Work system barriers to patient, provider, and caregiver use of personal health records: A systematic review

Macroergonomic components of the patient work system shaping dyadic care management during adolescence: a case study of type 1 diabetes

The role of the social, physical, and organisational environments in shaping how patients and their caregivers perform work remains largely unexplored in human factors/ergonomics literature. This study recruited 19 dyads consisting of a parent and their child with type 1 diabetes to be interviewed individually and analysed using a macroergonomic framework. Our findings aligned with the macroergonomic factors as presented in previous models, while highlighting the need to expand upon certain components to gain a more comprehensive representation of the patient work system as relevant to dyadic management. Examples of design efforts that should follow from these findings include expanding existing data sharing options to include information from the external environment and capitalising on the capabilities of artificial intelligence as a decision support system. Future research should focus on longitudinally assessing patient work systems throughout transition periods in addition to more explicitly exploring the roles of social network members.

Perceived barriers and enablers of a personal health record from the healthcare provider perspective

Personal health records (PHRs) have been implemented around the world as a means to increase the safety, quality, and efficiency of health care. The Ministry of National Guard Health Affairs in the Kingdom of Saudi Arabia launched their PHR in 2018. This study aimed to explore healthcare provider (HCP) perspectives of barriers to and enablers of PHR adoption in Saudi Arabia. The 291 participating HCPs (40.5% nurses, 23.0% pharmacists, 17.2% physicians, 15.5% technicians, and 3.8% other) selected the following as top-3 barriers to PHR adoption: 1) lack of patient awareness (19.4%), 2) patient low literacy (17.7%), and 3) patient resistance to new technologies (12.5%). Of these, 36 responded to the open-ended question gauging feedback on the PHR. Three main themes were identified from the comments: 1) general perceptions of the PHR (positive attitudes, negative attitudes, additional features); 2) patient engagement as a requirement for the successful implementation of the PHR; and 3) education/training of HCPs, patients, and caregivers. This analysis extends our understanding of HCP perspectives of barriers and enablers to PHR adoption. Further qualitative research with patients is required to confirm our findings.

Assessing patient readiness for a patient portal implementation in the UAE

Purpose

This paper proposes a Web-based patient portal based on the electronic medical record. Such a portal can allow patients to manage their own health care, reduce health-care visits and significantly improve the quality of their health care.

Design/methodology/approach

A patient portal prototype and an accompanying online survey were distributed to assess the adoption readiness among a group of people in the United Arab Emirates (UAE).

Findings

The results from 470 survey participants demonstrated an enhanced awareness of this technology, and support the study hypotheses indicating that both intrinsic and extrinsic factors are important when considering the implementation of a patient portal in the UAE.

Originality/value

This study adds value to the few research studies undertaken in the Middle East discussing online health information technology and its adoption and usage among the population at large. The extended technology acceptance model, which contains two additional constructs, had not been previously validated in terms of a patient portal in the UAE, according to the author’s knowledge, adding more value. The UAE’s health-care system must use the benefits from the available IT infrastructure to provide a user-friendly online portal to encourage patients to manage their health care and health information.

Patient empowerment through a user-centered design of an electronic personal health record: a qualitative study of user requirements in chronic kidney disease

Background

To improve chronic disease outcomes, self-management is an effective strategy. An electronic personal health record (ePHR) is a promising tool with the potential to support chronic patient’s education, counseling, and self-management. Fitting ePHRs within the daily practices of chronic care providers and chronic patients requires user-centered design approaches. We aimed to understand users’ needs and requirements in chronic kidney disease (CKD) care to consider in the design of an ePHR to facilitate its implementation, adoption, and use.

Methods

A qualitative study was conducted in a major Iranian nephrology center including inpatient and outpatient settings in 2019. We conducted 28 semi-structured interviews with CKD patients, nurses, and adult nephrologists. To confirm or modify the requirements extracted from the interviews, a focus group was also held. Data were analyzed to extract especially those requirements that can facilitate implementation, adoption, and sustained use based on the PHR adoption model and the unified theory of acceptance and use of technology.

Results

Participants requested an ePHR that provides access to up to date patient information, facilitates patient-provider communication, and increases awareness about patient individualized conditions. Participants expected a system that is able to cater to low patient e-health literacy and high provider workload. They requested the ePHR to include purposeful documentation of medical history, diagnostic and therapeutic procedures, tailored educational content, and scheduled care reminders. Messaging function, tailored educational content to individual patients’ conditions, and controlled access to information were highly valued in order to facilitate its implementation, adoption, and use.

