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Sprackling CM, Kieren MQ, Nacht CL, Moreno MA, Wooldridge A, Kelly MM. Adolescent Access to Clinicians' Notes: Adolescent, Parent, and Clinician Perspectives. J Adolesc Health 2024; 74:155-160. [PMID: 37831050 PMCID: PMC10842681 DOI: 10.1016/j.jadohealth.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE In 2021, federal guidelines mandated that health-care organizations share clinicians' notes with patients to increase information transparency. While findings indicate advantages for adult patients, less is known about note-sharing from the viewpoint of adolescents. This study aims to identify adolescent, parent, and clinician perspectives on the anticipated benefits and concerns of giving adolescents access to clinicians' notes and strategies to support note-sharing in this population. METHODS We conducted six focus groups with adolescents, parents, and clinicians at a children's hospital from May to October 2021. A semistructured facilitator guide captured participant perspectives of note-sharing benefits, concerns, and strategies. Two researchers independently coded and analyzed transcript data using thematic analysis; a third researcher reconciled discrepancies. RESULTS 38 stakeholders (17 adolescents, 10 parents, and 11 clinicians) described four benefits, three concerns, and four implementation strategies regarding adolescent note-sharing. Potential benefits included adolescents using notes to remember and reinforce the visit, gaining knowledge about their health, strengthening the adolescent-clinician relationship, and increasing agency in health care decisions. Concerns included notes leading to a breach in confidentiality, causing negative emotions, and becoming less useful for clinicians. Strategies included making note-sharing more secure, optimizing note layout and content, setting clear expectations, and having a portion of the note for clinician use only. DISCUSSION Stakeholders suggest multiple strategies to optimize the implementation of note-sharing to support adolescent patients, parents, and clinicians as hospitals work to comply with federal regulations. These strategies may reinforce the potential benefits and mitigate the challenges of sharing notes with adolescent patients.
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Affiliation(s)
- Carley M Sprackling
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Madeline Q Kieren
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Carrie L Nacht
- School of Public Health, San Diego State University, San Diego, California
| | - Megan A Moreno
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Abigail Wooldridge
- Department of Industrial and Enterprise Systems Engineering, University of Illinois Urbana-Champaign, Champaign, Illinois
| | - Michelle M Kelly
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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Kelly MM, Hoonakker PLT, Nacht CL, Smith CA, Dean SM, Sklansky DJ, Smith W, Sprackling CM, Zellmer BM, Coller RJ. Parent Perspectives on Sharing Pediatric Hospitalization Clinical Notes. Pediatrics 2023; 151:e2022057756. [PMID: 36450655 PMCID: PMC9998186 DOI: 10.1542/peds.2022-057756] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Federal guidelines mandate that hospitals provide patients and caregivers with free, online access to their physician's clinical notes. This study sought to identify parent perceptions of the benefits and challenges of real-time note access during their child's hospitalization and strategies to optimize note-sharing at the bedside. METHODS This qualitative study was conducted with parents of children aged <12 years admitted to a pediatric hospitalist service in April 2019. Parents were given access to their child's admission and daily progress notes on a bedside tablet (iPad), and interviewed upon discharge. In-depth, 60-minute interviews were audio-recorded and transcribed. Two researchers developed and refined a codebook and coded data inductively and deductively with validation by a third researcher. Thematic analysis was used to identify emergent themes. RESULTS The 28 interviewed parents described 6 benefits of having note access, which: provided a recap and improved their knowledge about their child's care plan, enhanced communication, facilitated empowerment, increased autonomy, and incited positive emotions. Potential challenges included that notes: caused confusion, hindered communication with the health care team, highlighted problems with note content, and could incite negative emotions. Parents recommended 4 strategies to support sharing: provide preemptive communication about expectations, optimize the note release process, consider parent-friendly note template modifications, and offer informational resources for parents. CONCLUSIONS Findings provide a framework for operationalizing note-sharing with parents during hospitalization. These results have important implications for hospitals working to comply with federal regulations and researchers assessing the effects of increased information transparency in the inpatient setting.
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Affiliation(s)
- Michelle M Kelly
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | - Carrie L Nacht
- School of Public Health, San Diego State University, San Diego, California
| | | | - Shannon M Dean
- St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Daniel J Sklansky
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | - Carley M Sprackling
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Benjamin M Zellmer
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ryan J Coller
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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The 21st Century Cures Act and Emergency Medicine - Part 1: Digitally Sharing Notes and Results. Ann Emerg Med 2021; 79:7-12. [PMID: 34756447 DOI: 10.1016/j.annemergmed.2021.07.133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Indexed: 01/13/2023]
Abstract
Among the provisions of the 21st Century Cures Act is the mandate for digital sharing of clinician notes and test results through the patient portal of the clinician's electronic health record system. Although there is considerable evidence of the benefit to clinic patients from open notes and minimal apparent additional burden to primary care clinicians, emergency department (ED) note sharing has not been studied. With easier access to notes and results, ED patients may have an enhanced understanding of their visit, findings, and clinician's medical decisionmaking, which may improve adherence to recommendations. Patients may also seek clarifications and request edits to their notes. EDs can develop workflows to address patient concerns without placing new undue burden on clinicians, helping to realize the benefits of sharing notes and test results digitally.
