward this change.

RESULTS

One hundred twenty-nine oncologists were surveyed, and 82 (64%) responded. A small majority (54%) responded that the release of reports was somewhat or very beneficial for patients who received normal radiology/pathology results before discussion with a physician, but 87% said it was somewhat or very harmful for patients to receive abnormal results before discussion. Forty-nine percent reported that release of reports had a somewhat or very negative impact on communication with their patients.

CONCLUSION

Almost half of oncologists reported that sharing digital radiology and pathology records had a negative impact on their communication with patients. Patient surveys in similar cancer populations would complement the physician perspective. Efforts are needed to improve consensus among oncologists and patients on how to best communicate such results in a timely fashion.

Normalizing acronyms and abbreviations to aid patient understanding of clinical texts: ShARe/CLEF eHealth Challenge 2013, Task 2

BACKGROUND

The ShARe/CLEF eHealth challenge lab aims to stimulate development of natural language processing and information retrieval technologies to aid patients in understanding their clinical reports. In clinical text, acronyms and abbreviations, also referenced as short forms, can be difficult for patients to understand. For one of three shared tasks in 2013 (Task 2), we generated a reference standard of clinical short forms normalized to the Unified Medical Language System. This reference standard can be used to improve patient understanding by linking to web sources with lay descriptions of annotated short forms or by substituting short forms with a more simplified, lay term.

METHODS

In this study, we evaluate 1) accuracy of participating systems' normalizing short forms compared to a majority sense baseline approach, 2) performance of participants' systems for short forms with variable majority sense distributions, and 3) report the accuracy of participating systems' normalizing shared normalized concepts between the test set and the Consumer Health Vocabulary, a vocabulary of lay medical terms.

RESULTS

The best systems submitted by the five participating teams performed with accuracies ranging from 43 to 72 %. A majority sense baseline approach achieved the second best performance. The performance of participating systems for normalizing short forms with two or more senses with low ambiguity (majority sense greater than 80 %) ranged from 52 to 78 % accuracy, with two or more senses with moderate ambiguity (majority sense between 50 and 80 %) ranged from 23 to 57 % accuracy, and with two or more senses with high ambiguity (majority sense less than 50 %) ranged from 2 to 45 % accuracy. With respect to the ShARe test set, 69 % of short form annotations contained common concept unique identifiers with the Consumer Health Vocabulary. For these 2594 possible annotations, the performance of participating systems ranged from 50 to 75 % accuracy.

CONCLUSION

Short form normalization continues to be a challenging problem. Short form normalization systems perform with moderate to reasonable accuracies. The Consumer Health Vocabulary could enrich its knowledge base with missed concept unique identifiers from the ShARe test set to further support patient understanding of unfamiliar medical terms.

Street-Level Strategies of Child Welfare Social Workers in Flanders: The Use of Electronic Client Records in Practice

The use of information and communication technology (ICT) in child welfare services has increased significantly during the last decades, and so have the possibilities to process health data. Parton (2009) states that this evolution has led to a shift in the nature of social work itself: from 'the social' to 'the informational'. It is claimed that social workers primarily are becoming information processors concerned with the gathering, sharing and monitoring of information, instead of being focused on the relational dimensions of their work. However, social workers have considerable discretion concerning the way they use ICT. In this paper, we investigate (i) the street-level strategies social workers develop regarding ICT and (ii) how these relate to a narrative social work approach. To illustrate this, an evaluation of Charlotte was conducted, a client registration system that is used by social workers in child welfare services in Flanders, Belgium. Based on fifteen interviews, we find that social workers develop various strategies regarding Charlotte to preserve a relational and narrative work approach. These strategies not only result in a gap between ICT policy and the execution of that policy in practice, but also decrease the extent to which accountability can be realised via registration data.

Prompting participation in health: Fostering favorable attitudes toward personal health records through message design

OBJECTIVE

Personal health records (PHRs) offer many benefits. However, a relatively small amount of individuals take advantage of PHRs. This study examined how message composition influences attitudes toward electronic PHRs.

METHODS

Participants (N=329) were randomly assigned to read one of two fictitious editorials proposing that all patients have PHRs. One version assigned linguistic agency (capacity for action) to PHRs (e.g.,PHRs can guard against long-term health problems) and the other to humans (e.g.,people can guard themselves against long-term health problems).