Conclusions

We focused on the ePHR’s content and functionalities in the face of facilitators and/or barriers envisioned for its adoption in nephrology care. Designers and implementers should value CKD patients’ needs and requirements for self-management such as providing personalized education and counseling (on the basis of their condition and risk factors), health literacy, and disease progression levels. The socio-technical aspects of care also need further attention to facilitate ePHR’s adoption.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01689-2.

Health Care Providers' Acceptance of a Personal Health Record: Cross-sectional Study

BACKGROUND

Personal health records (PHRs) are eHealth tools designed to support patient engagement, patient empowerment, and patient- and person-centered care. Endorsement of a PHR by health care providers (HCPs) facilitates patient acceptance. As health care organizations in the Kingdom of Saudi Arabia begin to adopt PHRs, understanding the perspectives of HCPs is important because it can influence patient adoption. However, no studies evaluated HCPs' acceptance of PHRs in the Kingdom of Saudi Arabia.

OBJECTIVE

The aim of this study was to identify predictors of HCPs' acceptance of PHRs using behavioral intention to recommend as a proxy for adoption.

METHODS

This cross-sectional study was conducted among HCPs (physicians, pharmacists, nurses, technicians, others) utilizing a survey based on the Unified Theory of Acceptance and Use of Technology. The main theory constructs of performance expectancy, effort expectancy, social influence, facilitating conditions, and positive attitude were considered independent variables. Behavioral intention was the dependent variable. Age, years of experience, and professional role were tested as moderators between the main theory constructs and behavioral intention using partial least squares structural equation modeling.

RESULTS

Of the 291 participants, 246 were included in the final analysis. Behavioral intention to support PHR use among patients was significantly influenced by performance expectancy (β=.17, P=.03) and attitude (β=.61, P<.01). No moderating effects were present.

CONCLUSIONS

This study identified performance expectancy and attitude as predictors of HCPs' behavioral intention to recommend PHR to patients. To encourage HCPs to endorse PHRs, health care organizations should involve HCPs in the implementation and provide training on the features available as well as expected benefits. Future studies should be conducted in other contexts and include other potential predictors.

A Worker-Centered Personal Health Record App for Workplace Health Promotion Using National Health Care Data Sets: Design and Development Study

Background

Personal health record (PHR) technology can be used to support workplace health promotion, and prevent social and economic losses related to workers’ health management. PHR services can not only ensure interoperability, security, privacy, and data quality, but also consider the user’s perspective in their design.

Objective

Using Fast Healthcare Interoperability Resources (FHIR) and national health care data sets, this study aimed to design and develop an app for providing worker-centered, interconnected PHR services.

Methods

This study considered the user’s perspective, using the human-centered design (HCD) methodology, to develop a PHR app suitable for occupational health. We developed a prototype after analyzing quantitative and qualitative data collected from workers and a health care professional group, after which we performed a usability evaluation. We structured workers’ PHR items based on the analyzed data, and ensured structural and semantic interoperability using FHIR, Systematized Nomenclature of Medicine–Clinical Terms (SNOMED-CT), and Logical Observation Identifiers Names and Codes (LOINC). This study integrated workers’ health information scattered across different Korean institutions through an interface method, and workers’ PHRs were managed through a cloud server, using Azure API for FHIR.

Results

In total, 562 workers from industrial parks participated in the quantitative study. The preferred data items for PHR were medication, number of steps walked, diet, blood pressure, weight, and blood glucose. The preferred features were ability to access medical checkup results, health information content provision, consultation record inquiry, and teleconsultation. The worker-centered PHR app collected data on, among others, life logs, vital signs, and medical checkup results; offered health care services such as reservation and teleconsultation; and provided occupational safety and health information through material safety data sheet search and health questionnaires. The app reflected improvements in user convenience and app usability proposed by 19 participants (7 health care professionals and 12 end users) in the usability evaluation. The After-Scenario Questionnaire (ASQ) was evaluated with a mean score of 5.90 (SD 0.34) out of 7, and the System Usability Scale (SUS) was evaluated a mean score of 88.7 (SD 4.83) out of 100.

Conclusions

The worker-centered PHR app integrates workers’ health information from different institutions and provides a variety of health care services from linked institutions through workers’ shared PHR. This app is expected to increase workers’ autonomy over their health information and support medical personnel’s decision making regarding workers’ health in the workplace. Particularly, the app will provide solutions for current major PHR challenges, and its design, which considers the user’s perspective, satisfies the prerequisites for its utilization in occupational health.