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Zellmer BM, Nacht CL, Coller RJ, Hoonakker PLT, Smith CA, Sklansky DJ, Dean SM, Smith W, Sprackling CM, Ehlenfeldt BD, Kelly MM. BedsideNotes: Sharing Physicians' Notes With Parents During Hospitalization. Hosp Pediatr 2021; 11:503-508. [PMID: 33795371 DOI: 10.1542/hpeds.2020-005447] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Physicians increasingly share ambulatory visit notes with patients to meet new federal requirements, and evidence suggests patient experiences improve without overburdening physicians. Whether sharing inpatient notes with parents of hospitalized children yields similar outcomes is unknown. In this pilot study, we evaluated parent and physician perceptions of sharing notes with parents during hospitalization. METHODS Parents of children aged <12 years admitted to a hospitalist service at a tertiary children's hospital in April 2019 were offered real-time access to their child's admission and daily progress notes on a bedside inpatient portal (MyChart Bedside). Upon discharge, ambulatory OpenNotes survey items assessed parent and physician (attendings and interns) perceptions of note sharing. RESULTS In all, 25 parents and their children's discharging attending and intern physicians participated. Parents agreed that the information in notes was useful and helped them remember their child's care plan (100%), prepare for rounds (96%), and feel in control (91%). Although many physicians (34%) expressed concern that notes would confuse parents, no parent reported that notes were confusing. Some physicians perceived that they spent more time writing and/or editing notes (28%) or that their job was more difficult (15%). Satisfaction with sharing was highest among parents (100%), followed by attendings (81%) and interns (35%). CONCLUSIONS Parents all valued having access to physicians' notes during their child's hospital stay; however, some physicians remained concerned about the potential negative consequences of sharing. Comparative effectiveness studies are needed to evaluate the effect of note sharing on outcomes for hospitalized children, families, and staff.
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Affiliation(s)
| | - Carrie L Nacht
- Department of Pediatrics, School of Medicine and Public Health
| | - Ryan J Coller
- Department of Pediatrics, School of Medicine and Public Health
| | | | | | | | - Shannon M Dean
- Department of Pediatrics, School of Medicine and Public Health.,University of Wisconsin Health, Madison, Wisconsin
| | - Windy Smith
- University of Wisconsin Health, Madison, Wisconsin
| | | | | | - Michelle M Kelly
- Department of Pediatrics, School of Medicine and Public Health, .,Center for Quality and Productivity Improvement, and
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Kelly MM, Smith CA, Hoonakker PL, Nacht CL, Dean SM, Sklansky DJ, Smith W, Moreno MA, Thurber AS, Coller RJ. Stakeholder Perspectives in Anticipation of Sharing Physicians' Notes With Parents of Hospitalized Children. Acad Pediatr 2021; 21:259-264. [PMID: 33259951 PMCID: PMC7940595 DOI: 10.1016/j.acap.2020.11.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/10/2020] [Accepted: 11/21/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Elicit stakeholder perspectives on the anticipated benefits and challenges of sharing hospital physicians' admission and daily progress notes with parents at the bedside during their child's hospitalization and identify strategies to aid implementation of inpatient note sharing. METHODS Five semistructured focus groups were conducted with 34 stakeholders (8 parents, 8 nurses, 5 residents, 7 hospitalists, 6 administrators) at a tertiary children's hospital from October to November 2018 to identify anticipated benefits, challenges, and implementation strategies prior to sharing inpatient physicians' notes. A facilitator guide elicited participants' perspectives about the idea of sharing notes with parents during their child's hospitalization. Three researchers used content analysis to analyze qualitative data inductively. RESULTS Anticipated benefits of sharing inpatient notes included: Reinforcement of information, improved parental knowledge and empowerment, enhanced parent communication and partnership with providers, and increased provider accountability and documentation quality. Expected challenges included: Increased provider workload, heightened parental confusion, distress or anxiety, impaired parent relationship with providers, and compromised note quality and purpose. Suggested implementation strategies included: Setting staff and parent expectations upfront, providing tools to support parent education, and limiting shared note content and family eligibility. CONCLUSIONS Stakeholders anticipated multiple benefits and drawbacks of sharing notes with parents during their child's hospital stay and made practical suggestions for ways to implement inpatient note sharing to promote these benefits and mitigate challenges. Findings will inform the design and implementation of an intervention to share notes using an inpatient portal and evaluation of its effect on child, parent, and healthcare team outcomes.
