HIV patients' willingness to share personal health information electronically

Measuring the willingness to share personal health information: a systematic review

Background

In the age of digitalization and big data, personal health information is a key resource for health care and clinical research. This study aimed to analyze the determinants and describe the measurement of the willingness to disclose personal health information.

Methods

The study conducted a systematic review of articles assessing willingness to share personal health information as a primary or secondary outcome. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol. English and Italian peer-reviewed research articles were included with no restrictions for publication years. Findings were narratively synthesized.

Results

The search strategy found 1,087 papers, 89 of which passed the screening for title and abstract and the full-text assessment.

Conclusion

No validated measurement tool has been developed for willingness to share personal health information. The reviewed papers measured it through surveys, interviews, and questionnaires, which were mutually incomparable. The secondary use of data was the most important determinant of willingness to share, whereas clinical and socioeconomic variables had a slight effect. The main concern discouraging data sharing was privacy, although good data anonymization and the high perceived benefits of sharing may overcome this issue.

My data choices: Pilot evaluation of patient-controlled medical record sharing technology

Patients desire greater control over sharing their digital health data. Consent2Share (C2S) is an open-source consent tool offered by SAMHA and the VA to support granular data sharing (GDS) options that align with patient preferences and data privacy regulations. The need to validate this tool exists. We pilot tested C2S with 199 English and Spanish-speaking patients with behavioral health conditions (BHCs) and patient guardians. Data were analyzed using mixed methodology. All participants desired granular control over the sharing of their health data. Most participants (87%) were highly interested in using a tool that offered granular options for executing data sharing decisions, with over half (55%) indicated that being able to specify the data type, data recipient, and data use purpose made them more willing to share their medical records. Majority (83%) indicated that the supported data type sharing categories satisfied their data-sharing privacy preferences. Majority (87%) also reported that knowing the purpose of data use made them more comfortable in sharing. Some participants (28%) accessed the education materials provided on data type sharing options. Patients want granular choices when sharing medical records. Consent2Share and its supported data type sharing categories are adequate to capture patients’ data sharing preferences. Further development is needed before deployment in clinical environments.

Observation and Patients' Perceptions of Incorporating Their Photograph Into the Electronic Health Record

OBJECTIVES

Wrong-patient errors are common and have the potential to cause serious harm. The Office of the National Coordinator for Health Information Technology Patient Identification SAFER Guide recommends displaying patient photographs in electronic health record (EHR) systems to facilitate patient identification and reduce wrong-patient errors. A potential barrier to implementation is patient refusal; however, patients' perceptions about having their photograph captured during registration and integrated into the EHR are unknown.

METHODS

The study was conducted in an emergency department (ED) and primary care outpatient clinic within a large integrated health system in New York City. The study consisted of 2 components: (1) direct observation of the registration process to quantify the frequency of patient refusals and (2) semistructured interviews to elicit patients' feedback on perceived benefits and barriers to integrating their photograph into the EHR.

RESULTS

Of 172 registrations where patients were asked to take a photograph for patient identification, 0 refusals were observed (ED, 0 of 87; primary care outpatient clinic, 0 of 85). A convenience sample of 30 patients were interviewed (female, 70%; age ≥55 years, 43%; Hispanic/Latino, 67%; Black, 23%). Perceived benefits of integrating patient photographs into the EHR included improved security (40%), improved patient identification (23%), and ease of registration (17%). A small proportion of patients raised privacy concerns.

CONCLUSIONS

Patient refusal was not found to be a barrier to implementation of patient photographs in the EHR. Efforts to identify and address other potential barriers would help ensure that the highest proportion of patients has photographs in their medical record.

Behavioral Health Professionals' Perceptions on Patient-Controlled Granular Information Sharing (Part 2): Focus Group Study

BACKGROUND

Patient-directed selection and sharing of health information "granules" is known as granular information sharing. In a previous study, patients with behavioral health conditions categorized their own health information into sensitive categories (eg, mental health) and chose the health professionals (eg, pharmacists) who should have access to those records. Little is known about behavioral health professionals' perspectives of patient-controlled granular information sharing (PC-GIS).

OBJECTIVE

This study aimed to assess behavioral health professionals' (1) understanding of and opinions about PC-GIS; (2) accuracy in assessing redacted medical information; (3) reactions to patient rationale for health data categorization, assignment of sensitivity, and sharing choices; and (4) recommendations to improve PC-GIS.

METHODS

Four 2-hour focus groups and pre- and postsurveys were conducted at 2 facilities. During the focus groups, outcomes from a previous study on patients' choices for medical record sharing were discussed. Thematic analysis was applied to focus group transcripts to address study objectives.

RESULTS

A total of 28 health professionals were recruited. Over half (14/25, 56%) were unaware or provided incorrect definitions of granular information sharing. After PC-GIS was explained, all professionals demonstrated understanding of the terminology and process. Most (26/32 codes, 81%) recognized that key medical data had been redacted from the study case. A majority (41/62 codes, 66%) found the patient rationale for categorization and data sharing choices to be unclear. Finally, education and other approaches to inform and engage patients in granular information sharing were recommended.

CONCLUSIONS

This study provides detailed insights from behavioral health professionals on granular information sharing. Outcomes will inform the development, deployment, and evaluation of an electronic consent tool for granular health data sharing.

Considerations for an integrated population health databank in Africa: lessons from global best practices

Background: The rising digitisation and proliferation of data sources and repositories cannot be ignored. This trend expands opportunities to integrate and share population health data. Such platforms have many benefits, including the potential to efficiently translate information arising from such data to evidence needed to address complex global health challenges. There are pockets of quality data on the continent that may benefit from greater integration. Integration of data sources is however under-explored in Africa. The aim of this article is to identify the requirements and provide practical recommendations for developing a multi-consortia public and population health data-sharing framework for Africa.

Methods: We conducted a narrative review of global best practices and policies on data sharing and its optimisation. We searched eight databases for publications and undertook an iterative snowballing search of articles cited in the identified publications. The Leximancer software © enabled content analysis and selection of a sample of the most relevant articles for detailed review. Themes were developed through immersion in the extracts of selected articles using inductive thematic analysis. We also performed interviews with public and population health stakeholders in Africa to gather their experiences, perceptions, and expectations of data sharing.