Doctors documenting: an ethnographic and informatics approach to understanding attending physician documentation in the pediatric emergency department

OBJECTIVE

The pediatric emergency department is a highly complex and evolving environment. Despite the fact that physicians spend a majority of their time on documentation, little research has examined the role of documentation in provider workflow. The aim of this study is to examine the task of attending physician documentation workflow using a mixed-methods approach including focused ethnography, informatics, and the Systems Engineering Initiative for Patient Safety (SEIPS) model as a theoretical framework.

MATERIALS AND METHODS

In a 2-part study, we conducted a hierarchical task analysis of patient flow, followed by a survey of documenting ED providers. The second phase of the study included focused ethnographic observations of ED attendings which included measuring interruptions, time and motion, documentation locations, and qualitative field notes. This was followed by analysis of documentation data from the electronic medical record system.

RESULTS

Overall attending physicians reported low ratings of documentation satisfaction; satisfaction after each shift was associated with busyness and resident completion. Documentation occurred primarily in the provider workrooms, however strategies such as bedside documentation, dictation, and multitasking with residents were observed. Residents interrupted attendings more often but also completed more documentation actions in the electronic medical record.

DISCUSSION

Our findings demonstrate that complex work processes such as documentation, cannot be measured with 1 single data point or statistical analysis but rather a combination of data gathered from observations, surveys, comments, and thematic analyses.

CONCLUSION

Utilizing a sociotechnical systems framework and a mixed-methods approach, this study provides a holistic picture of documentation workflow. This approach provides a valuable foundation not only for researchers approaching complex healthcare systems but also for hospitals who are considering implementing large health information technology projects.

Capturing the Impact of Patient Portals Based on the Quadruple Aim and Benefits Evaluation Frameworks: Scoping Review

Background

Despite extensive and continuing research in the area of patient portals, measuring the impact of patient portals remains a convoluted process.

Objective

This study aims to explore what is known about patient portal evaluations and to provide recommendations for future endeavors. The focus is on mapping the measures used to assess the impact of patient portals on the dimensions of the Quadruple Aim (QA) framework and the Canada Health Infoway’s Benefits Evaluation (BE) framework.

Methods

A scoping review was conducted using the methodological framework of Arksey and O’Malley. Reporting was guided by the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) extension for scoping reviews. A systematic and comprehensive search was conducted using the Ovid platform, and the following databases were searched: Ovid MEDLINE (R) ALL (including epub ahead of print, in-process, and other nonindexed citations), EMBASE, and PsycINFO. CINAHL on the EBSCO platform and Web of Science were searched for studies published between March 2015 and June 2020. A systematic gray literature search was conducted using the Google search engine. Extracted data were tabulated based on a coding template developed to categorize the literature into themes and areas of interest.

Results

A total of 96 studies were included for data extraction. The studies were categorized based on the QA dimensions, with strict adherence to the definitions for each dimension. From the patients’ perspective, it was determined that most evaluations focused on benefits and barriers to access, access to test results, medication adherence, condition management, medical notes, and secure messaging. From the population perspective, the evaluations focused on the increase in population outreach, decrease in disparities related to access to care services, and improvement in quality of care. From the health care workforce perspective, the evaluations focused on the impact of patients accessing medical records, impact on workflow, impact of bidirectional secure messaging, and virtual care. From the health system perspective, the evaluations focused on decreases in no-show appointments, impact on office visits and telephone calls, impact on admission and readmission rates and emergency department visits, and impact on health care use. Overall, 77 peer-reviewed studies were mapped on the expanded version of the BE framework. The mapping was performed using subdimensions to create a more precise representation of the areas that are currently explored when studying patient portals. Most of the studies evaluated more than one subdimension.

Conclusions

The QA and BE frameworks provide guidance in identifying gaps in the current literature by providing a way to show how an impact was assessed. This study highlights the need to appropriately plan how the impact will be assessed and how the findings will be translated into effective adaptations.

Barriers to patient, provider, and caregiver adoption and use of electronic personal health records in chronic care: a systematic review

Background

Electronic personal health records (ePHRs) are defined as electronic applications through which individuals can access, manage, and share health information in a private, secure, and confidential environment. Existing evidence shows their benefits in improving outcomes, especially for chronic disease patients. However, their use has not been as widespread as expected partly due to barriers faced in their adoption and use. We aimed to identify the types of barriers to a patient, provider, and caregiver adoption/use of ePHRs and to analyze their extent in chronic disease care.