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Richards S, Carlson K, Matthias T, Birge J. Perception versus reality: Does provider documentation behavior change when clinic notes are shared electronically with patients? Int J Med Inform 2020; 145:104304. [PMID: 33129123 DOI: 10.1016/j.ijmedinf.2020.104304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 09/07/2020] [Accepted: 10/16/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Secure patient portals have improved patient access to information, including provider notes. Although there is evidence suggesting that electronic note sharing improves communication and care quality, some studies have reported provider concerns regarding note sharing. MATERIAL AND METHODS This mixed-methods single site study utilized survey questions from a previously published landmark study to assess provider perceptions of electronic note sharing as well as objective EHR data. Surveys were sent to 628 providers in 34 primary and specialty care clinics approximately 12 weeks after the implementation of phase 1 (April 1, 2018) and phase 2 (July 1, 2018). EHR data were extracted from three months pre- and three months post-implementation of note sharing to determine whether or not note authoring times were affected. RESULTS Nearly one-quarter (n = 150) of the responses sent to 628 providers were retained for analysis (23.9 % response rate). A majority (84.7 %) of respondents believed notes were useful vehicles for communication and 73.3 % agreed that making notes available to patients was a good idea. Additionally, 16.0 % of respondents (14.0 % for primary care and 17.0 % for specialists) believed they "spent more time writing/dictating/editing their notes." A comparison of pre-post note authoring time revealed the aggregated primary care median increased 0.14 min (7.93-8.07 min) while aggregated specialty care median was identical (11.6 min). DISCUSSION The EHR comparison of note authoring time pre-post did not reflect provider concerns identified in the survey regarding electronic note sharing.
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Affiliation(s)
- Sarah Richards
- University of Nebraska Medical Center, Department of Internal Medicine, Division of General Internal Medicine, Section of Hospital Medicine, United States.
| | - Kristy Carlson
- University of Nebraska Medical Center, Department of Internal Medicine, Division of General Internal Medicine, Section of Hospital Medicine, United States.
| | - Tabatha Matthias
- University of Nebraska Medical Center, Department of Internal Medicine, Division of General Internal Medicine, Section of Hospital Medicine, United States.
| | - Justin Birge
- University of Nebraska Medical Center, Department of Internal Medicine, Division of General Internal Medicine, Section of Hospital Medicine, United States.
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Kelly MM, Thurber AS, Coller RJ, Khan A, Dean SM, Smith W, Hoonakker PLT. Parent Perceptions of Real-time Access to Their Hospitalized Child's Medical Records Using an Inpatient Portal: A Qualitative Study. Hosp Pediatr 2020; 9:273-280. [PMID: 30894398 DOI: 10.1542/hpeds.2018-0166] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND OBJECTIVES Engaging with parents in care improves pediatric care quality and patient safety; however, parents of hospitalized children often lack the information necessary to effectively participate. To enhance engagement, some hospitals now provide parents with real-time online access to information from their child's inpatient medical record during hospitalization. Whether these "inpatient portals" provide benefits for parents of hospitalized children is unknown. Our objectives were to identify why parents used an inpatient portal application on a tablet computer during their child's hospitalization and identify their perspectives of ways to optimize the technology. METHODS Semistructured in-person interviews were conducted with 14 parents who were given a tablet computer with a commercially available inpatient portal application for use throughout their child's hospitalization. The portal included vital signs, diagnoses, medications, laboratory test results, patients' schedule, messaging, education, and provider pictures and/or roles. Interviews were audio recorded and transcribed and continued until reaching thematic saturation. Three researchers used an inductive approach to identify emergent themes regarding why parents used the portal. RESULTS Five themes emerged regarding parent motivations for accessing information within the portal: (1) monitoring progress, (2) feeling empowered and/or relying less on staff, (3) facilitating rounding communication and/or decision-making, (4) ensuring information accuracy and/or providing reassurance, and (5) aiding memory. Parents recommended that the hospital continue to offer the portal and expand it to allow parents to answer admission questions, provide feedback, and access doctors' daily notes. CONCLUSIONS Providing parents with real-time clinical information during their child's hospitalization using an inpatient portal may enhance their ability to engage in caregiving tasks critical to ensuring inpatient care quality and safety.
