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

Patient and Public Willingness to Share Personal Health Data for Third-Party or Secondary Uses: Systematic Review

BACKGROUND

International advances in information communication, eHealth, and other digital health technologies have led to significant expansions in the collection and analysis of personal health data. However, following a series of high-profile data sharing scandals and the emergence of COVID-19, critical exploration of public willingness to share personal health data remains limited, particularly for third-party or secondary uses.

OBJECTIVE

This systematic review aims to explore factors that affect public willingness to share personal health data for third-party or secondary uses.

METHODS

A systematic search of 6 databases (MEDLINE, Embase, PsycINFO, CINAHL, Scopus, and SocINDEX) was conducted with review findings analyzed using inductive-thematic analysis and synthesized using a narrative approach.

RESULTS

Of the 13,949 papers identified, 135 were included. Factors most commonly identified as a barrier to data sharing from a public perspective included data privacy, security, and management concerns. Other factors found to influence willingness to share personal health data included the type of data being collected (ie, perceived sensitivity); the type of user requesting their data to be shared, including their perceived motivation, profit prioritization, and ability to directly impact patient care; trust in the data user, as well as in associated processes, often established through individual choice and control over what data are shared with whom, when, and for how long, supported by appropriate models of dynamic consent; the presence of a feedback loop; and clearly articulated benefits or issue relevance including valued incentivization and compensation at both an individual and collective or societal level.

CONCLUSIONS

There is general, yet conditional public support for sharing personal health data for third-party or secondary use. Clarity, transparency, and individual control over who has access to what data, when, and for how long are widely regarded as essential prerequisites for public data sharing support. Individual levels of control and choice need to operate within the auspices of assured data privacy and security processes, underpinned by dynamic and responsive models of consent that prioritize individual or collective benefits over and above commercial gain. Failure to understand, design, and refine data sharing approaches in response to changeable patient preferences will only jeopardize the tangible benefits of data sharing practices being fully realized.

Communication and coordination of care for people living with HIV: a qualitative study of the patient perspective

BACKGROUND

There is growing consensus that primary health care (PHC) providers have an important role in providing holistic, preventative care for people living with human immunodeficiency virus (PLHIV). In regional Australia, HIV care is primarily delivered through specialist services, thus adequate coordination and communication between specialist and PHC professionals is crucial. This study aimed to explore patient experiences of the coordination of care and health care professional communication for PLHIV in regional Australia.

METHODS

Semi-structured interviews with PLHIV in a regional area of Australia were conducted in March to April 2022. Interviews were conducted via video conferencing, face-to-face, or via telephone call. Interviews were audio-recorded and manually transcribed. Transcripts were coded inductively and thematic analysis was conducted to explore perspectives on communication and coordination.

RESULTS

Thirteen participants were interviewed. Most participants were male, aged 50-70, were diagnosed with HIV more than ten years ago, and had been living in regional Australia long-term. Through qualitative analysis, themes emerged in the following areas: (1) Patient perception of care coordination; (2) Patient understanding of modality of communication; (3) Positive attitudes towards communication between healthcare professionals; and (4) Concerns for information sharing between healthcare professionals. Many participants highlighted lack of clarity around care coordination as a key issue in their healthcare, with some citing themselves as the primary care coordinator. Participants identified that coordination and communication between PHC professionals and specialist services are essential in the delivery of their health care, but some were hesitant for this to occur. Hesitancy was entrenched in some patients' distrust of healthcare due to previous experiences of confidentiality breaches and stigma.

CONCLUSION

This study identifies the need for clarity in coordination between health care professionals to deliver safe and effective HIV care, which may occur through care plans. Patient support for communication between healthcare providers may be strengthened by ensuring trust in the people and systems involved. Eliminating stigma in healthcare as well as building more trustworthy electronic-based communication technologies are essential components to trust-building between PLHIV and healthcare systems.

What is public trust in national electronic health record systems? A scoping review of qualitative research studies from 1995 to 2021

Objective

Public trust in national electronic health record systems is essential for the successful implementation within a healthcare system. Research investigating public trust in electronic health records is limited, leading to a lack of conceptual clarity. In response, the objective of this study is to gain a clearer understanding on the conceptualizations of public trust in electronic health records, which can support the implementation of national electronic health record systems.