Results: Our findings described global stakeholder experiences on research data sharing. We identified some challenges and measures to harness available resources and incentivise data sharing.  We further highlight progress made by the different groups in Africa and identified the infrastructural requirements and considerations when implementing data sharing platforms. Furthermore, the review suggests key reforms required, particularly in the areas of consenting, privacy protection, data ownership, governance, and data access.

Conclusions: The findings underscore the critical role of inclusion, social justice, public good, data security, accountability, legislation, reciprocity, and mutual respect in developing a responsive, ethical, durable, and integrated research data sharing ecosystem.

Factors Associated With Willingness to Share Health Information: Rapid Review

Background

To expand research and strategies to prevent disease, comprehensive and real-time data are essential. Health data are increasingly available from platforms such as pharmaceuticals, genomics, health care imaging, medical procedures, wearable devices, and internet activity. Further, health data are integrated with an individual’s sociodemographic information, medical conditions, genetics, treatments, and health care. Ultimately, health information generation and flow are controlled by the patient or participant; however, there is a lack of understanding about the factors that influence willingness to share health information. A synthesis of the current literature on the multifactorial nature of health information sharing preferences is required to understand health information exchange.

Objective

The objectives of this review are to identify peer-reviewed literature that reported factors associated with health information sharing and to organize factors into cohesive themes and present a narrative synthesis of factors related to willingness to share health information.

Methods

This review uses a rapid review methodology to gather literature regarding willingness to share health information within the context of eHealth, which includes electronic health records, personal health records, mobile health information, general health information, or information on social determinants of health. MEDLINE and Google Scholar were searched using keywords such as electronic health records AND data sharing OR sharing preference OR willingness to share. The search was limited to any population that excluded health care workers or practitioners, and the participants aged ≥18 years within the US or Canadian context. The data abstraction process using thematic analysis where any factors associated with sharing health information were highlighted and coded inductively within each article. On the basis of shared meaning, the coded factors were collated into major themes.

Results

A total of 26 research articles met our inclusion criteria and were included in the qualitative analysis. The inductive thematic coding process revealed multiple major themes related to sharing health information.

Conclusions

This review emphasized the importance of data generators’ viewpoints and the complex systems of factors that shape their decision to share health information. The themes explored in this study emphasize the importance of trust at multiple levels to develop effective information exchange partnerships. In the case of improving precision health care, addressing the factors presented here that influence willingness to share information can improve sharing capacity for individuals and allow researchers to reorient their methods to address hesitation in sharing health information.

Durrant A, Lloyd K. Understanding the attitudes and experiences of people living with potentially stigmatised long-term health conditions with respect to collecting and sharing health and lifestyle data

Background

The emerging landscape of patient-generated data (PGData) provides an opportunity to collect large quantities of information that can be used to develop our understanding of different health conditions and potentially improve the quality of life for those living with long-term health condition (LTHCs). If the potential benefits of PGData are to be realised, we need a better understanding of the psychological barriers and facilitators to the collection and beneficial sharing of health and lifestyle data. Due to the understudied role that stigma plays in sharing PGData, we explore the attitudes and experiences of those living with potentially stigmatised LTHCs with respect to collecting and sharing health and lifestyle data.

Methods

This study used semi-structured interviews and a card sorting task to explore the attitudes and experiences of people living with potentially stigmatised LTHCs. Fourteen adult participants who reported having a range of conditions were recruited in England. Template analysis was used to analyse interview transcripts and descriptive statistics were used for the card sorting task.

Results

The findings present four overarching themes: Preferences for collecting health and lifestyle data, Importance of anonymity, Expected use of data, and Sources of emotional support. Participants illustrated a general willingness to share health and lifestyle data; however, there were some notable differences in sharing experiences, varying both by information type and recipient group. Overall, participants did not identify health-related stigma as a barrier to collecting or sharing their personal health and lifestyle data.

Conclusions

We outline a number of preferences that participants feel would encourage them to collect and share data more readily, which may be considered when developing data sharing tools for the future.

Understanding the Barriers and Facilitators to Sharing Patient-Generated Health Data Using Digital Technology for People Living With Long-Term Health Conditions: A Narrative Review

Using digital technology to share patient-generated health data has the potential to improve the self-management of multiple long-term health conditions. Sharing these data can allow patients to receive additional support from healthcare professionals and peer communities, as well as enhance their understanding of their own health. A deeper understanding of the concerns raised by those living with long-term health conditions when considering whether to share health data via digital technology may help to facilitate effective data sharing practices in the future. The aim of this review is to identify whether trust, identity, privacy and security concerns present barriers to the successful sharing of patient-generated data using digital technology by those living with long-term health conditions. We also address the impact of stigma on concerns surrounding sharing health data with others. Searches of CINAHL, PsychInfo and Web of Knowledge were conducted in December 2019 and again in October 2020 producing 2,581 results. An iterative review process resulted in a final dataset of 23 peer-reviewed articles. A thorough analysis of the selected articles found that issues surrounding trust, identity, privacy and security clearly present barriers to the sharing of patient-generated data across multiple sharing contexts. The presence of enacted stigma also acts as a barrier to sharing across multiple settings. We found that the majority of literature focuses on clinical settings with relatively little attention being given to sharing with third parties. Finally, we suggest the need for more solution-based research to overcome the discussed barriers to sharing.

Evaluating the Balance Between Privacy and Access in Digital Information Sharing

Supplemental Digital Content is available in the text.

Access to personal health records in an ICU by persons involved in the patient’s care (referred to broadly as “family members” below) has the potential to increase engagement and reduce the negative psychologic sequelae of such hospitalizations. Currently, little is known about patient preferences for information sharing with a designated family member in the ICU. We sought to understand the information-sharing preferences of former ICU patients and their family members and to identify predictors of information-sharing preferences.

Do personal health concerns and trust in healthcare providers mitigate privacy concerns? Effects on patients' intention to share personal health data on electronic health records

RATIONALE

Health digitalization raises important challenges for personal health-data management. Particularly, the advantages underlying the implementation of Electronic Health Record (EHR) remain limited in many countries due to patients' privacy concerns.

OBJECTIVE

Drawing on the privacy calculus theory, the objective of this research is to introduce personal health concerns and trust in healthcare providers as new predictors, beyond the constituent variables of the privacy calculus model - the perceived benefits and risk. We propose and test a conceptual model that investigates simultaneously the effects of these four variables on patients' privacy concerns and intention to share personal health-data on EHR.