RESULTS

One-way analyses of variance revealed significant main effects of agency on perceptions of PHR benefits. Respondents reported feeling more comfortable using PHRs and perceived them as more effective at protecting patients when agency was assigned to PHRs rather than to humans.

CONCLUSION

Messages with PHRs as the primary acting agents elicited favorable reactions about PHR use. Patients may be more willing to engage with this technology if the emphasis is put on what PHRs can do for patients.

PRACTICE IMPLICATIONS

Providers and staff can make strategic choices about wording when discussing PHRs and healthcare. Attention to linguistic agency can help providers better engage patients in discussions about this topic and enable patients to become more proactive.

Opening Residents' Notes to Patients: A Qualitative Study of Resident and Faculty Physician Attitudes on Open Notes Implementation in Graduate Medical Education

PURPOSE

OpenNotes is a growing national initiative inviting patients to read clinician progress notes (open notes) through a secure electronic portal. The goals of this study were to (1) identify resident and faculty preceptor attitudes about sharing notes with patients, and (2) assess specific educational needs, policy recommendations, and approaches to facilitate open notes implementation.

METHOD

This was a qualitative study using focus groups with residents and faculty physicians who supervise residents, representing primary care, general surgery, surgical and procedural specialties, and nonprocedural specialties, from Beth Israel Deaconess Medical Center and Geisinger Health System in spring 2013. Data were audio recorded and transcribed verbatim, then coded and organized into themes.

RESULTS

Thirty-six clinicians (24 [66.7%] residents and 12 [33.3%] faculty physicians) participated. Four main themes emerged: (1) implications of full transparency, (2) note audiences and ideology, (3) trust between patients and doctors, and (4) time pressures. Residents and faculty discussed how open notes might yield more engaged patients and better notes but were concerned about the time needed to edit notes and respond to patient inquiries. Residents were uncertain how much detail they should share with patients and were concerned about the potential to harm the patient-doctor relationship. Residents and faculty offered several recommendations for open notes implementation.

CONCLUSIONS

Overall, participants were ambivalent about resident participation in open notes. Residents and faculty identified clinical and educational benefits to open notes but were concerned about potential effects on the patient-doctor relationship, requirements for oversight, and increased workload and burnout.

Engaging patients through open notes: an evaluation using mixed methods

OBJECTIVES

(A) To gain insights into the experiences of patients invited to view their doctors' visit notes, with a focus on those who review multiple notes; (B) to examine the relationships among fully transparent electronic medical records and quality of care, the patient-doctor relationship, patient engagement, self-care, self-management skills and clinical outcomes.

DESIGN

Mixed methods qualitative study: analyses of survey data, including content analysis of free-text answers, and quantitative-descriptive measures combined with semistructured individual interviews, patient activation measures, and member checks.

SETTING

Greater Boston, USA.

PARTICIPANTS

Patients cared for by primary care physicians (PCPs) at the Beth Israel Deaconess Medical Center who had electronic access to their PCP visit notes. Among those submitting surveys, 576 free-text answers were identified and analysed (414 from female patients, 162 from male patients; 23-88 years). In addition, 13 patients (9 female, 4 male; 58-87 years) were interviewed.

RESULTS

Patient experiences indicate improved understanding (of health information), better relationships (with doctors), better quality (adherence and compliance; keeping track) and improved self-care (patient-centredness, empowerment). Patients want more doctors to offer access to their notes, and some wish to contribute to their generation. Those patients with repeated experience reviewing notes express fewer concerns and more perceived benefits.

CONCLUSIONS

As the use of fully transparent medical records spreads, it is important to gain a deeper understanding of possible benefits or harms, and to characterise target populations that may require varying modes of delivery. Patient desires for expansion of this practice extend to specialty care and settings beyond the physician's office. Patients are also interested in becoming involved actively in the generation of their medical records. The OpenNotes movement may increase patient activation and engagement in important ways.

VA mental health clinician experiences and attitudes toward OpenNotes

OBJECTIVE

To describe Department of Veterans Affairs (VA) mental health clinician attitudes toward and experiences with OpenNotes (also known as Blue Button), which provides patients direct access to clinical notes online.