Methods

Guided by the PRISMA-ScR checklist, a scoping review of 27 qualitative studies on public trust in electronic health records found between January 2022 and June 2022 was conducted using an inclusive search method. In an iterative process, conceptual themes were derived describing the promoters and outcomes of public trust in electronic health records.

Results

Five major conceptual themes with 15 sub-themes were present across the literature. Comprehension, autonomy, and data protection promote public trust in electronic health record; while personal and system benefits are the outcomes once public trust in electronic health records exists. Additional findings highlight the pivotal role of healthcare actors for the public trust building process.

Conclusions

The results underscore comprehension, autonomy, and data protection as important themes that help ascertain and solidify public trust in electronic health records. As well, health system actors have the capacity to promote or hinder national electronic health record implementation, depending on their actions and how the public perceives those actions. The findings can assist researchers, policymakers, and other health system actors in attaining a better understanding of the intricacies of public trust in electronic health records.

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.

Rapid start antiretroviral therapies for improved engagement in HIV care: implementation science evaluation protocol

BACKGROUND

In 2020, the Health Resources and Services Administration's HIV/AIDS Bureau funded an initiative to promote implementation of rapid antiretroviral therapy initiation in 14 HIV treatment settings across the U.S. The goal of this initiative is to accelerate uptake of this evidence-based strategy and provide an implementation blueprint for other HIV care settings to reduce the time from HIV diagnosis to entry into care, for re-engagement in care for those out of care, initiation of treatment, and viral suppression. As part of the effort, an evaluation and technical assistance provider (ETAP) was funded to study implementation of the model in the 14 implementation sites.

METHOD

The ETAP has used implementation science methods framed by the Dynamic Capabilities Model integrated with the Conceptual Model of Implementation Research to develop a Hybrid Type II, multi-site mixed-methods evaluation, described in this paper. The results of the evaluation will describe strategies associated with uptake, implementation outcomes, and HIV-related health outcomes for patients.

DISCUSSION

This approach will allow us to understand in detail the processes that sites to implement and integrate rapid initiation of antiretroviral therapy as standard of care as a means of achieving equity in HIV care.

Patients' and Members of the Public's Wishes Regarding Transparency in the Context of Secondary Use of Health Data: Scoping Review

BACKGROUND

Secondary use of health data has reached unequaled potential to improve health systems governance, knowledge, and clinical care. Transparency regarding this secondary use is frequently cited as necessary to address deficits in trust and conditional support and to increase patient awareness.

OBJECTIVE

We aimed to review the current published literature to identify different stakeholders' perspectives and recommendations on what information patients and members of the public want to learn about the secondary use of health data for research purposes and how and in which situations.

METHODS

Using PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines, we conducted a scoping review using Medline, CINAHL, PsycINFO, Scopus, Cochrane Library, and PubMed databases to locate a broad range of studies published in English or French until November 2022. We included articles reporting a stakeholder's perspective or recommendations of what information patients and members of the public want to learn about the secondary use of health data for research purposes and how or in which situations. Data were collected and analyzed with an iterative thematic approach using NVivo.

RESULTS

Overall, 178 articles were included in this scoping review. The type of information can be divided into generic and specific content. Generic content includes information on governance and regulatory frameworks, technical aspects, and scientific aims. Specific content includes updates on the use of one's data, return of results from individual tests, information on global results, information on data sharing, and how to access one's data. Recommendations on how to communicate the information focused on frequency, use of various supports, formats, and wording. Methods for communication generally favored broad approaches such as nationwide publicity campaigns, mainstream and social media for generic content, and mixed approaches for specific content including websites, patient portals, and face-to-face encounters. Content should be tailored to the individual as much as possible with regard to length, avoidance of technical terms, cultural competence, and level of detail. Finally, the review outlined 4 major situations where communication was deemed necessary: before a new use of data, when new test results became available, when global research results were released, and in the advent of a breach in confidentiality.

CONCLUSIONS

This review highlights how different types of information and approaches to communication efforts may serve as the basis for achieving greater transparency. Governing bodies could use the results: to elaborate or evaluate strategies to educate on the potential benefits; to provide some knowledge and control over data use as a form of reciprocity; and as a condition to engage citizens and build and maintain trust. Future work is needed to assess which strategies achieve the greatest outreach while striking a balance between meeting information needs and use of resources.