METHOD

A cross-sectional study using an on online survey was administered from December 2019 to February 2020 in France to both users and non-users of EHR. A structural equation modelling was used to assess the reliability and validity of the measurement as well as to test the research hypotheses.

RESULTS

The results confirm the positive effects of personal health concerns and trust in healthcare providers on (a) the intention to create an EHR and (b) to share personal health-data. In the same vein, we do not find any significant effect of patients' privacy concerns on the intention to create an EHR and intention to share personal health-data. Furthermore, the patients' perceived benefits outweigh the perceived risks for EHR using.

CONCLUSIONS

This research provides a more holistic understanding of patients' privacy concerns. Particularly, we highlight the key role of personal health concerns and trust in healthcare providers with the intention to create an EHR and to share personal health data. Empirical evidence underlines the importance to involve all the stakeholders in the implementation process. Findings are discussed according to existing literature and practical guidelines are suggested to the health policymakers and healthcare providers.

Vulnerable patients' attitudes towards sharing medical data and granular control in patient portal systems: an interview study

BACKGROUND

The collection, storage and exchange of medical information are becoming increasingly complex. More parties are involved in this process, and the data are expected to serve many different purposes beside patient care. This raises several ethical questions regarding privacy, data ownership, security and confidentiality. It is vital to consider patients' moral attitudes and preferences in this digital information exchange. The voice of vulnerable patients is rarely heard in research addressing these questions. This study aims to address this void.

METHOD

Fourteen vulnerable patients without prior experience with patient portal systems were interviewed for this study. First, participants were introduced to the portal and given time to read their personal medical data. Afterwards, semi-structured interviews were conducted and analysed thematically to explore participants' first experience with the portal and their views on sharing medical information with care providers and other parties.

RESULTS

Data analysis resulted in four themes: barriers to and benefits of portal access, emotional responses to reading medical information, diverging views on sharing information with third parties and balancing granular control and the best possible care. First, participants appreciated access to their health information in the portal despite experiencing obstacles. Second, reading medical information online could evoke emotional responses. Third, patients were generally unaware of the meaning and value of medical data to third parties, resulting in inconsistent views on data sharing. Finally, although patients generally supported granular control, they were willing to give up on their autonomy if that would ensure them to receive the best possible care.

CONCLUSIONS

Patient portal design should take into consideration the obstacles that discourage vulnerable patients' access and hamper meaningful use. There is a need for more transparency on secondary use of medical data by third parties. Patients should be better informed about the potential consequences of sharing data with them.

Longitudinal analysis of social and behavioral determinants of health in the EHR: exploring the impact of patient trajectories and documentation practices

Social and behavioral determinants of health (SBDH) are environmental and behavioral factors that impede disease self-management and can exacerbate clinical conditions. While recent research in the informatics community has focused on building systems that can automatically infer SBDH from the patient record, it is unclear how such determinants change overtime. This study analyzes the longitudinal characteristics of 4 common SBDH as expressed in the patient record and compares the rates of change among distinct SBDH. In addition, manual review of patient notes was undertaken to establish whether changes in patient SBDH status reflected legitimate changes in patient status or rather potential data quality issues. Our findings suggest that a patient's SBDH status is liable to change over time and that some changes reflect poor social history taking by clinicians.

Mental health professional perspectives on health data sharing: Mixed methods study

This study explores behavioral health professionals’ perceptions of granular data. Semi-structured in-person interviews of 20 health professionals were conducted at two different sites. Qualitative and quantitative analysis was performed. While most health professionals agreed that patients should control who accesses their personal medical record (70%), there are certain types of health information that should never be restricted (65%). Emergent themes, including perceived reasons that patients might share or withhold certain types of health information (65%), care coordination (12%), patient comprehension (11%), stigma (5%), trust (3%), sociocultural understanding (3%), and dissatisfaction with consent processes (1%), are explored. The impact of care role (prescriber or non-prescriber) on data-sharing perception is explored as well. This study informs the discussion on developing technology that helps balance provider and patient data-sharing and access needs.

Mental health professionals’ perceptions on patients control of data sharing

Integrated mental and physical care environments require data sharing, but little is known about health professionals’ perceptions of patient-controlled health data sharing. We describe mental health professionals’ views on patient-controlled data sharing using semi-structured interviews and a mixed-method analysis with thematic coding. Health information rights, specifically those of patients and health care professionals, emerged as a key theme. Behavioral health professionals identified patient motivations for non-sharing sensitive mental health records relating to substance use, emergency treatment, and serious mental illness (94%). We explore conflicts between professional need for timely access to health information and patient desire to withhold some data categories. Health professionals’ views on data sharing are integral to the redesign of health data sharing and informed consent. As well, they seek clarity about the impact of patient-controlled sharing on health professionals’ roles and scope of practice.

The public's comfort with sharing health data with third-party commercial companies

Healthcare systems are using big data-driven methods to realize the vision of learning health systems and improve care quality. In so doing, many are partnering with third-party commercial companies to provide novel data processing and analysis capabilities, while also providing personal health information to a for-profit industry that may store and sell data. In this research we describe the public's comfort with sharing health data with third-party commercial companies for patient and business purposes and how this comfort is associated with demographic factors (sex, age, race/ethnicity, education, employment, income, insurance status, and self-reported health status), perceived healthcare access, and concerns about privacy. We surveyed the US public (n = 1841) to assess comfort with sharing health data with third-party commercial companies for patient or business purposes and examined whether there was a difference between comfort with data sharing for patient or business purposes. Univariate and stepwise regression modeling is used here to estimate the relationship between comfort with third-party commercial companies for patient and business purposes (outcomes) and demographic factors, self-reported health status, perceived healthcare access, and privacy concerns. The public is more comfortable sharing health data with third party commercial companies for patient purposes as compared to business purposes (paired t = 39.84, p < 0.001). Higher education was associated with greater comfort with sharing health data for patient purposes (β = 0.205, p < 0.001) and decreased comfort with sharing health data for business purposes (β = -0.145, p = 0.079). An inverse relationship exists between privacy concerns and comfort with sharing health data for both patient (β = -0.223, p < 0.001) and business purposes (β = -0.246, p < 0.001). Participants ages 45-59 were less comfortable sharing health data with third party commercial companies for patient purposes (β = -0.154, p = 0.0012) than participants aged 18-29. Proactive acknowledgment of privacy concerns and better communication of the steps being taken to protect the privacy of health data can increase patient comfort. Healthcare systems may be able to increase public and patient comfort with sharing health data with third-party commercial companies by emphasizing the patient-centered benefits of these partnerships.