METHOD

A 35-item online survey was administered to 263 mental health clinicians and nurses from one VA Medical Center.

RESULTS

Seventy-nine percent of eligible subjects participated. Most respondents agreed or somewhat agreed that OpenNotes is a good idea in general, but only half agreed that making mental health notes available online is a good idea. Most believed that patients will better remember plans of care and be better prepared for visits. Most also felt that patients will worry more and request changes in notes. Many clinicians reported being less detailed and changing the tone of their notes.

CONCLUSION

As a group, mental health clinicians are positive about OpenNotes in general but ambivalent about the use of OpenNotes in mental health care. The results call for research on outcomes of OpenNotes use in mental health and to develop education and support to help clinicians adapt to OpenNotes.

A Patient Portal With Electronic Messaging: Controlled Before-and-After Study

Background

Patients’ access to their medical records, along with electronic messaging, offers an efficient means of information transition between patients and their caregivers. Easier access to information and interaction with health care professionals may reduce use of other services while increasing patients’ activation in the management of their own health. Patient portals may therefore have a favorable impact on the cost-effectiveness of care.

Objective

The aim was to assess the benefits and risks of providing electronic messaging services to patients with chronic conditions. Using cost-effectiveness analysis, the outcomes and costs of providing access to an electronic patient portal were evaluated in a real-life treatment process in primary care.

Methods

A total of 876 chronically ill patients from public primary care were allocated to either an intervention group receiving immediate access to a patient portal that included their medical records, care plan, and secure messaging with a care team, or to a control group receiving standard care. Incremental direct heath care costs, health status based on the Short-Form Health Survey, version 2 (SF-36v2), and patient activation based on the short form of the Patient Activation Measure (PAM13) were compared to standard care in a 6-month follow-up. Incremental cost-effectiveness ratios were calculated using a sample of 80 patients in the intervention group and 57 patients in the control group; thus, a total of 137 patients were included in the final analysis. Propensity-score matching was used to assess the sensitivity of the results to the possible attrition bias.

Results

Patient activation improved more in the intervention group but the effect was not statistically significant. The effect on cost of care was ambiguous; costs decreased by an average of €91 in the unadjusted model, but increased by €48 in the adjusted model. Due to the controversial results on cost, the unadjusted analysis showed an 89% probability of cost-effectiveness with no willingness to pay for increased patient activation, whereas in the adjusted sample, the probability of the portal being more cost-effective than care as usual exceeded 50% probability at a willingness to pay €700 per clinically significant increase in patient activation score. There was no marked short-term impact on health status based on the SF-36v2 measure.

Conclusions

Offering the possibility to substitute health care visits with less costly contacts using self-management tools did not seem to compromise the health status or treatment of chronic care patients. Patient activation increased, and this could be achieved with moderate costs in a short-term experiment. In the long term, increased activation is proposed to lead to better health outcomes and eventually cut down resource use. Future studies should assess the long-term effects of patient portals on patients’ health status and cost of care.

Characteristics of Patients Who Report Confusion After Reading Their Primary Care Clinic Notes Online

Patient access to online electronic medical records (EMRs) is increasing and may offer benefits to patients. However, the inherent complexity of medicine may cause confusion. We elucidate characteristics and health behaviors of patients who report confusion after reading their doctors' notes online. We analyzed data from 4,528 patients in Boston, MA, central Pennsylvania, and Seattle, WA, who were granted online access to their primary care doctors' clinic notes and who viewed at least one note during the 1-year intervention. Three percent of patients reported confusion after reading their visit notes. These patients were more likely to be at least 70 years of age (p < .0001), have fewer years of education (p < .0017), be unemployed (p < .0001), have lower levels of self-reported health (p < .0043), and worry more after reading visit notes (relative risk [RR] 4.83; confidence interval [CI] 3.17, 7.36) compared to patients who were not confused. In adjusted analyses, they were less likely to report feeling more in control of their health (RR 0.42; CI 0.25, 0.71), remembering their care plan (RR 0.26; CI 0.17, 0.42), and understanding their medical conditions (RR 0.32; CI 0.19, 0.54) as a result of reading their doctors' notes compared to patients who were not confused. Patients who were confused by reading their doctors' notes were less likely to report benefits in health behaviors. Understanding this small subset of patients is a critical step in reducing gaps in provider-patient communication and in efforts to tailor educational approaches for patients.