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Affiliation(s)
- Michelle M Kelly
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; .,Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, Wisconsin
| | - Anne S Thurber
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ryan J Coller
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Alisa Khan
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and
| | - Shannon M Dean
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.,University of Wisconsin Health, Madison, Wisconsin
| | - Windy Smith
- University of Wisconsin Health, Madison, Wisconsin
| | - Peter L T Hoonakker
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, Wisconsin
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Asan O, Scanlon MC, Crotty B, Holden RJ, Flynn KE. Parental Perceptions of Displayed Patient Data in a PICU: An Example of Unintentional Empowerment. Pediatr Crit Care Med 2019; 20:435-441. [PMID: 31058783 PMCID: PMC6716150 DOI: 10.1097/pcc.0000000000001895] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To explore the perceptions of parents of pediatric patients in a PICU regarding real-time open electronic health record data displayed in patient rooms. DESIGN Cross-sectional qualitative interview study. SETTING PICU in a large Midwestern tertiary-care children's hospital. SUBJECTS Parents of patients in a PICU (n = 33). MEASUREMENTS AND MAIN RESULTS Qualitative data were collected through in-person semi-structured, individual, and small-group interviews. Data were collected from March 2016 to July 2016, with approval from the study hospital's institutional review board. Data were analyzed using inductive thematic analysis. Results included positive effects of accessing real-time open electronic health record data on family empowerment, situation awareness, potential error detection, understanding of medical data, and facilitating discussions during rounds. Concerns were reported regarding privacy of information as well as potential misinterpretation of displayed data. We identified several ways to improve this collaborative technology to make it more family-centered. CONCLUSIONS This study suggests that a new health information technology system providing continuous access to open electronic health record data may be an effective way to empower and engage parents in the PICU, but potential drawbacks were also noted. The results also provide insights into the collaborative use of health information technology in the PICU setting.
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Affiliation(s)
- Onur Asan
- School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, NJ,USA
| | - Matthew C. Scanlon
- Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Bradley Crotty
- Center for Advancing Population Science, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI,USA
| | - Richard J. Holden
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kathryn E. Flynn
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Stein JN, Klein JW, Payne TH, Jackson SL, Peacock S, Oster NV, Carpenter TP, Elmore JG. Communicating with Vulnerable Patient Populations: A Randomized Intervention to Teach Inpatients to Use the Electronic Patient Portal. Appl Clin Inform 2018; 9:875-883. [PMID: 30541152 PMCID: PMC6291377 DOI: 10.1055/s-0038-1676333] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/14/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Patient portals are expanding as a means to engage patients and have evidence for benefit in the outpatient setting. However, few studies have evaluated their use in the inpatient setting, or with vulnerable patient populations. OBJECTIVE This article assesses an intervention to teach hospitalized vulnerable patients to access their discharge summaries using electronic patient portals. METHODS Patients at a safety net hospital were randomly assigned to portal use education or usual care. Surveys assessed perceptions of discharge paperwork and the electronic portal. RESULTS Of the 202 prescreened eligible patients (e.g., deemed mentally competent, spoke English, and had a telephone), only 43% had working emails. Forty-four percent of participants did not remember receiving or reading discharge paperwork. Patients trained in portal use (n = 47) or receiving usual care (n = 23) preferred hospitals with online record access (85 and 83%, respectively), and felt that online access would increase their trust in doctors (85 and 87%) and satisfaction with care (91% each). Those who received training in portal use were more likely to register for the portal (48% vs. 11%; p < 0.01). CONCLUSION Patients had positive perceptions of portals, and education increased portal use. Lack of email access is a notable barrier to electronic communication with vulnerable patients.
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Affiliation(s)
- Jacob N. Stein
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, United States
| | - Jared W. Klein
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, United States
| | - Thomas H. Payne
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, United States
- Information Technology Services, University of Washington School of Medicine, Seattle, Washington, United States
| | - Sara L. Jackson
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, United States
| | - Sue Peacock
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, United States
| | - Natalia V. Oster
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, United States
| | - Trinell P. Carpenter
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, United States
| | - Joann G. Elmore
- University of California, Los Angeles, California, United States
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Kelly MM, Coller RJ, Hoonakker PL. Inpatient Portals for Hospitalized Patients and Caregivers: A Systematic Review. J Hosp Med 2018; 13:405-412. [PMID: 29261819 PMCID: PMC6136247 DOI: 10.12788/jhm.2894] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patient portals, web-based personal health records linked to electronic health records (EHRs), provide patients access to their healthcare information and facilitate communication with providers. Growing evidence supports portal use in ambulatory settings; however, only recently have portals been used with hospitalized patients. Our objective was to review the literature evaluating the design, use, and impact of inpatient portals, which are patient portals designed to give hospitalized patients and caregivers inpatient EHR clinical information for the purpose of engaging them in hospital care. Literature was reviewed from 2006 to 2017 in PubMed, Web of Science, CINALPlus, Cochrane, and Scopus to identify English language studies evaluating patient portals, engagement, and inpatient care. Data were analyzed considering the following 3 themes: inpatient portal design, use and usability, and impact. Of 731 studies, 17 were included, 9 of which were published after 2015. Most studies were qualitative with small samples focusing on inpatient portal design; 1 nonrandomized trial was identified. Studies described hospitalized patients' and caregivers' information needs and design recommendations. Most patient and caregiver participants in included studies were interested in using an inpatient portal, used it when offered, and found it easy to use and/or useful. Evidence supporting the role of inpatient portals in improving patient and caregiver engagement, knowledge, communication, and care quality and safety is limited. Included studies indicated providers had concerns about using inpatient portals; however, the extent to which these concerns have been realized remains unclear. Inpatient portal research is emerging. Further investigation is needed to optimally design inpatient portals to maximize potential benefits for hospitalized patients and caregivers while minimizing unintended consequences for healthcare teams.