State of the art and a mixed-method personalized approach to assess patient perceptions on medical record sharing and sensitivity

OBJECTIVE

Sensitive health information possesses risks, such as stigma and discrimination, when disclosed. Few studies have used a patient's own electronic health records (EHRs) to explore what types of information are considered sensitive andhow such perceptions affect data sharing preferences. After a systematic literature review, we designed and piloted a mixed-method approach that employs an individual's own records to assess content sensitivity and preferences for granular data sharing for care and research.

METHODS

A systematic literature review of methodologies employed to assess data sharing willingness and perceptions on data sensitivity was conducted. A methodology was designed to organize and categorize sensitive health information from EHRs. Patients were asked permission to access their EHRs, including those available through the state's health information exchange. A semi-structured interview script with closed card sorting was designed and personalized to each participant's own EHRs using 30 items from each patient record. This mixed method combines the quantitative outcomes from the card sorting exercises with themes captured from interview audio recording analysis.

RESULTS

Eight publications on patients' perspectives on data sharing and sensitivity were found. Based on our systematic review, the proposed method meets a need to use EHRs to systematize the study of data privacy issues. Twenty-five patients with behavioral health conditions, English and Spanish-speaking, were recruited. On average, participants recognized 82.7% of the 30 items from their own EHRs. Participants considered mental health (76.0%), sexual and reproductive health (75.0%) and alcohol use and alcoholism (50.0%) sensitive information. Participants were willing to share information related to other addictions (100.0%), genetic data (95.8%) and general physical health information (90.5%).

CONCLUSION

The findings indicate diversity in patient views on EHR sensitivity and data sharing preferences and the need for more granular and patient-centered electronic consent mechanisms to accommodate patient needs. More research is needed to validate the generalizability of the proposed methodology.

The Effects of Public Concern for Information Privacy on the Adoption of Health Information Exchanges (HIEs) by Healthcare Entities

The implementation of Health Information Exchanges (HIEs) by healthcare organizations may not achieve the desired outcomes as consumers may request that their health information remains unshared because of information privacy concerns. Drawing on the insights of concern for information privacy (CFIP) literature, this work extends the application of CFIP to the HIE domain. This study attempts to develop and test a model centered on the four dimensions of CFIP construct (collection, errors, unauthorized access, and secondary use) and their antecedents to predict consumers' opt-in behavioral intention toward HIE in the presence of the perceived health status' effects. We conducted an online survey in the United States using 826 samples. The results demonstrate that the perceived health information sensitivity and computer anxiety meaningfully contribute to information privacy concerns and CFIP construct significantly impedes consumers' opt-in decision to HIEs. Interestingly, contrary to our expectation, perceived poor health status considerably attenuates the negative effects exerted by CFIP on opt-in intention. The model proposed by this study can be used as a useful conceptual tool by both further studies and practitioners to examine the complex nature of patients' reactions to information privacy threats associated with the use of HIE technology in the healthcare industry.

Multimorbidity, not human immunodeficiency virus (HIV) markers predicts unplanned admission among people with HIV in regional New South Wales

BACKGROUND

Multimorbidity and unplanned admissions are common among people with human immunodeficiency virus (PWH).

AIMS

To determine factors predictive of unplanned admission among PWH in regional New South Wales and compare care coordination between people with and without unplanned admissions.

METHODS

A prospective cohort study of PWH attending a regional human immunodeficiency virus (HIV) service was conducted. Baseline HIV-specific results and multimorbidity markers including Cumulative Illness Rating Scale (CIRS) were assessed as predictors of time to first unplanned admission using Cox regression analysis. Care coordination markers were compared between people with and without unplanned admission, using χ² statistic for proportions and t-test for means.

RESULTS

A cohort of 181 PWH was followed for a maximum of 5 years. During a total of 739 person-years of follow up, 39 (20.6%) patients reached the endpoint of unplanned admission. In multivariate analysis, the baseline CIRS score was predictive of unplanned admission (P < 0.001). Age, HIV-specific markers and missed visits were not predictive of unplanned admission. For patients with an unplanned admission, discharge summaries were documented for 22/39 (56.4%). Of 180 PWH with a visit after baseline, 131 (72.8%) had a letter to a general practitioner and 79 (43.7%) had two or more prescribers. Having two or more prescribers was more common in people with an unplanned admission than in those without (64.1% vs 38.0%, P = 0.004).

CONCLUSION

Unplanned admission among PWH is predicted by multimorbidity. Care for PWH should include coordinated management of other health conditions in order to reduce their severity and prevent unplanned admissions.

Challenges and Opportunities of Health Information Exchange (HIE) From Health Consumers' Perspective

The implementation of HIE depends on a number of entities and one of the key participants is health consumers. All potential gains of HIE cannot be achieved without consumers' favorable beliefs and support. However, little is known about the factors affecting consumers to endorse electronic information exchange between healthcare organizations. The primary objective of this article is to identify how and why patients would support HIE used by healthcare providers. The author has conducted an online questionnaire-based survey in the U.S. This study has shown that perceived value of HIE is significantly related to consumers HIE supportive intention. Moreover, perceived value fully mediates the effects of perceived benefit and cost of HIE implementation on consumer tendency to endorse HIE. The findings also provide evidence to highlight that consumers' attitude toward exchange model moderates the relationship between value perception and intention to support HIE. Relying on the results, this study offers several practical and theoretical contributions.

Greater patient health information control to improve the sustainability of health information exchanges

Health information exchanges (HIEs) are multisided platforms that facilitate the sharing of patient health information (PHI) between providers and payers across organizations within a region, community or hospital system. The benefits of HIEs to payers and providers include lower cost, faster services, and better health outcome. However, most HIEs have configured the patient healthcare consent process to give all providers who sign up with the exchange access to PHI for all consenting patients, leaving no control to patients in customized what information to share and with who. This research investigates the impact of granting greater control to patients in sharing their personal health information on consent rates and making them active participants in the HIEs system. This research utilizes a randomized experimental survey design study. The study uses responses from 388 participants and structural equation modeling (SEM) to test the conceptual model. The main findings of this research include that patients consent rate increases significantly when greater control in sharing PHI is offered to the patient. In addition, greater control reduces the negative impact of privacy concern on the intention to consent. Similarly, trust in healthcare professionals leads to higher consent when greater control is offered to the patient. Thus, greater control empowers the role of trust in engaging patients and sustaining HIEs. The paper makes a theoretical contribution to research by extending the unified theory of acceptance and use of technology (UTAUT) model. The findings impact practice by providing insights that will help sustain HIEs.