Disparities in Electronic Health Record Patient Portal Use in Nephrology Clinics

BACKGROUND AND OBJECTIVES

Electronic health record (EHR) patient portals allow individuals to access their medical information with the intent of patient empowerment. However, little is known about portal use in nephrology patients. We addressed this gap by characterizing adoption of an EHR portal, assessing secular trends, and examining the association of portal adoption and BP control (<140/90 mmHg).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Patients seen between January 1, 2010, and December 31, 2012, at any of four university-affiliated nephrology offices who had at least one additional nephrology follow-up visit before June 30, 2013, were included. Sociodemographic characteristics, comorbidities, clinical measurements, and office visits were abstracted from the EHR. Neighborhood median household income was obtained from the American Community Survey 2012.

RESULTS

Of 2803 patients, 1098 (39%) accessed the portal. Over 87% of users reviewed laboratory results, 85% reviewed their medical information (e.g., medical history), 85% reviewed or altered appointments, 77% reviewed medications, 65% requested medication refills, and 31% requested medical advice from their renal provider. In adjusted models, older age, African-American race (odds ratio [OR], 0.50; 95% confidence interval [95% CI], 0.39 to 0.64), Medicaid status (OR, 0.53; 95% CI, 0.36 to 0.77), and lower neighborhood median household income were associated with not accessing the portal. Portal adoption increased over time (2011 versus 2010: OR, 1.38 [95% CI, 1.09 to 1.75]; 2012 versus 2010: OR, 1.95 [95% CI, 1.44 to 2.64]). Portal adoption was correlated with BP control in patients with a diagnosis of hypertension; however, in the fully adjusted model this was somewhat attenuated and no longer statistically significant (OR, 1.11; 95% CI, 0.99 to 1.24).

CONCLUSION

While portal adoption appears to be increasing, greater attention is needed to understand why vulnerable populations do not access it. Future research should examine barriers to the use of e-health technologies in underserved patients with CKD, interventions to address them, and their potential to improve outcomes.

"Nothing About Me Without Me": An Interpretative Review of Patient Accessible Electronic Health Records

Background

Patient accessible electronic health records (PAEHRs) enable patients to access and manage personal clinical information that is made available to them by their health care providers (HCPs). It is thought that the shared management nature of medical record access improves patient outcomes and improves patient satisfaction. However, recent reviews have found that this is not the case. Furthermore, little research has focused on PAEHRs from the HCP viewpoint. HCPs include physicians, nurses, and service providers.

Objective

We provide a systematic review of reviews of the impact of giving patients record access from both a patient and HCP point of view. The review covers a broad range of outcome measures, including patient safety, patient satisfaction, privacy and security, self-efficacy, and health outcome.

Methods

A systematic search was conducted using Web of Science to identify review articles on the impact of PAEHRs. Our search was limited to English-language reviews published between January 2002 and November 2014. A total of 73 citations were retrieved from a series of Boolean search terms including “review*” with “patient access to records”. These reviews went through a novel scoring system analysis whereby we calculated how many positive outcomes were reported per every outcome measure investigated. This provided a way to quantify the impact of PAEHRs.

Results

Ten reviews covering chronic patients (eg, diabetes and hypertension) and primary care patients, as well as HCPs were found but eight were included for the analysis of outcome measures. We found mixed outcomes across both patient and HCP groups, with approximately half of the reviews showing positive changes with record access. Patients believe that record access increases their perception of control; however, outcome measures thought to create psychological concerns (such as patient anxiety as a result of seeing their medical record) are still unanswered. Nurses are more likely than physicians to gain time efficiencies by using a PAEHR system with the main concern from physicians being the security of the PAEHRs.

Conclusions

This review implements a novel scoring system, which shows there is a lack of rigorous empirical testing that separates the effect of record access from other existing disease management programs. Current research is too targeted within certain clinical groups’ needs, and although there are positive signs for the adoption of PAEHRs, there is currently insufficient evidence about the effect of PAEHRs on health outcomes for patients or HCPs.