Methods

A systematic search in Medline, PubMed, Science Direct, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Central Register of Controlled Trials, and the Institute of Electrical and Electronics Engineers (IEEE) database was performed to find original studies assessing barriers to ePHR adoption/use in chronic care until the end of 2018. Two researchers independently screened and extracted data. We used the PHR adoption model and the Unified Theory of Acceptance and Use of Technology to analyze the results. The Mixed Methods Appraisal Tool (MMAT) version 2018 was used to assess the quality of evidence in the included studies.

Results

Sixty publications met our inclusion criteria. Issues found hindering ePHR adoption/use in chronic disease care were associated with demographic factors (e.g., patient age and gender) along with key variables related to health status, computer literacy, preferences for direct communication, and patient’s strategy for coping with a chronic condition; as well as factors related to medical practice/environment (e.g., providers’ lack of interest or resistance to adopting ePHRs due to workload, lack of reimbursement, and lack of user training); technological (e.g., concerns over privacy and security, interoperability with electronic health record systems, and lack of customized features for chronic conditions); and chronic disease characteristics (e.g., multiplicities of co-morbid conditions, settings, and providers involved in chronic care).

Conclusions

ePHRs can be meaningfully used in chronic disease care if they are implemented as a component of comprehensive care models specifically developed for this care. Our results provide insight into hurdles and barriers mitigating ePHR adoption/use in chronic disease care. A deeper understating of the interplay between these barriers will provide opportunities that can lead to an enhanced ePHR adoption/use.

Towards an Adoption Framework for Patient Access to Electronic Health Records: Systematic Literature Mapping Study

Background

Patient access to electronic health records (EHRs) is associated with increased patient engagement and health care quality outcomes. However, the adoption of patient portals and personal health records (PHRs) that facilitate this access is impeded by barriers. The Clinical Adoption Framework (CAF) has been developed to analyze EHR adoption, but this framework does not consider the patient as an end-user.

Objective

We aim to extend the scope of the CAF to patient access to EHRs, develop guidance documentation for the application of the CAF, and assess the interrater reliability.

Methods

We systematically reviewed existing systematic reviews on patients' access to EHRs and PHRs. Results of each review were mapped to one of the 43 CAF categories. Categories were iteratively adapted when needed. We measured the interrater reliability with Cohen’s unweighted kappa and statistics regarding the agreement among reviewers on mapping quotes of the reviews to different CAF categories.

Results

We further defined the framework’s inclusion and exclusion criteria for 33 of the 43 CAF categories and achieved a moderate agreement among the raters, which varied between categories.

Conclusions

In the reviews, categories about people, organization, system quality, system use, and the net benefits of system use were addressed more often than those about international and regional information and communication technology infrastructures, standards, politics, incentive programs, and social trends. Categories that were addressed less might have been underdefined in this study. The guidance documentation we developed can be applied to systematic literature reviews and implementation studies, patient and informal caregiver access to EHRs, and the adoption of PHRs.

User-centered design and enhancement of an electronic personal health record to support survivors of pediatric cancers

PURPOSE

The objective of this article is to demonstrate how user-centered design theory and methods can be employed to develop and iteratively improve technologies to support survivors of childhood cancer.

METHODS

Focus groups and structured interviews with young adult survivors of pediatric cancer (N = 3), parents (N = 11), and healthcare providers (N = 14) were conducted to understand their needs as potential users and the contexts in which they would use an electronic personal health record (PHR) for survivors, Cancer SurvivorLink^TM (https://cancersurvivorlink.org/). Usability evaluations were conducted to assess the functionality of the PHR using think aloud protocol with survivors/parents (N = 4) and focus groups with providers (N = 12).

RESULTS

Major themes identified through the needs assessment guided design of the PHR, including (1) education about the lifelong healthcare needs of pediatric cancer survivors ("Learn"), (2) secure electronic storage for healthcare documents to direct long-term follow-up care ("Store"), and (3) communication functionality to allow sharing of health documents with healthcare providers ("Share"). Usability evaluations identified challenges with the PHR design, which informed site enhancements to improve PHR usefulness and ease of use including a registration wizard and healthcare provider directory.

CONCLUSIONS

User-centered design methods informed iterative enhancements to an untethered, patient-controlled PHR to address usability barriers and meet the self-identified needs of survivors of childhood cancer and their providers.

Growing Disparities in Patient-Provider Messaging: Trend Analysis Before and After Supportive Policy

BACKGROUND

Public policy introduced since 2011 has supported provider adoption of electronic medical records (EMRs) and patient-provider messaging, primarily through financial incentives. It is unclear how disparities in patients' use of incentivized electronic health (eHealth) tools, like patient-provider messaging, have changed over time relative to disparities in use of eHealth tools that were not directly incentivized.