Putting the Focus Back on the Patient: How Privacy Concerns Affect Personal Health Information Sharing Intentions

Background

Health care providers are driven by greater participation and systemic cost savings irrespective of benefits to individual patients derived from sharing Personal Health Information (PHI). Protecting PHI is a critical issue in the sharing of health care information systems; yet, there is very little literature examining the topic of sharing PHI electronically. A good overview of the regulatory, privacy, and societal barriers to sharing PHI can be found in the 2009 Health Information Technology for Economic and Clinical Health Act.

Objective

This study investigated the factors that influence individuals’ intentions to share their PHI electronically with health care providers, creating an understanding of how we can represent a patient’s interests more accurately in sharing settings, instead of treating patients like predetermined subjects. Unlike privacy concern and trust, patient activation is a stable trait that is not subject to change in the short term and, thus, is a useful factor in predicting sharing behavior. We apply the extended privacy model in the health information sharing context and adapt this model to include patient activation and issue involvement to predict individuals’ intentions.

Methods

This was a survey-based study with 1600+ participants using the Health Information National Trends Survey (HINTS) data to validate a model through various statistical techniques. The research method included an assessment of both the measurement and structural models with post hoc analysis.

Results

We find that privacy concern has the most influence on individuals’ intentions to share. Patient activation, issue involvement, and patient-physician relationship are significant predictors of sharing intention. We contribute to theory by introducing patient activation and issue involvement as proxies for personal interest factors in the health care context.

Conclusions

Overall, this study found that although patients are open to sharing their PHI, they still have concerns over the privacy of their PHI during the sharing process. It is paramount to address this factor to increase information flow and identify how patients can assure that their privacy is protected. The outcome of this study is a set of recommendations for motivating the sharing of PHI. The goal of this research is to increase the health profile of the patients by integrating the testing and diagnoses of various doctors across health care providers and, thus, bring patients closer to the physicians.

Collaborative development of an educational resource on rehabilitation for people living with HIV

OBJECTIVE

The objective of this study is to describe the collaborative development of a rehabilitation guide for people living with human immunodeficiency virus (HIV) which was adapted from an online resource for clinicians.

METHODS

We adapted a comprehensive evidence-informed online clinical resource for people living with HIV using a three-phase participatory process. In Phase 1, we interviewed 26 clinicians and 16 people living with HIV to gather recommendations on how to adapt and format the content to benefit people living with HIV. In Phase 2, we adapted the patient education resource using the recommendations that emerged from Phase 1. Phase 3 consisted of comprehensive stakeholder review of the revised resource on the adaptability, usability, communicability, and relevance of the information. Stakeholders participated in an interview to obtain in-depth information on their perspectives. Transcribed interviews underwent qualitative content analysis.

RESULTS

Stakeholders indicated that the e-guide had utility for people living with HIV, community HIV service organizations, and care providers.

CONCLUSION

Engaging people living with HIV resulted in a more relevant and meaningful resource that incorporated patients' values, needs, and preferences.

IMPLICATIONS

Involving multiple stakeholders and user groups in the adaptation and evaluation of online patient education resources can assist in meeting patients' needs through increasing the relevance, organization and presentation of the content, and incorporating patients' values and needs. Implications for Rehabilitation Online patient education resources should be adapted in order to maximize relevance and meaningfulness to patients. Involving multiple stakeholders in the adaptation and evaluation of online patient education resources can assist in meeting patients' needs. Involving multiple stakeholders increases the relevance, organization and presentation of the content and allows the incorporation of patient values and needs. This collaborative approach with an emphasis on meaningful participation of patients and community may be of interest to others interested in promoting knowledge translation.

A Study to Elicit Behavioral Health Patients' and Providers' Opinions on Health Records Consent

A main objective of this study is to assess the opinions of 50 behavioral health patients on selective control over their behavioral and physical health information. We explored patients' preferences regarding current consent models, what health information should be shared for care and research and whether these preferences vary based on the sensitivity of health information and/or the type of provider involved. The other objective of this study was to solicit opinions of 8 behavioral health providers on patient-driven granular control of health information and potential impact on care.

Electronic surveys were implemented at an outpatient Behavioral Health facility that provides care for behavioral health patients with non-serious mental illnesses. The Patient Survey included questions regarding patients' demographics and about their concerns and preferences for data sharing for care and research. The Provider Survey included questions about their view on the current consent process and perceptions on barriers and facilitators to implement patient-controlled granular consent models.

This novel study provides valuable preliminary data that can help guide future studies to better understand privacy choices of this underrepresented patient group.

The benefits, risks and costs of privacy: patient preferences and willingness to pay

OBJECTIVE

Multiple surveys show that patients want medical privacy; however, there are costs to maintaining privacy. There are also risks if information is not shared. A review of previous surveys found that most surveys asked questions about patient's privacy concerns and willingness to share their medical information. We found only one study that asked about sharing medical information for better care and no survey that asked patients about the risk, cost or comparison between medical privacy and privacy in other areas. To fill this gap, we designed a survey to: (1) compare medical privacy preferences to privacy preferences in other areas; (2) measure willingness to pay the cost of additional privacy measures; and (3) measure willingness to accept the risks of not sharing information.

METHODS

A total of 834 patients attending physician offices at 14 sites completed all or part of an anonymous questionnaire.

RESULTS

Over 95% of patients were willing to share all their medical information with their treating physicians. There was no difference in willingness to share between primary care and specialty sites including psychiatry and an HIV clinic. In our survey, there was no difference in sharing preference between standard medical information and information with additional legal protections including genetic testing, drug/alcohol treatment and HIV results. Medical privacy was ranked lower than sharing social security and credit card numbers, but was deemed more private than other information including tax returns and handgun purchases. There was no statistical difference for any questions by site except for HIV/AIDS clinic patients ranking privacy of the medical record more important than reducing high medical costs and risk of medical errors (p < .05). Most patients were willing to spend a modest amount of additional time for privacy, but few were willing to pay more for additional medical privacy. Most patients were unwilling to take on additional risks to keep medical information hidden.