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Affiliation(s)
- Michelle M Kelly
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.
- Center for Quality and Productivity Improvement, University of Wisconsin, Madison, Wisconsin, USA
| | - Ryan J Coller
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Peter Lt Hoonakker
- Center for Quality and Productivity Improvement, University of Wisconsin, Madison, Wisconsin, USA
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Dalal AK, Bates DW, Collins S. Opportunities and Challenges for Improving the Patient Experience in the Acute and Postacute Care Setting Using Patient Portals: The Patient's Perspective. J Hosp Med 2017; 12:1012-1016. [PMID: 29073310 DOI: 10.12788/jhm.2860] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Efforts to improve the patient experience are increasingly focusing on engaging patients and their "care partners" by using patient portals. The Acute Care Patient Portal Task Force was supported by the Gordon and Betty Moore Foundation to convene a national meeting of an interdisciplinary group of stakeholders, including patient advocates, to consider how the acute and postacute care patient experience can be improved by using patient-facing technologies. We identified key opportunities and challenges for enhancing cognitive support, promoting respect while maintaining boundaries, and facilitating patient and family empowerment through the lens of the patient. Institutions, clinicians, and vendors would benefit tremendously by considering these 3 patient-centered themes when partnering with patients and family advisors to implement and realize the full potential of patient portals to enhance the acute and postacute care experience.
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Affiliation(s)
- Anuj K Dalal
- Brigham and Women's Hospital, Boston, Massachusetts, USA.
- Harvard Medical School, Boston, Massachusetts, USA
| | - David W Bates
- Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah Collins
- Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Partners Healthcare System, Wellesley, Massachusetts, USA
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12
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Wass S, Vimarlund V, Ros A. Exploring patients' perceptions of accessing electronic health records: Innovation in healthcare. Health Informatics J 2017; 25:203-215. [PMID: 28457195 DOI: 10.1177/1460458217704258] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Sofie Wass
- Jönköping International Business School, Jönköping University, Sweden
| | - Vivian Vimarlund
- Jönköping International Business School, Jönköping University, Sweden; Linköping University, Sweden
| | - Axel Ros
- School of Health and Welfare, Jönköping University, Sweden
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13
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Chung CF, Munson SA, Thompson MJ, Baldwin LM, Kaplan J, Cline R, Green BB. Implementation of a New Kiosk Technology for Blood Pressure Management in a Family Medicine Clinic: from the WWAMI Region Practice and Research Network. J Am Board Fam Med 2016; 29:620-9. [PMID: 27613795 PMCID: PMC5065060 DOI: 10.3122/jabfm.2016.05.160096] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 06/02/2016] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Using a self-service kiosk to measure blood pressure (BP) has the potential to increase patients' awareness of their BP control and free up medical assistant (MA) time. The objective of this study was to evaluate BP kiosk acceptability and usability, as well as its effects on the workflow of patient BP self-measurement in a primary care clinic. METHODS We used qualitative and quantitative assessments of kiosk implementation via meetings with clinic leaders, focus groups with clinic providers and staff, observations of kiosk users, and surveys of kiosk users at 2 and 8 months. RESULTS Most patients were comfortable using the kiosk (82% at 2 months, 87% at 8 months). Initial provider concerns included accuracy, but most gained confidence after comparing it with other monitors and reviewing the literature supporting its accuracy. Patients and providers saw many benefits: easier BP checks, increased patient engagement, and saved MA time for other tasks. The clinic addressed early concerns (eg, infection control, confusing instructions, perceived loss of personal touch). Most patients (86%) supported the clinic continuing to use the kiosks. CONCLUSIONS Providers, staff, and patients adapted to the use of BP kiosks, providing value by engaging patients in their own care and saving MA time. The clinic decided to keep the self-service kiosk after the pilot period.