OBJECTIVE

This study examines trends in eHealth disparities before and after the introduction of US federal financial incentives. We compare rates of patient-provider messaging, which was directly incentivized, with rates of looking for health information on the Web, which was not directly incentivized.

METHODS

We used nationally representative Health Information National Trends Survey data from 2003 to 2018 (N=37,300) to describe disparities in patient-provider messaging and looking for health information on the Web. We first reported the percentage of individuals across education and racial and ethnic groups who reported using these tools in each survey year and compared changes in unadjusted disparities during preincentive (2003-2011) and postincentive (2011-2018) periods. Using multivariable linear probability models, we then examined adjusted effects of education and race and ethnicity in 3 periods-preincentive (2003-2005), early incentive (2011-2013), and postincentive (2017-2018)-controlling for sociodemographic and health factors. In the postincentive period, an additional model tested whether internet adoption, provider access, or providers' use of EMRs explained disparities.

RESULTS

From 2003 to 2018, overall rates of provider messaging increased from 4% to 36%. The gap in provider messaging between the highest and lowest education groups increased by 10 percentage points preincentive (P<.001) and 22 additional points postincentive (P<.001). The gap between Hispanics and non-Hispanic whites increased by 3.2 points preincentive (P=.42) and 11 additional points postincentive (P=.01). Trends for blacks resembled those for Hispanics, whereas trends for Asians resembled those for non-Hispanic whites. In contrast, education-based disparities in looking for health information on the Web (which was not directly incentivized) did not significantly change in preincentive or postincentive periods, whereas racial disparities narrowed by 15 percentage points preincentive (P=.008) and did not significantly change postincentive. After adjusting for other sociodemographic and health factors, observed associations were similar to unadjusted associations, though smaller in magnitude. Including internet adoption, provider access, and providers' use of EMRs in the postincentive model attenuated, but did not eliminate, education-based disparities in provider messaging and looking for health information on the Web. Racial and ethnic disparities were no longer statistically significant in adjusted models.

CONCLUSIONS

Disparities in provider messaging widened over time, particularly following federal financial incentives. Meanwhile, disparities in looking for health information on the Web remained stable or narrowed. Incentives may have disproportionately benefited socioeconomically advantaged groups. Future policy could address disparities by incentivizing providers treating these populations to adopt messaging capabilities and encouraging patients' use of messaging.

Digital Inclusion & Health Communication: A Rapid Review of Literature

Information and communication technologies can be a valuable tool for enhancing health communication. However, not everyone is utilising the wide suite of digital opportunities. This disparity has the potential to exacerbate existing social and health inequalities, particularly among vulnerable groups such as those who are in poor health and the elderly. This review aimed to systematically identify the common barriers to, and facilitators of, digital inclusion. A comprehensive database search yielded 969 citations. Following screening, seven systematic reviews and three non-systematic reviews were identified. Collectively, the reviews found that physical access continues to be a barrier to digital inclusion. However, provision of access alone is insufficient, as digital ability and attitude were also potential barriers. Social support, direct user experience and collaborative learning/design were identified as key strategies to improve inclusion. These review findings provide guidance for health communication practitioners in designing and implementing effective programmes in the digital environment.

Determinants and outcomes of patient access to medical records: Systematic review of systematic reviews

BACKGROUND

Patient access to electronic health records (EHRs) is associated with several determinants and outcomes, which are interrelated. However, individual studies and the reviews summarizing them have only addressed particular aspects, such as policy, usability or health outcomes of adoption. Therefore, no comprehensive overview exists. Additionally, reviews used different theoretical frameworks, which makes results difficult to compare.

OBJECTIVE

We aimed to systematically review recent systematic reviews on determinants and outcomes of patient access to EHRs to create a comprehensive overview and inform policy-makers and EHR implementers about the available literature, and to identify knowledge gaps in the literature reviews.

METHODS

We searched MEDLINE, EMBASE and PsycINFO for systematic reviews on patient portals, personal health records, and patient access to records that addressed determinants and outcomes of adoption. We synthesized the results from these reviews into the Clinical Adoption Framework (CAF), by mapping quotes from the reviews to categories and dimensions of the CAF, starting with the most recent ones until saturation of the CAF had been reached. The risk of bias in the reviews was assessed using the AMSTAR2 checklist.