Improving quality of care and long-term health outcomes through continuity of care with the use of an electronic or paper patient-held portable health file (COMMUNICATE): study protocol for a randomized controlled trial

BACKGROUND

The advantages of patient-held portable health files (PHF) and personal health records (PHR), paper or electronic, are said to include improved health-care provider continuity-of-care and patient empowerment in maintaining health. Top-down approaches are favored by public sector government and health managers. Bottom-up approaches include systems developed directly by health-care providers, consumers and industry, implemented locally on devices carried by patient-consumers or shared via web-based portals. These allow individuals to access, manage and share their health information, and that of others for whom they are authorized, in a private, secure and confidential environment. Few medical record technologies have been evaluated in randomized trials to determine whether there are important clinical benefits of these interventions. The COMMUNICATE trial will assess the acceptability and long-term clinical outcomes of an electronic and paper patient-held PHF.

METHODS/DESIGN

This is a 48-month, open-label pragmatic, superiority, parallel-group design randomized controlled trial. Subjects (n = 792) will be randomized in a 1:1:1 ratio to each of the trial arms: the electronic PHF added to usual care, the paper PHF added to usual care and usual care alone (no PHF). Inclusion criteria include those 60 years or older living independently in the community, but who have two or more chronic medical conditions that require prescription medication and regular care by at least three medical practitioners (general and specialist care). The primary objective is whether use of a PHF compared to usual care reduces a combined endpoint of deaths, overnight hospitalizations and blindly adjudicated serious out-of-hospital events. All primary analyses will be undertaken masked to randomized arm allocation using intention-to-treat principles. Secondary outcomes include quality of life and health literacy improvements.

DISCUSSION

Lack of blinding creates potential for bias in trial conduct and ascertainment of clinical outcomes. Mechanisms are provided to reduce bias, including balanced study contact with all participants, a blinded adjudication committee determining which out-of-hospital events are serious and endpoints that are objective (overnight hospitalizations and mortality). The PRECIS tool provides a summary of the trial's design on the Pragmatic-Explanatory Continuum.

TRIAL REGISTRATION

Registered with Clinicaltrials.gov (identifier: NCT01082978) on 8 March 2010.

Patient Preferences and Perspectives on Accessing Their Medical Records

BACKGROUND

Personal health record platforms and patient portals have the potential to empower patients by providing access to health records, but not all patients may be interested in this. The purpose of this study was to explore inpatients' opinions on their hospital paper medical records after they had incidental access to them.

METHODS

A survey and observational study were conducted in the computed tomography department at a large academic hospital. Patients in the computed tomography hallway were left with their paper records and either started reading them or not.

RESULTS

Of 174 patients receiving the survey, 102 returned the questionnaire (59% response rate); two were excluded. Among the 100 included patients, 65 read their records, and 35 did not; 37.1% (13/35) nonreaders indicated interest to access their records but did not know they had the legal right. The physician's notes was the section that most patients read (n = 35, 53.8%) followed by the laboratory reports (n = 31, 47.7%) and nurse's notes (n = 29, 44.6%). Overall, 70.8% (46/65) of readers found their records easy to understand, and most found their records correct (64.4%) or complete (58.5%) and did not find anything unexpected (63.1%) or distressing (66.2%). However, a significant minority found errors in their records (7.7%) including missing test results, medications, and a wrong birthday. According to multivariate analysis, being female (odds ratio [OR] = 2.8; 95% confidence interval [CI], 1.0-8.0), younger than 60 years (OR = 3.0; 95% CI, 1.2-8.0), and having a higher level of education (OR = 3.9; 95% CI, 1.4-10.8) predicted readership.

CONCLUSION

A surprisingly high number of patients are still unaware of their legal right to access their health record. Predictors for access suggest a "social divide" in motivation and ability to access health records.

Development of MijnAVL, an Interactive Portal to Empower Breast and Lung Cancer Survivors: An Iterative, Multi-Stakeholder Approach

BACKGROUND

MijnAVL (MyAVL) is an interactive portal being developed to empower cancer survivors. Literature review and focus groups yielded the selection of features such as access to the electronic medical record (EMR), patient reported outcomes (PROs) and related feedback, and a physical activity support program.

OBJECTIVE

Our aim was to present a final design of MijnAVL based on (1) health professionals' evaluation of proposed features, (2) cancer survivors' evaluation of a first draft, and (3) cancer survivors' evaluation of a functional online prototype.