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Affiliation(s)
- Chia-Fang Chung
- From the Department of Human Centered Design & Engineering, University of Washington, Seattle (C-FC, SAM); Department of Family Medicine, University of Washington, Seattle (MJT, L-MB); the Memorial Physicians/Yakima Valley Memorial Hospital, Yakima, WA (JK, RC); and the Group Health Research Institute, Seattle (BBG).
| | - Sean A Munson
- From the Department of Human Centered Design & Engineering, University of Washington, Seattle (C-FC, SAM); Department of Family Medicine, University of Washington, Seattle (MJT, L-MB); the Memorial Physicians/Yakima Valley Memorial Hospital, Yakima, WA (JK, RC); and the Group Health Research Institute, Seattle (BBG)
| | - Matthew J Thompson
- From the Department of Human Centered Design & Engineering, University of Washington, Seattle (C-FC, SAM); Department of Family Medicine, University of Washington, Seattle (MJT, L-MB); the Memorial Physicians/Yakima Valley Memorial Hospital, Yakima, WA (JK, RC); and the Group Health Research Institute, Seattle (BBG)
| | - Laura-Mae Baldwin
- From the Department of Human Centered Design & Engineering, University of Washington, Seattle (C-FC, SAM); Department of Family Medicine, University of Washington, Seattle (MJT, L-MB); the Memorial Physicians/Yakima Valley Memorial Hospital, Yakima, WA (JK, RC); and the Group Health Research Institute, Seattle (BBG)
| | - Jeffrey Kaplan
- From the Department of Human Centered Design & Engineering, University of Washington, Seattle (C-FC, SAM); Department of Family Medicine, University of Washington, Seattle (MJT, L-MB); the Memorial Physicians/Yakima Valley Memorial Hospital, Yakima, WA (JK, RC); and the Group Health Research Institute, Seattle (BBG)
| | - Randall Cline
- From the Department of Human Centered Design & Engineering, University of Washington, Seattle (C-FC, SAM); Department of Family Medicine, University of Washington, Seattle (MJT, L-MB); the Memorial Physicians/Yakima Valley Memorial Hospital, Yakima, WA (JK, RC); and the Group Health Research Institute, Seattle (BBG)
| | - Beverly B Green
- From the Department of Human Centered Design & Engineering, University of Washington, Seattle (C-FC, SAM); Department of Family Medicine, University of Washington, Seattle (MJT, L-MB); the Memorial Physicians/Yakima Valley Memorial Hospital, Yakima, WA (JK, RC); and the Group Health Research Institute, Seattle (BBG)
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Weinert C. Giving Doctors' Daily Progress Notes to Hospitalized Patients and Families to Improve Patient Experience. Am J Med Qual 2016; 32:58-65. [PMID: 26453323 DOI: 10.1177/1062860615610424] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hospital quality includes excellent physician-patient communication. The objective was to determine effects of distributing physicians' notes to patients. Hospitalized patients or family members on 6 wards at a university hospital received daily a printed copy of their medical team's progress note. Surveys were completed about the benefits and adverse effects of reading the physician notes. In all, 74% to 86% of patients or family members responded favorably that receiving doctors' notes improved understanding of their health condition or gave them more control over their hospital course. Patient concerns about privacy or offense were uncommon, although 16% thought notes were confusing or caused worry. Note distribution had minor effects on physician note writing practice. Having patients and family members read their physicians' progress notes is feasible and enhances patients' understanding of their diagnostic and treatment plan. Notes supplement traditional physician-patient verbal communication practice and have the potential to improve the hospitalized patient experience.
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Esch T, Mejilla R, Anselmo M, Podtschaske B, Delbanco T, Walker J. Engaging patients through open notes: an evaluation using mixed methods. BMJ Open 2016; 6:e010034. [PMID: 26826154 PMCID: PMC4735137 DOI: 10.1136/bmjopen-2015-010034] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
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.