RESULTS

We included nineteen reviews from 8871 records that were retrieved until February 19^th, 2018. The reviews had a median of 4 (IQR: 4-4) critical flaws according to the AMSTAR2 checklist. The reviews contained a total of 1054 quotes that were mapped to the CAF. All reviews reported on the dimension 'People' that can affect adoption (e.g. personal characteristics such as age) and the dimension 'HIS use' (health information system use). Most reviews reported the dimensions 'Organisation', 'Implementation', HIS 'System quality', and outcomes of HIS use. However, gaps in knowledge might exist on macro-level determinants and outcomes, such as healthcare standards, funding, and incentives, because few reviews addressed these aspects.

CONCLUSIONS

No review covered all aspects of the CAF and there was a large variety in aspects that were addressed, but all dimensions of the CAF were addressed by at least two reviews. Although reviews had critical flaws according to the AMSTAR2 checklist, almost half of the reviews did use methods to assess bias in primary studies. Implementers can use the synthesized results from this study as a reference for implementation and development when taking quality restrictions into account. Researchers should address the risk of bias in primary studies in future reviews and use a framework such as CAF to make results more comparable and reusable.

Exchanging personal health data with electronic health records: A standardized information model for patient generated health data and observations of daily living

OBJECTIVE

The development of a middleware information model to facilitate better interoperability between Personal and Electronic Health Record systems in order to allow exchange of Patient Generated Health Data and Observations of Daily Leaving between patients and providers in order to encourage patient self-management.

MATERIALS AND METHODS

An information model based on HL7 standards for interoperability has been extended to support PGHD and ODL data types. The new information models uses HL7 CDA to represent data, is instantiated as a Protégé ontology and uses a set of mapping rules to transfer data between Personal and Electronic Health Record systems.

RESULTS

The information model was evaluated by executing a set of use case scenarios containing data exported from three consumer health apps, transformed to CDA according to developed mapping rules and validated against a CDA schema. This allowed various challenges to emerge as well as revealed gaps in current standards in use and the information model has been refined accordingly.

DISCUSSION AND CONCLUSION

Our proposed middleware solution offers a number of advantages. When modifications are made to either a Personal or Health Electronic Health Record system or any integrated consumer app, they can be incorporated by altering only the instantiation of the information model. Our proposition uses current standards in use such as CDA. The solution is applicable to any EHR system with HL7 CDA support.

Usability Assessment of Secure Messaging for Clinical Document Sharing between Health Care Providers and Patients

BACKGROUND

Web-based patient portals feature secure messaging systems that enable health care providers and patients to communicate information. However, little is known about the usability of these systems for clinical document sharing.

OBJECTIVE

This article evaluates the usability of a secure messaging system for providers and patients in terms of its ability to support sharing of electronic clinical documents.

METHODS

We conducted usability testing with providers and patients in a human-computer interaction laboratory at a Midwestern U.S. hospital. Providers sent a medication list document to a fictitious patient via secure messaging. Separately, patients retrieved the clinical document from a secure message and returned it to a fictitious provider. We collected use errors, task completion, task time, and satisfaction.

RESULTS

Twenty-nine individuals participated: 19 providers (6 physicians, 6 registered nurses, and 7 pharmacists) and 10 patients. Among providers, 11 (58%) attached and sent the clinical document via secure messaging without requiring assistance, in a median (range) of 4.5 (1.8-12.7) minutes. No patients completed tasks without moderator assistance. Patients accessed the secure messaging system within 3.6 (1.2-15.0) minutes; retrieved the clinical document within 0.8 (0.5-5.7) minutes; and sent the attached clinical document in 6.3 (1.5-18.1) minutes. Although median satisfaction ratings were high, with 5.8 for providers and 6.0 for patients (scale, 0-7), we identified 36 different use errors. Physicians and pharmacists requested additional features to support care coordination via health information technology, while nurses requested features to support efficiency for their tasks.

CONCLUSION

This study examined the usability of clinical document sharing, a key feature of many secure messaging systems. Our results highlight similarities and differences between provider and patient end-user groups, which can inform secure messaging design to improve learnability and efficiency. The observations suggest recommendations for improving the technical aspects of secure messaging for clinical document sharing.

Making it work for me: beliefs about making a personal health record relevant and useable

Background

A Personal Health Record (PHR) is an electronic record that individuals use to manage and share their health information, e.g. data from their medical records and data collected by apps. However, engagement with their record can be low if people do not find it beneficial to their health, wellbeing or interactions with health and other services. We have explored the beliefs potential users have about a PHR, how it could be made personally relevant, and barriers to its use.