Building trusting relationships to support implementation: A proposed theoretical model

This paper presents a theory of change that articulates (a) proposed strategies for building trust among implementation stakeholders and (b) the theoretical linkages between trusting relationships and implementation outcomes. The theory of change describes how trusting relationships cultivate increases in motivation, capability, and opportunity for supporting implementation among implementation stakeholders, with implications for commitment and resilience for sustained implementation, and ultimately, positive implementation outcomes. Recommendations related to the measurement of key constructs in the theory of change are provided. The paper highlights how the development of a testable causal model on trusting relationships and implementation outcomes can provide a bridge between implementation research and implementation practice.

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.

Understanding and addressing privacy and confidentiality concerns associated with the provision of mobile HIV care: a qualitative study

Less than half the people with HIV (PLWH) in the United States (US) are retained in HIV care, underscoring the importance of novel reengagement and retention strategies. Mobile HIV clinics (MHCs) are one such strategy, but privacy and confidentiality concerns have limited their use. As part of a larger mixed-methods study in Atlanta, Georgia, from June 2019- July 2020, we conducted 41 qualitative interviews with key stakeholders to explore confidentiality, privacy and stigma concerns and strategies to address them. Interviews were recorded, transcribed and coded thematically. Four key themes emerged: 1) the need to understand MHC acceptance in the context of high HIV stigma in the South, 2) the multidimensionality of confidentiality and stigma concerns (e.g., related to exterior labeling, layout, location attracting unwanted attention), 3) the counter perspective: potential for MHCs to positively reframe HIV and reduce stigma, and 4) strategies to overcome stigma and confidentiality concerns, including co-delivery of non-HIV services, unidirectional flow, and non-HIV exterior labeling. In furthering understanding of the breadth of privacy and confidentiality concerns associated with an MHC and strategies for addressing them, this exploratory study lays a critical foundation for the development of an MHC to reengage and retain PLWH in the US.

Acceptability and Feasibility of Perioperative Music Listening: A Rapid Qualitative Inquiry Approach

Perioperative music decreases pain, anxiety, and analgesia requirements while increasing patient satisfaction. We investigated the acceptability of perioperative music at a women's and children's hospital in Singapore, seeking to uncover barriers and facilitators to implementation in routine practice over a 12-week period. We used an undergraduate-led Rapid Qualitative Inquiry approach that includes data collection from multiple sources, iterative analysis, and additional data collection when necessary. Participants consisted of anesthesiologists and nurses working in the preoperative area, operating room, and postoperative recovery areas. In Stage 1, nurses and anesthesiologists answered a survey assessing attitudes and knowledge about perioperative music and attended a presentation introducing the intervention. In Stage 2, the results of the Stage 1 survey were disclosed, and nurses and anesthesiologists completed a second survey (Stage 1 survey questions with an additional query about implementation). Twenty-nine nurses were interviewed with semi-structured questions on barriers and facilitators to implementation. In Stage 3, nurses retook the Stage 2 survey after one month of implementation. The implementation of perioperative music was both acceptable and feasible in Singapore. The nurses' and anesthesiologists' acceptability increased over time with mostly positive qualitative feedback. Implementation barriers, including patient interest, timing of patient turnover, and added staff workload, appeared minor and could potentially be overcome by utilizing the intervention in the preoperative instead of postoperative area, deploying music in operating rooms with slower turnover, and evenly distributing staff workload. Local implementation stakeholders may make additional recommendations for scaling-up perioperative music interventions to fit other workflows while improving the patient experience.