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Affiliation(s)
- Tobias Esch
- Division of General Medicine and Primary Care, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Division of Integrative Health Promotion, Coburg University of Applied Sciences, Coburg, Germany
| | - Roanne Mejilla
- Division of General Medicine and Primary Care, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Melissa Anselmo
- Division of General Medicine and Primary Care, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Beatrice Podtschaske
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Tom Delbanco
- Division of General Medicine and Primary Care, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jan Walker
- Division of General Medicine and Primary Care, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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16
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Kaziunas E, Hanauer DA, Ackerman MS, Choi SW. Identifying unmet informational needs in the inpatient setting to increase patient and caregiver engagement in the context of pediatric hematopoietic stem cell transplantation. J Am Med Inform Assoc 2016; 23:94-104. [PMID: 26510878 PMCID: PMC5009939 DOI: 10.1093/jamia/ocv116] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 06/24/2015] [Accepted: 06/30/2015] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Patient-centered care has been shown to improve patient outcomes, satisfaction, and engagement. However, there is a paucity of research on patient-centered care in the inpatient setting, including an understanding of unmet informational needs that may be limiting patient engagement. Pediatric hematopoietic stem cell transplantation (HSCT) represents an ideal patient population for elucidating unmet informational needs, due to the procedure's complexity and its requirement for caregiver involvement. METHODS We conducted field observations and semi-structured interviews of pediatric HSCT caregivers and patients to identify informational challenges in the inpatient hospital setting. Data were analyzed using a thematic grounded theory approach. RESULTS Three stages of the caregiving experience that could potentially be supported by a health information technology system, with the goal of enhancing patient/caregiver engagement, were identified: (1) navigating the health system and learning to communicate effectively with the healthcare team, (2) managing daily challenges of caregiving, and (3) transitioning from inpatient care to long-term outpatient management. DISCUSSION We provide four practical recommendations to meet the informational needs of pediatric HSCT patients and caregivers: (1) provide patients/caregivers with real-time access to electronic health record data, (2) provide information about the clinical trials in which the patient is enrolled, (3) provide information about the patient's care team, and (4) properly prepare patients and caregivers for hospital discharge. CONCLUSION Pediatric HSCT caregivers and patients have multiple informational needs that could be met with a health information technology system that integrates data from several sources, including electronic health records. Meeting these needs could reduce patients' and caregivers' anxiety surrounding the care process; reduce information asymmetry between caregivers/patients and providers; empower patients/caregivers to participate in the care process; and, ultimately, increase patient/caregiver engagement in the care process.
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Affiliation(s)
| | - David A Hanauer
- School of Information, University of Michigan, Ann Arbor, MI, USA Department of Pediatrics, University of Michigan Health System, Ann Arbor, MI, USA
| | - Mark S Ackerman
- School of Information, University of Michigan, Ann Arbor, MI, USA
| | - Sung Won Choi
- Department of Pediatrics, University of Michigan Health System, Ann Arbor, MI, USA Blood and Marrow Transplantation Program, University of Michigan Health System, Ann Arbor, MI USA
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18
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Jarrar M, Abdul Rahman H, Don MS. Optimizing Quality of Care and Patient Safety in Malaysia: The Current Global Initiatives, Gaps and Suggested Solutions. Glob J Health Sci 2015; 8:44132. [PMID: 26755459 PMCID: PMC4954916 DOI: 10.5539/gjhs.v8n6p75] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 09/14/2015] [Accepted: 09/14/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND & OBJECTIVE Demand for health care service has significantly increased, while the quality of healthcare and patient safety has become national and international priorities. This paper aims to identify the gaps and the current initiatives for optimizing the quality of care and patient safety in Malaysia. DESIGN Review of the current literature. Highly cited articles were used as the basis to retrieve and review the current initiatives for optimizing the quality of care and patient safety. The country health plan of Ministry of Health (MOH) Malaysia and the MOH Malaysia Annual Reports were reviewed. RESULTS The MOH has set four strategies for optimizing quality and sustaining quality of life. The 10th Malaysia Health Plan promotes the theme "1 Care for 1 Malaysia" in order to sustain the quality of care. Despite of these efforts, the total number of complaints received by the medico-legal section of the MOH Malaysia is increasing. The current global initiatives indicted that quality performance generally belong to three main categories: patient; staffing; and working environment related factors. CONCLUSIONS There is no single intervention for optimizing quality of care to maintain patient safety. Multidimensional efforts and interventions are recommended in order to optimize the quality of care and patient safety in Malaysia.
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Affiliation(s)
- Mu'taman Jarrar
- College of Business, Universiti Utara Malaysia, Kedah, Malaysia.
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19
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Hanauer DA, Preib R, Zheng K, Choi SW. Patient-initiated electronic health record amendment requests. J Am Med Inform Assoc 2014; 21:992-1000. [PMID: 24863430 DOI: 10.1136/amiajnl-2013-002574] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Providing patients access to their medical records offers many potential benefits including identification and correction of errors. The process by which patients ask for changes to be made to their records is called an 'amendment request'. Little is known about the nature of such amendment requests and whether they result in modifications to the chart. METHODS We conducted a qualitative content analysis of all patient-initiated amendment requests that our institution received over a 7-year period. Recurring themes were identified along three analytic dimensions: (1) clinical/documentation area, (2) patient motivation for making the request, and (3) outcome of the request. RESULTS The dataset consisted of 818 distinct requests submitted by 181 patients. The majority of these requests (n=636, 77.8%) were made to rectify incorrect information and 49.7% of all requests were ultimately approved. In 6.6% of the requests, patients wanted valid information removed from their record, 27.8% of which were approved. Among all of the patients requesting a copy of their chart, only a very small percentage (approximately 0.2%) submitted an amendment request. CONCLUSIONS The low number of amendment requests may be due to inadequate awareness by patients about how to make changes to their records. To make this approach effective, it will be important to inform patients of their right to view and amend records and about the process for doing so. Increasing patient access to medical records could encourage patient participation in improving the accuracy of medical records; however, caution should be used.