CONCLUSIONS

Patients were very willing to share medical information with their providers. They were able to see the importance of sharing medical information to provide the best possible care. They were unwilling to hide information from providers if there was increased medical risk. Patients were willing to spend additional time for privacy, but most were unwilling to spend extra money. Sixty-eight percent of patients favored reducing medical costs over privacy.

Patients' support for health information exchange: a literature review and classification of key factors

Background

Literature indicates that one of the most important factors affecting the widespread adoption of Health Information Exchange (HIE) is patient support and endorsement. In order to reap all the expected benefits of HIE, patients’ acceptance of technology is a challenge that is not fully studied. There are a few studies which have focused on requirements of electronic medical information exchange from consumers’ views and expectations. This study is aimed at reviewing the literature to articulate factors that affect patients to support HIE efforts.

Methods

A literature review of current studies addressing patients’ views on HIE from 2005 was undertaken. Five electronic research databases (Science Direct, PubMed, Web of Science, CINAHL, and Academic Search Premiere) were searched to retrieve articles reporting pros and cons of HIE from patients’ opinion.

Results

One hundred and ninety six articles were initially retrieved from the databases. Out of 196, 36 studies met the inclusion criteria and were fully reviewed. Our findings indicate that patient’s attitude toward HIE is affected by seven main factors: perceived benefits, perceived concerns, patient characteristics, patient participation level in HIE, type of health information, identity of recipients, and patient preferences regarding consent and features.

Conclusions

The findings provide useful theoretical implications for research by developing a classification of significant factors and a framework based on the lessons learned from the literature to help guide HIE efforts. Our results also have fundamental practical implications for policy makers, current and potential organizers of HIEs by highlighting the role of patients in the widespread implementation of HIE. The study indicates that new approaches should be applied to completely underline HIE benefits for patients and also address their concerns.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-017-0436-2) contains supplementary material, which is available to authorized users.

GPs' approaches to documenting stigmatising information: a qualitative study

BACKGROUND

Complete medical documentation is essential for continuity of care, but the competing need to protect patient confidentiality presents an ethical dilemma. This is particularly poignant for GPs because of their central role in facilitating continuity.

AIM

To examine how GPs manage medical documentation of stigmatising mental health (MH) and non-MH information.

DESIGN AND SETTING

A qualitative sub-study of a factorial experiment with GPs practising in Massachusetts, US.

METHOD

Semi-structured interviews (n = 128) were audiorecorded and transcribed verbatim. Transcripts were coded and analysed for themes.

RESULTS

GPs expressed difficulties with and inconsistent strategies for documenting stigmatising information. Without being asked directly about stigmatising information, 44 GPs (34%) expressed difficulties documenting it: whether to include clinically relevant but sensitive information, how to word it, and explaining to patients the importance of including it. Additionally, 75 GPs (59%) discussed strategies for managing documentation of stigmatising information. GPs reported four strategies that varied by type of information: to exclude stigmatising information to respect patient confidentiality (MH: 26%, non-MH: 43%); to include but restrict access to information (MH: 13%, non-MH: 25%); to include but neutralise information to minimise potential stigma (MH: 26%, non-MH: 29%); and to include stigmatising information given the potential impact on care (MH: 68%, non-MH: 32%).

CONCLUSION

Lack of consistency undermines the potential of medical documentation to efficiently facilitate continuous, coordinated health care because providers cannot be certain how to interpret what is or is not in the chart. A proactive consensus process within the field of primary care would provide much needed guidance for GPs and, ultimately, could enhance quality of care.

Improving Individual Acceptance of Health Clouds through Confidentiality Assurance

BACKGROUND

Cloud computing promises to essentially improve healthcare delivery performance. However, shifting sensitive medical records to third-party cloud providers could create an adoption hurdle because of security and privacy concerns.

OBJECTIVES

This study examines the effect of confidentiality assurance in a cloud-computing environment on individuals' willingness to accept the infrastructure for inter-organizational sharing of medical data.

METHODS

We empirically investigate our research question by a survey with over 260 full responses. For the setting with a high confidentiality assurance, we base on a recent multi-cloud architecture which provides very high confidentiality assurance through a secret-sharing mechanism: Health information is cryptographically encoded and distributed in a way that no single and no small group of cloud providers is able to decode it.

RESULTS

Our results indicate the importance of confidentiality assurance in individuals' acceptance of health clouds for sensitive medical data. Specifically, this finding holds for a variety of practically relevant circumstances, i.e., in the absence and despite the presence of conventional offline alternatives and along with pseudonymization. On the other hand, we do not find support for the effect of confidentiality assurance in individuals' acceptance of health clouds for non-sensitive medical data. These results could support the process of privacy engineering for health-cloud solutions.

Sociotechnical Analysis of Health Information Exchange Consent Processes in an HIV Clinic

Federal regulations have encouraged the electronic sharing of protected health information (PHI). As an opt-in state, New York abides by an affirmative consent model where PHI is electronically shared only after written consent is obtained. The purpose of our study was to describe sociotechnical factors that influence health information exchange (HIE) consent for persons living with HIV (PLWH) at one clinic in New York City. We employed mixed methods to gather perceptions of facilitators and barriers to HIE consent. Study participants included PLWH, staff, and clinicians. The mixed-methods approach revealed multiple interruptions in clinical workflow, staff and providers' time constraints, and lack of dedicated personnel focused on HIE consent as the major barriers to HIE consent. Although there is no one strategy to resolve barriers to HIE consent, having a dedicated person was identified as the most salient factor for facilitating HIE consent.

Comparison of consumers' views on electronic data sharing for healthcare and research

New models of healthcare delivery such as accountable care organizations and patient-centered medical homes seek to improve quality, access, and cost. They rely on a robust, secure technology infrastructure provided by health information exchanges (HIEs) and distributed research networks and the willingness of patients to share their data. There are few large, in-depth studies of US consumers' views on privacy, security, and consent in electronic data sharing for healthcare and research together.

OBJECTIVE

This paper addresses this gap, reporting on a survey which asks about California consumers' views of data sharing for healthcare and research together.

MATERIALS AND METHODS

The survey conducted was a representative, random-digit dial telephone survey of 800 Californians, performed in Spanish and English.

RESULTS

There is a great deal of concern that HIEs will worsen privacy (40.3%) and security (42.5%). Consumers are in favor of electronic data sharing but elements of transparency are important: individual control, who has access, and the purpose for use of data. Respondents were more likely to agree to share deidentified information for research than to share identified information for healthcare (76.2% vs 57.3%, p < .001).