Acceptability of a Patient Portal (Opal) in HIV Clinical Care: A Feasibility Study

Opal (opalmedapps.com), a patient portal in use at the Cedars Cancer Centre of the McGill University Health Centre (MUHC) (Montreal, Canada), gives cancer patients access to their medical records, collects information on patient-reported outcome measures (PROMs), and has demonstrated patient satisfaction with care. This feasibility study aims to evaluate Opal's potential acceptability in the context of HIV care. People living with HIV (PLWH) and their healthcare providers (HCPs) completed cross-sectional surveys from August 2019 to February 2020 at large HIV centers, including the Chronic Viral Illness Service of the MUHC, and other HIV clinical sites in Montreal and Paris, France. This study comprised 114 PLWH (mean age 48 years old, SD = 12.4), including 74% men, 24% women, and 2% transgender or other; and 31 HCPs (mean age 46.5 years old, SD = 11.4), including 32% men, 65% women, and 3% other. Ownership of smartphones and tablets was high (93% PLWH, 96% HCPs), and participants were willing to use Opal (74% PLWH, 68% HCPs). Participants were interested in most Opal functions and PROMs, particularly PROMs capturing quality of life (89% PLWH, 77% HCPs), experience of healthcare (86% PLWH, 97% HCPs), and HIV self-management (92% PLWH, 97% HCPs). This study suggests Opal has high acceptability and potential usefulness as perceived by PLWH and HCPs.

An Examination of People’s Privacy Concerns, Perceptions of Social Benefits, and Acceptance of COVID-19 Mitigation Measures That Harness Location Information: A Comparative Study of the U.S. and South Korea

This paper examines people’s privacy concerns, perceptions of social benefits, and acceptance of various COVID-19 control measures that harness location information using data collected through an online survey in the U.S. and South Korea. The results indicate that people have higher privacy concerns for methods that use more sensitive and private information. The results also reveal that people’s perceptions of social benefits are low when their privacy concerns are high, indicating a trade-off relationship between privacy concerns and perceived social benefits. Moreover, the acceptance by South Koreans for most mitigation methods is significantly higher than that by people in the U.S. Lastly, the regression results indicate that South Koreans (compared to people in the U.S.) and people with a stronger collectivist orientation tend to have higher acceptance for the control measures because they have lower privacy concerns and perceive greater social benefits for the measures. These findings advance our understanding of the important role of geographic context and culture as well as people’s experiences of the mitigation measures applied to control a previous pandemic.

Unintended consequences: a qualitative study exploring the impact of collecting implementation process data with phone interviews on implementation activities

Background

Qualitative data are crucial for capturing implementation processes, and thus necessary for understanding implementation trial outcomes. Typical methods for capturing such data include observations, focus groups, and interviews. Yet little consideration has been given to how such methods create interactions between researchers and study participants, which may affect participants’ engagement, and thus implementation activities and study outcomes. In the context of a clinical trial, we assessed whether and how ongoing telephone check-ins to collect data about implementation activities impacted the quality of collected data, and participants’ engagement in study activities.

Methods

Researchers conducted regular phone check-ins with clinic staff serving as implementers in an implementation study. Approximately 1 year into this trial, 19 of these study implementers were queried about the impact of these calls on study engagement and implementation activities. The two researchers who collected implementation process data through phone check-ins with the study implementers were also interviewed about their perceptions of the impact of the check-ins.

Results

Study implementers’ assessment of the check-ins’ impact fell into three categories: (1) the check-ins had no effect on implementation activities, (2) the check-ins served as a reminder about study participation (without relating a clear impact on implementation activities), and (3) the check-ins caused changes in implementation activities. The researchers similarly perceived that the phone check-ins served as reminders and encouraged some implementers’ engagement in implementation activities; their ongoing nature also created personal connections with study implementers that may have impacted implementation activities. Among some study implementers, anticipation of the check-in calls also improved their ability to recount implementation activities and positively affected quality of the data collected.

Conclusion

These results illustrate the potential impact of qualitative data collection on implementation activities during implementation science trials. Mitigating such effects may prove challenging, but acknowledging these consequences—or even embracing them, perhaps by designing data collection methods as implementation strategies—could enhance scientific rigor. This work is presented to stimulate debate about the complexities involved in capturing data on implementation processes using common qualitative data collection methods.

Trial registration

ClinicalTrials.gov, NCT02325531. Registered 15 December 2014.

Ethical Considerations in HIV eHealth Intervention Research: Implications for Informational Risk in Recruitment, Data Maintenance, and Consent Procedures

PURPOSE OF REVIEW

Along with the benefits of eHealth HIV interventions are challenges to participant privacy and confidentiality inherent in the use of online strategies. This paper reviews current guidelines and recent publications to identify ethical issues and suggested solutions in recruitment, data management, and informed consent.