METHODS

Professionals from various disciplines gave input to the content of and procedures related to MijnAVL. Subsequently, 16 cancer survivors participated in an interview to evaluate content and graphic design of a first draft (shown with screenshots). Finally, 7 survivors participated in a usability test with a fully functional prototype. They performed predefined tasks (eg, logging in, finding a test result, completing a questionnaire) while thinking aloud. Descriptive statistics and simple content analysis were used to analyze the data of both the interviews and the usability tests.

RESULTS

Professionals supported access to the EMR (eg, histology reports, lab results, and their letters to general practitioners). They also informed the development of PROs and the physical activity support program. Based on the first draft, survivors selected the preferred graphic design, approved the features and provided suggestions for the content (eg, explanation of medical jargon, more concise texts, notification by emails). Usability tests revealed that it was relatively easy to navigate the website and use the different features. Recommendations included, among others, a frequently asked questions section and the use of hyperlinks between different parts of the website.

CONCLUSIONS

The development of MijnAVL, an interactive portal to empower breast and lung cancer survivors, was performed iteratively and involved multiple groups of end-users. This approach resulted in a usable and understandable final version. Its effectiveness should be determined in further research.

The patient portal and abnormal test results: An exploratory study of patient experiences

Many health care institutions are implementing patient portals that allow patients to track and maintain their personal health information, mostly in response to the Health Information Technology for Economic and Clinical Health Act requirements. Test results review is an area of high interest to patients and provides an opportunity to foster their involvement in preventing abnormal test results from being overlooked, a common patient safety concern. However, little is known about how patients engage with portals to review abnormal results and which strategies could facilitate that interaction in order to ensure safe follow-up on abnormalities. The objective of this qualitative study was to explore patients' experiences related to abnormal test result notifications through patient portals. The authors conducted semi-structured telephone interviews with 13 participants, patients and primary caregivers, between February 2014 and October 2014. Using content analysis, the authors explored patient experiences accessing abnormal test results through their portals. Respondents strongly favored access to all types of abnormal test results, but they raised several concerns including need for more timely notification and not being able to interpret the exact relevance of the result. Respondents' personal experiences with physicians, test result notification, and the portal heavily influenced respondents' notification preferences. Patient experiences with portals could be improved by development of strategies to help patients understand and manage the information received. These findings suggest important considerations for health professionals and institutions aiming to better engage patients in follow-up of their test results.

Use of an electronic patient portal among the chronically ill: an observational study

Background

Electronic patient portals may enhance effective interaction between the patient and the health care provider. To grasp the full potential of patient portals, health care providers need more knowledge on which patient groups prefer electronic services and how patients should be served through this channel.

Objective

The objective of this study was to assess how chronically ill patients’ state of health, comorbidities, and previous care are associated with their adoption and use of a patient portal.

Methods

A total of 222 chronically ill patients, who were offered access to a patient portal with their health records and secure messaging with care professionals, were included in the study. Differences in the characteristics of non-users, viewers, and interactive users of the patient portal were analyzed before access to the portal. Patients’ age, gender, diagnoses, levels of the relevant physiological measurements, health care contacts, and received physiological measurements were collected from the care provider’s electronic health record. In addition, patient-reported health and patient activation were assessed by a survey.

Results

Despite the broad range of measures used to indicate the patients’ state of health, the portal user groups differed only in their recorded diagnosis for hypertension, which was most common in the non-user group. However, there were significant differences in the amount of care received during the year before access to the portal. The non-user group had more nurse visits and more measurements of relevant physiological outcomes than viewers and interactive users. They also had fewer referrals to specialized care during the year before access to the portal than the two other groups. The viewers and the interactive users differed from each other significantly in the number of nurse calls received, the interactive users having more calls than the viewers. No significant differences in age, gender, or patient activation were detected between the user groups.

Conclusions

Previous care received by the patient is an important predictor for the use of a patient portal. In a group of patients with a similar disease burden, demand for different types of health services and preferences related to the service channel seem to contribute to the choice to use the patient portal. Further research on patient portal functionalities and their potential to meet patient needs by complementing or substituting for traditional health care services is suggested.