DISCUSSION

While consumers show willingness to share health information electronically, they value individual control and privacy. Responsiveness to these needs, rather than mere reliance on Health Insurance Portability and Accountability Act (HIPAA), may improve support of data networks.

CONCLUSION

Responsiveness to the public's concerns regarding their health information is a pre-requisite for patient-centeredness. This is one of the first in-depth studies of attitudes about electronic data sharing that compares attitudes of the same individual towards healthcare and research.

Designing a patient-centered user interface for access decisions about EHR data: implications from patient interviews

BACKGROUND

Electronic health records change the landscape of patient data sharing and privacy by increasing the amount of information collected and stored and the number of potential recipients. Patients desire granular control over who receives what information in their electronic health record (EHR), but there are no current patient interfaces that allow them to record their preferences for EHR access.

OBJECTIVE

Our aim was to derive the user needs of patients regarding the design of a user interface that records patients' individual choices about who can access data in their EHRs.

DESIGN

We used semi-structured interviews.

SETTING

The study was conducted in Central Indiana.

PARTICIPANTS

Thirty patients with data stored in an EHR, the majority of whom (70 %) had highly sensitive health EHR data, were included in the study.

APPROACH

We conducted a thematic and quantitative analysis of transcribed interview data.

KEY RESULTS

Patients rarely knew what data were in their EHRs, but would have liked to know. They also wanted to be able to control who could access what information in their EHR and wanted to be notified when their data we re accessed.

CONCLUSIONS

We derived six implications for the design of a patient-centered tool to allow individual choice in the disclosure of EHR: easy patient access to their EHRs; an overview of current EHR sharing permissions; granular, hierarchical control over EHR access; EHR access controls based on dates; contextual privacy controls; and notification when their EHRs are accessed.

Patient preferences in controlling access to their electronic health records: a prospective cohort study in primary care

INTRODUCTION

Previous studies have measured individuals' willingness to share personal information stored in electronic health records (EHRs) with health care providers, but none has measured preferences among patients when they are allowed to determine the parameters of provider access.

METHODS

Patients were given the ability to control access by doctors, nurses, and other staff in a primary care clinic to personal information stored in an EHR. Patients could restrict access to all personal data or to specific types of sensitive information, and could restrict access for a specific time period. Patients also completed a survey regarding their understanding of and opinions regarding the process.

RESULTS

Of 139 eligible patients who were approached, 105 (75.5 %) were enrolled, and preferences were collected from all 105 (100 %). Sixty patients (57 %) did not restrict access for any providers. Of the 45 patients (43 %) who chose to limit the access of at least one provider, 36 restricted access only to all personal information in the EHR, while nine restricted access of some providers to a subset of the their personal information. Thirty-four (32.3 %) patients blocked access to all personal information by all doctors, nurses, and/or other staff, 26 (24.8 %) blocked access by all doctors and/or nurses, and five (4.8 %) denied access to all doctors, nurses, and staff.

CONCLUSIONS

A significant minority of patients chose to restrict access by their primary care providers to personal information contained in an EHR, and few chose to restrict access to specific types of information. More research is needed to identify patient goals and understanding of the implications when facing decisions of this sort, and to identify the impact of patient education regarding information contained in EHRs and their use in the clinical care setting.

Engagement with Health Care Providers Affects Self- Efficacy, Self-Esteem, Medication Adherence and Quality of Life in People Living with HIV

The engagement of patients with their health care providers (HCP) improves patients' quality of life (QOL), adherence to antiretroviral therapy, and life satisfaction. Engagement with HCP includes access to HCP as needed, information sharing, involvement of client in decision making and self-care activities, respect and support of the HCP for the client's choices, and management of client concerns. This study compares country-level differences in patients' engagement with HCP and assesses statistical associations relative to adherence rates, self-efficacy, self-esteem, QOL, and symptom self-reporting by people living with HIV (PLHIV). A convenience sample of 2,182 PLHIV was enrolled in the United States, Canada, Puerto Rico, Namibia, and China. Cross-sectional data were collected between September 2009 and January 2011. Inclusion criteria were being at least 18 years of age, diagnosed with HIV, able to provide informed consent, and able to communicate in the local language with site researchers. In the HCP scale, a low score indicated greater provider engagement. Country comparisons showed that PLHIV in Namibia had the most HCP engagement (OR 2.80, p < 0.001) and that PLHIV in China had the least engagement (OR -7.03, p < 0.0001) compared to the PLHIV in the Western countries. Individuals having better HCP engagement showed better self-efficacy for adherence (t = -5.22, p < 0.0001), missed fewer medication doses (t = 1.92, p ≤ 0.05), had lower self-esteem ratings (t = 2.67, p < 0.01), fewer self-reported symptoms (t = 3.25, p < 0.0001), and better overall QOL physical condition (t = -3.39, p < 0.001). This study suggests that promoting engagement with the HCP is necessary to facilitate skills that help PLHIV manage their HIV. To improve ART adherence, HCPs should work on strategies to enhance self-efficacy and self-esteem, therefore, exhibiting fewer HIV-related symptoms and missing less medication doses to achieve better QOL.

Online access to doctors' notes: patient concerns about privacy

Background

Offering patients online access to medical records, including doctors’ visit notes, holds considerable potential to improve care. However, patients may worry about loss of privacy when accessing personal health information through Internet-based patient portals. The OpenNotes study provided patients at three US health care institutions with online access to their primary care doctors’ notes and then collected survey data about their experiences, including their concerns about privacy before and after participation in the intervention.

Objective

To identify patients’ attitudes toward privacy when given electronic access to their medical records, including visit notes.

Methods

The design used a nested cohort study of patients surveyed at baseline and after a 1-year period during which they were invited to read their visit notes through secure patient portals. Participants consisted of 3874 primary care patients from Beth Israel Deaconess Medical Center (Boston, MA), Geisinger Health System (Danville, PA), and Harborview Medical Center (Seattle, WA) who completed surveys before and after the OpenNotes intervention. The measures were patient-reported levels of concern regarding privacy associated with online access to visit notes.