RECENT FINDINGS

Across eHealth HIV research, recruitment, data collection, and storage efforts to protect informational risk highlight the tension between the investigators' ability to protect participant confidentiality and the evolving informational risk posed by the online platforms on which they are operating. Adequately addressing these challenges requires updating technical competencies and educating participants on their own responsibilities to guard against privacy violations. Additional protections are required when interventions involve peer or community support, especially with minors. The rapid progression of technology presents challenges in solidifying best practices for future interventions. This article draws on published works describing investigator experiences to contribute to the ongoing development of guidance in this area.

Social Determinants of Potential eHealth Engagement Among People Living with HIV Receiving Ryan White Case Management: Health Equity Implications from Project TECH

OBJECTIVES

Evaluate the relationships between social characteristics of Floridian persons living with HIV (PLWH) and both use of digital technologies and willingness to use eHealth for HIV-related information.

METHODS

Ryan White case managers (N = 155) from 55 agencies in 47 Florida counties administered a survey to PLWH (N = 1268) from June 2016-April 2017. Multilevel logistic regression models were used to identify correlates of technology use and willingness.

RESULTS

Use of mobile phones with text messaging was high (89%). Older (vs. younger) adults and non-Hispanic blacks (vs. whites) were less likely to use most technologies. These groups, along with Hispanics (vs. whites) were less likely to express willingness to use technologies for HIV-related information in models adjusting for use.

CONCLUSIONS

Among PLWH in Florida, eHealth-related inequities exist. Willingness to engage in HIV-related eHealth is affected by social determinants, even when considering technology access. Although eHealth may reduce some healthcare inequities, it may exacerbate others.

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.

Acceptability of electronic healthcare predictive analytics for HIV prevention: a qualitative study with men who have sex with men in New York City

BACKGROUND

Large data sets, also known as "big data", shared in health information exchanges (HIEs), can be used in novel ways to advance health, including among communities at risk for HIV infection. We examined values and opinions about the acceptability of using electronic healthcare predictive analytics (eHPA) to promote HIV prevention in men who have sex with men (MSM). Our aims were twofold: (I) to evaluate the perspectives of MSM with diverse race/ethnicity and age on the acceptability of predictive analytics to determine individual HIV risk and (II) to determine acceptability of having targeted prevention messaging based upon those risk estimates sent directly to the consumer.Method: Two of the authors facilitated 12 focus groups (n=57) with adult MSM without HIV, living in NYC. Groups were divided by ethnicity (Black, Latino, and White) and age (under 35 and 35 and over). Participants were recruited through HIV prevention sites, community-based organizations, social media, and Internet sites that serve these communities. Grounded theory methods were used to analyze the data with Dedoose.

RESULTS

We identified six main themes related to acceptability: (I) reach, relevance, and potential uptake of using predictive analytics to establish HIV risk and deliver targeted prevention messaging; (II) patient-provider communication; (III) public health and individual rights; (IV) perceptions of intervention effectiveness; (V) electronic health data security; and (VI) stigma. Within each thematic domain, MSM discussed concerns, benefits, and provided recommendations for implementation.

CONCLUSIONS

MSM in this study were supportive of the use of "big data" and technology to reach marginalized populations and improve public health, yet expressed concerns about the relevance, effectiveness, and security eHPA. Efforts to advance eHPA for HIV prevention should address these concerns, especially among the most-at-risk communities of color. Development of eHPA for HIV prevention should involve targeted messaging that addresses specific concerns regarding eHPA security, accuracy, and relevance.

Reorienting health systems to care for people with HIV beyond viral suppression

The effectiveness of antiretroviral therapy and its increasing availability globally means that millions of people living with HIV now have a much longer life expectancy. However, people living with HIV have disproportionately high incidence of major comorbidities and reduced health-related quality of life. Health systems must respond to this situation by pioneering care and service delivery models that promote wellness rather than mere survival. In this Series paper, we review evidence about the emerging challenges of the care of people with HIV beyond viral suppression and identify four priority areas for action: integrating HIV services and non-HIV services, reducing HIV-related discrimination in health-care settings, identifying indicators to monitor health systems' progress toward new goals, and catalysing new forms of civil society engagement in the more broadly focused HIV response that is now needed worldwide. Furthermore, in the context of an increasing burden of chronic diseases, we must consider the shift that is underway in the HIV field in relation to burgeoning policy and programmatic efforts to promote healthy ageing.