Methods

A qualitative design comprising eight focus groups, each with 6–8 participants. Groups included adults with long-term health conditions, young people, physically active adults, data experts, and members of the voluntary sector. Each group lasted 60–90 min, was audio recorded and transcribed verbatim. We analysed the data using thematic analysis to address the question “What are people’s beliefs about making a Personal Health Record have relevance and impact?”

Results

We found four themes. Making it work for me is about how to encourage individuals to actively engage with their PHR. I control my information is about individuals deciding what to share and who to share it with. My concerns is about individuals’ concerns about information security and if and how their information will be acted upon. Potential impact shows the potential benefits of a PHR such as increasing self-efficacy, uptake of health-protective behaviours, and professionals taking a more holistic approach to providing care and facilitating behaviour change.

Conclusions

Our research shows the functionality that a PHR requires in order for people to engage with it. Interactive functions and integration with lifestyle and health apps are particularly important. A PHR could increase the effectiveness of behaviour change apps by specifying evidence-based behaviour change techniques that apps should incorporate. A PHR has the potential to increase health-protective behaviours and facilitate a more person-driven health and social care system. It could support patients to take responsibility for self-managing their health and treatment regimens, as well as helping patients to play a more active role when care transfers across boundaries of responsibility.

Inpatient Portals for Hospitalized Patients and Caregivers: A Systematic Review

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.

Potential of personal health record portals in the care of individuals with spinal cord injuries and disorders: Provider perspectives

CONTEXT/OBJECTIVE

Although personal health record (PHR) portals are designed for patients, healthcare providers are a key influence in how patients use their features and realize benefits from them. A few studies have examined provider attitudes toward PHR portals, but none have focused on those who care for individuals with spinal cord injuries and disorders (SCI/D). We characterize SCI/D provider perspectives of PHR portals, including perceived advantages and disadvantages of PHR portal use in SCI/D care.

DESIGN

Cross-sectional; semi-structured interviews.

SETTING

Spinal Cord Injury (SCI) Centers in the Veterans Health Administration.

PARTICIPANTS

Twenty-six SCI/D healthcare providers.

INTERVENTIONS

None.

OUTCOME MEASURES

Perceived advantages and disadvantages of PHR portals.

RESULTS

The complex situations of individuals with SCI/D shaped provider perspectives of PHR portals and their potential role in practice. Perceived advantages of PHR portal use in SCI/D care included the ability to coordinate information and care, monitor and respond to outpatient requests, support patient self-management activities, and provide reliable health information to patients. Perceived disadvantages of PHR portal use in SCI/D care included concerns about the quality of patient-generated health data, other potential liabilities for providers and workload burden, and the ability of individuals with SCI/D to understand clinical information accessed through a portal.

CONCLUSION

Our study highlights advantages and disadvantages that should be considered when promoting engagement of SCI/D healthcare providers in use of PHR portals, and portal features that may have the most utility in SCI/D care.

[Factors influencing electronic personal health record (ePHR) adoption by Primary Health Care providers in Quebec: Professional and organizational perspective]

INTRODUCTION

We aimed to describe and analyse the factors and conditions influencing ePHR adoption by primary healthcare professionals for the follow-up and management of chronic diseases, as perceived by healthcare professionals and health organization managers.

METHODS

A qualitative study was conducted in the context of an ePHR experimentation project in Quebec. In-depth semi-structured individual interviews were conducted with 11 professionals and three managers directly involved in ePHR implementation in a primary healthcare organization.

RESULTS

The results highlight the emergence of themes comprising facilitators or barriers to ePHR adoption. The main factors identified were the clinicians' leadership and previous involvement in organizational transformations, the context of practice, technology maturity providing a useful, additional and relevant content, integration with the available clinical information systems facilitating two-way communication and supporting the development of patient-professional partnerships and patients' use and adherence. The organizational precursors identified refer to the organizational receptivity to change, adjustment to participants' values, and the policies and practices set up to support ePHR adoption by professionals and their patients. Cost is a major issue determining ePHR implementation.

CONCLUSION

The factors and conditions identified will be useful strategically and operationally to design and implement new clinical and organizational practices and develop adapted technologies facilitating ePHR adoption by professionals.