Results

32.91% of patients (1275/3874 respondents) reported concerns about privacy at baseline versus 36.63% (1419/3874 respondents) post-intervention. Baseline concerns were associated with non-white race/ethnicity and lower confidence in communicating with doctors, but were not associated with choosing to read notes or desire for continued online access post-intervention (nearly all patients with notes available chose to read them and wanted continued access). While the level of concern among most participants did not change during the intervention, 15.54% (602/3874 respondents, excluding participants who responded “don’t know”) reported more concern post-intervention, and 12.73% (493/3874 respondents, excluding participants who responded “don’t know”) reported less concern.

Conclusions

When considering online access to visit notes, approximately one-third of patients had concerns about privacy at baseline and post-intervention. These perceptions did not deter participants from accessing their notes, suggesting that the benefits of online access to medical records may outweigh patients’ perceived risks to privacy.

The future of medical diagnostics: large digitized databases

The electronic health record mandate within the American Recovery and Reinvestment Act of 2009 will have a far-reaching affect on medicine. In this article, we provide an in-depth analysis of how this mandate is expected to stimulate the production of large-scale, digitized databases of patient information. There is evidence to suggest that millions of patients and the National Institutes of Health will fully support the mining of such databases to better understand the process of diagnosing patients. This data mining likely will reaffirm and quantify known risk factors for many diagnoses. This quantification may be leveraged to further develop computer-aided diagnostic tools that weigh risk factors and provide decision support for health care providers. We expect that creation of these databases will stimulate the development of computer-aided diagnostic support tools that will become an integral part of modern medicine.

Processes and outcomes of developing a continuity of care document for use as a personal health record by people living with HIV/AIDS in New York City

PURPOSE

To describe the processes and outcomes of developing and implementing a Continuity of Care Document (CCD), My Health Profile, as a personal health record for persons living with HIV (PLWH) in an HIV/AIDS Special Needs Plan in New York City.

METHODS

Multiple qualitative and quantitative data sources were used to describe the processes and outcomes of implementing My Health Profile including focus groups, Audio Computer Assisted Self Interview (ACASI) surveys, administrative databases, chart abstraction, usage logs, and project management records. Qualitative data were thematically analyzed. Quantitative data analytic methods included descriptive and multivariate statistics. Data were triangulated and synthesized using the Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) Framework.

RESULTS

Reach - SNP members are predominantly African American or Hispanic/Latino and about one-third are female. A larger proportion of African Americans and smaller proportions of Hispanics/Latinos and Whites were trained to use My Health Profile.Efficacy/Effectiveness - CCDs were produced for 8249 unique members and updated on a monthly basis, 509 members were trained to use My Health Profile. Total number of member logins for 112 active users was 1808 and the longest duration of use was 1008 days. There were no significant differences between users and non-users of My Health Profile in clinical outcomes, perceptions of the quality of medical care, or health service utilization. Adoption -My Health Profile was well-matched to organizational mission, values, and priorities related to coordination of care for a high-risk population of PLWH. Implementation - Pre-implementation focus group participants identified potential barriers to use of My Health Profile including functional and computer literacy, privacy and confidentiality concerns, potential reluctance to use technology, and cognitive challenges. Key strategies for addressing barriers included a dedicated bilingual coach for recruitment, training, and support; basic computer and My Health Profile training; transparent audit trail revealing clinician and case manager access of My Health Profile, time-limited passwords for sharing My Health Profile with others at the point of need, and emergency access mechanism. Maintenance -My Health Profile was integrated into routine operational activities and its sustainability is facilitated by its foundation on standards for Health Information Exchange (HIE).

CONCLUSIONS

Although potential barriers exist to the use of personal health records (PHRs) such as My Health Profile, PLWH with complex medical needs, low socioeconomic status, and limited computer experience will use such tools when a sufficient level of user support is provided and privacy and confidentiality concerns are addressed.

Trust, confidentiality, and the acceptability of sharing HIV-related patient data: lessons learned from a mixed methods study about Health Information Exchanges

BACKGROUND

Concerns about the confidentiality of personal health information have been identified as a potential obstacle to implementation of Health Information Exchanges (HIEs). Considering the stigma and confidentiality issues historically associated with human immunodeficiency virus (HIV) disease, we examine how trust-in technology, processes, and people-influenced the acceptability of data sharing among stakeholders prior to implementation of six HIEs intended to improve HIV care in parts of the United States. Our analyses identify the kinds of concerns expressed by stakeholders about electronic data sharing and focus on the factors that ultimately facilitated acceptability of the new exchanges.

METHODS

We conducted 549 surveys with patients and 66 semi-structured interviews with providers and other stakeholders prior to implementation of the HIEs to assess concerns about confidentiality in the electronic sharing of patient data. The patient quantitative data were analyzed using SAS 9.2 to yield sample descriptive statistics. The analysis of the qualitative interviews with providers and other stakeholders followed an open-coding process, and convergent and divergent perspectives emerging from those data were examined within and across the HIEs.

RESULTS

We found widespread acceptability for electronic sharing of HIV-related patient data through HIEs. This acceptability appeared to be driven by growing comfort with information technologies, confidence in the security protocols utilized to protect data, trust in the providers and institutions who use the technologies, belief in the benefits to the patients, and awareness that electronic exchange represents an enhancement of data sharing already taking place by other means. HIE acceptability depended both on preexisting trust among patients, providers, and institutions and on building consensus and trust in the HIEs as part of preparation for implementation. The process of HIE development also resulted in forging shared vision among institutions.

CONCLUSIONS

Patients and providers are willing to accept the electronic sharing of HIV patient data to improve care for a disease historically seen as highly stigmatized. Acceptability depends on the effort expended to understand and address potential concerns related to data sharing and confidentiality, and on the trust established among stakeholders in terms of the nature of the systems and how they will be used.

Creating a paper-based personal health record for HIV-infected persons

A personal health record (PHR) contains information that a client believes is important to his/her health status; it can be either paper or Internet-based. The purposes of this action research were to determine the length of time an expert HIV nurse clinician needed to create a comprehensive PHR and to determine how hard it was for the patient to understand different components of a PHR. The average respondent (N = 9) was older, female, completed high school, African American, diagnosed with AIDS, and taking HIV medications for 11 years. The HIV nurse expert spent an average of 79 minutes preparing the PHR. Clients had the greatest difficulty understanding laboratory tests, medications, medical history, and immunizations. PHRs are evolving through the consumer-empowerment movement, technology, and a growing awareness of the consequences of medical errors. Nurses need to assist clients to create and use the PHR as an important tool in self-care management.