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Affiliation(s)
- David A Hanauer
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA School of Information, University of Michigan, Ann Arbor, Michigan, USA
| | - Rebecca Preib
- College of Literature, Science, and the Arts, University of Michigan, Ann Arbor, Michigan, USA
| | - Kai Zheng
- School of Information, University of Michigan, Ann Arbor, Michigan, USA Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Sung W Choi
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
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20
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Turvey C, Klein D, Fix G, Hogan TP, Woods S, Simon SR, Charlton M, Vaughan-Sarrazin M, Zulman DM, Dindo L, Wakefield B, Graham G, Nazi K. Blue Button use by patients to access and share health record information using the Department of Veterans Affairs' online patient portal. J Am Med Inform Assoc 2014; 21:657-63. [PMID: 24740865 DOI: 10.1136/amiajnl-2014-002723] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The Blue Button feature of online patient portals promotes patient engagement by allowing patients to easily download their personal health information. This study examines the adoption and use of the Blue Button feature in the Department of Veterans Affairs' (VA) personal health record portal, My HealtheVet. MATERIALS AND METHODS An online survey presented to a 4% random sample of My HealtheVet users between March and May 2012. Questions were designed to determine characteristics associated with Blue Button use, perceived value of use, and how Veterans with non-VA providers use the Blue Button to share information with their non-VA providers. RESULTS Of the survey participants (N=18 398), 33% were current Blue Button users. The most highly endorsed benefit was that it helped patients understand their health history better because all the information was in one place (73%). Twenty-one percent of Blue Button users with a non-VA provider shared their VA health information, and 87% reported that the non-VA provider found the information somewhat or very helpful. Veterans' self-rated computer ability was the strongest factor contributing to both Blue Button use and to sharing information with non-VA providers. When comparing Blue Button users and non-users, barriers to adoption were low awareness of the feature and difficulty using the Blue Button. CONCLUSIONS This study contributes to the understanding of early Blue Button adoption and use of this feature for patient-initiated sharing of health information. Educational efforts are needed to raise awareness of the Blue Button and to address usability issues that hinder adoption.
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Affiliation(s)
- Carolyn Turvey
- Iowa City VA Health Care System, Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City, Iowa, USA Department of Psychiatry, The University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Dawn Klein
- Iowa City VA Health Care System, Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City, Iowa, USA Department of Psychiatry, The University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Gemmae Fix
- Edith Nourse Rogers Memorial Veterans Hospital, Center for Healthcare Organization and Implementation Research (CHOIR), A VA HSR&D Center of Innovation, Bedford, Massachusetts, USA Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Timothy P Hogan
- Edith Nourse Rogers Memorial Veterans Hospital, Center for Healthcare Organization and Implementation Research (CHOIR), A VA HSR&D Center of Innovation, Bedford, Massachusetts, USA Edith Nourse Rogers Memorial Veterans Hospital, eHealth Quality Enhancement Research Initiative, National eHealth QUERI Coordinating Center, Bedford, Massachusetts, USA Division of Health Informatics and Implementation Science, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Susan Woods
- Portland VA Medical Center, Health Services Research & Development, Portland, Oregon, USA Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, USA
| | - Steven R Simon
- Veterans Affairs Boston Healthcare System, Section of General Internal Medicine, Boston, Massachusetts, USA Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mary Charlton
- Iowa City VA Health Care System, Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City, Iowa, USA Department of Epidemiology, The University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Mary Vaughan-Sarrazin
- Iowa City VA Health Care System, Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City, Iowa, USA Department of Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Donna M Zulman
- Veterans Affairs Palo Alto Health Care System, Center for Innovation to Implementation, Menlo Park, California, USA Division of General Medical Disciplines, Stanford University, Stanford, California, USA
| | - Lilian Dindo
- Department of Psychiatry, The University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Bonnie Wakefield
- Iowa City VA Health Care System, Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City, Iowa, USA University of Missouri Sinclair School of Nursing, Columbia, Missouri, USA
| | - Gail Graham
- Veterans and Consumers Health Informatics Office, Office of Informatics & Analytics, Veterans Health Administration, Washington, DC, USA
| | - Kim Nazi
- Veterans and Consumers Health Informatics Office, Office of Informatics & Analytics, Veterans Health Administration, Washington, DC, USA
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