Patient Work Methods: Current Methods of Engaging Patients in Systems Design in Clinical, Community and Extraterrestrial Settings

As Human Factors and Ergonomics (HF/E) practice in health care expands, there is growing recognition of the need to consider and design for patient work. Over the past several years HF/E practitioners and researchers have begun to formalize the theoretical foundations of a patient work approach. Methodologically, patient work approaches have required adaptations of existing HF/E and social science approaches as well as the development of new approaches. This panel will focus on current approaches of engaging patients in designing interventions in the multiple settings in which patient work is performed. Each panelist will introduce their work by discussing the health care challenge and how existing methods were adapted or new methods created to engage patients in the design of systems. The panelists will then interact with audience members to solicit current health care challenges and to brainstorm ways in which methods could be adapted or innovated to engage patients in addressing these challenges.

Using scenarios and personas to enhance the effectiveness of heuristic usability evaluations for older adults and their care team

OBJECTIVE

Using heuristics to evaluate user experience is a common methodology for human-computer interaction studies. One challenge of this method is the inability to tailor results towards specific end-user needs. This manuscript reports on a method that uses validated scenarios and personas of older adults and care team members to enhance heuristics evaluations of the usability of commercially available personal health records for homebound older adults.

MATERIALS AND METHODS

Our work extends the Chisnell and Redish heuristic evaluation methodology by using a protocol that relies on multiple expert reviews of each system. It further standardizes the heuristic evaluation process through the incorporation of task-based scenarios.

RESULTS

We were able to use the modified version of the Chisnell and Redish heuristic evaluation methodology to identify potential usability challenges of two commercially available personal health record systems. This allowed us to: (1) identify potential usability challenges for specific types of users, (2) describe improvements that would be valuable to all end-users of the system, and (3) better understand how the interactions of different users may vary within a single personal health record.

CONCLUSIONS

The methodology described in this paper may help designers of consumer health information technology tools, such as personal health records, understand the needs of diverse end-user populations. Such methods may be particularly helpful when designing systems for populations that are difficult to recruit for end-user evaluations through traditional methods.

Consumer Adoption of Personal Health Record Systems: A Self-Determination Theory Perspective

Background

Personal Health Records (PHR) systems provide individuals with access and control over their health information and consequently can support individuals in becoming active participants, rather than passive recipients, in their own care process. In spite of numerous benefits suggested for consumers’ utilizing PHR systems, research has shown that such systems are not yet widely adopted or well known to consumers. Bearing in mind the potential benefits of PHRs to consumers and their potential interest in these systems—and that similar to any other type of information system, adoption is a prerequisite for realizing the potential benefits of PHR systems—research is needed to understand how to enhance the adoption rates for PHR systems.

Objective

This research seeks to understand how individuals’ intentions to adopt PHR systems are affected by their self-determination in managing their own health—the extent of their ability to take an active role in managing their own health. As such, this research aims to develop and empirically validate a theoretical model that explains PHR systems adoption by the general public through the integration of theories from the information systems and psychology literatures.

Methods

This research employs a cross-sectional survey method targeted at the Canadian general public without any prior experience in using PHR systems. A partial least squares approach to structural equation modeling was used to validate the proposed research model of this study (N=159).

Results

Individuals with higher levels of ability to manage their own health (self-determination) are more likely to adopt PHR systems since they have more positive perceptions regarding the use of such systems. Further, such self-determination is fueled by autonomy support from consumers’ physicians as well as the consumers’ personality trait of autonomy orientation.

Conclusions

This study advances our theoretical understanding of PHR systems adoption. It also contributes to practice by providing insightful implications for designing, promoting, and facilitating the use of PHR systems among consumers.

Lessons learned from the usability assessment of home-based telemedicine systems

At-home telemedicine visits are quickly becoming an acceptable alternative for in-person patient visits. However, little work has been done to understand the usability of these home-based telemedicine solutions. It is critical for user acceptance and real-world applicability to evaluate available telemedicine solutions within the context-specific needs of the users of this technology. To address this need, this study evaluated the usability of four home-based telemedicine software platforms: Doxy.me, Vidyo, VSee, and Polycom. Using a within-subjects experimental design, twenty participants were asked to complete a telemedicine session involving several tasks using the four platforms. Upon completion of these tasks for each platform, participants completed the IBM computer system usability questionnaire (CSUQ) and the NASA Task Load Index test. Upon completing the tasks on all four platforms, the participants completed a final post-test subjective questionnaire ranking the platforms based on their preference. Of the twenty participants, 19 completed the study. Statistically significant differences among the telemedicine software platforms were found for task completion time, total workload, mental demand, effort, frustration, preference ranking and computer system usability scores. Usability problems with installation and account creation led to high mental demand and task completion time, suggesting the participants preferred a system without such requirements. Majority of the usability issues were identified at the telemedicine initiation phase. The findings from this study can be used by software developers to develop user-friendly telemedicine systems.