How should electronic health records be designed? A cross-sectional study in patients with psoriasis

BACKGROUND

Electronic health records (EHRs) are promising tools for routine care. These applications might not only enhance the interaction between patient and physician but also support therapy management. This is crucial in complex and chronic conditions like psoriasis. However, EHRs can only unfold their full potential when being accepted by the users. Therefore, this study aims to analyse how EHRs should be designed for patients with psoriasis and to identify differences between patient subgroups.

METHODS

We developed a questionnaire on the acceptability of EHRs based on literature research and results from focus groups. Participants completed a paper-based or electronic version of the questionnaire. We recruited participants at an outpatient clinic as well as online via patient associations and a social media platform. We analysed data using descriptive statistics and bivariate analyses applying Chi-square and Fisher's exact test.

RESULTS

The sample encompassed 187 patients with psoriasis. Data reveals that 84.4% of the participants can think of entering data into an EHR. Participants prefer entering data at home (72.2%) instead of entering data in the waiting room (44.9%) and using an own internet-ready device (laptop/computer: 62.6%; smartphone/tablet: 61.5%) instead of a provided device (46.0%). Altogether, 55.6% of participants would accept entering data on a monthly basis when this lasts between one and 10 minutes and further 27.8% would accept even longer lasting data entry. Data privacy is of great concern (e.g. patient should decide who has access to data: 96.7%). Subgroup analyses reveal differences with regard to age, educational level, burden due to psoriasis, number of internet activities, use of electronic questionnaires and mode of administration.

CONCLUSION

The high acceptance of entering data is favourable for the implementation of EHRs. The results suggest technical and structural recommendations: Differences between subgroups support the development of flexible EHRs encompassing a basic module, which is expandable with further add-ons, and compatible to different devices. Furthermore, involving patients by entering data into an EHR requires that physicians communicate open-mindedly with the patient and consider data throughout decision-making. Patients should remain owner of their own health data and decide about its processing.

"Closing the Loop" Developing State-Level Data Sharing Interventions to Promote Optimum Outcomes Along the HIV Continuum of Care

This manuscript describes the experiences of three state departments of health (SDoH) that successfully launched data sharing interventions involving surveillance and/or patient data collected in clinics to improve care outcomes among people living with HIV. We examined 58 key informant interviews, gathered at two time points, to describe the development and implementation of data sharing interventions. We identified three common themes across states' experiences: creating standard practices, fostering interoperability, and negotiating the policy environment. Projects were successful when state teams adapted to changing circumstances and were committed to a consistent communication process. Once implemented, the interventions streamlined processes to promote linkage and retention in care among low-income populations living with HIV. Despite using routinely collected data, key informants emphasized the labor-intensive process to develop and sustain the interventions. Lessons learned from these three state experiences can help inform best practices for other SDoH that are considering launching similar interventions.

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.

The intention to use an electronic health record and its antecedents among three different categories of clinical staff

Background

Like other sectors, the healthcare sector has to deal with the issue of users’ acceptance of IT. In healthcare, different factors affecting healthcare professionals’ acceptance of software applications have been investigated. Unfortunately, inconsistent results have been found, maybe because the different studies focused on different IT and occupational groups. Consequently, more studies are needed to investigate these implications for recent technology, such as Electronic Health Records (EHR).

Methods

Given these findings in the existing literature, we pose the following research question: “To what extent do the different categories of clinical staff (physicians, paraprofessionals and administrative personnel) influence the intention to use an EHR and its antecedents?” To answer this research question we develop a research model that we empirically tested via a survey, including the following variables: intention to use, ease of use, usefulness, anxiety, self-efficacy, trust, misfit and data security. Our purpose is to clarify the possible differences existing between different staff categories.

Results

For the entire personnel, all the hypotheses are confirmed: anxiety, self-efficacy, trust influence ease of use; ease of use, misfit, self-efficacy, data security impact usefulness; usefulness and ease of use contribute to intention to use the EHR. They are also all confirmed for physicians, residents, carers and nurses but not for secretaries and assistants. Secretaries’ and assistants’ perception of the ease of use of EHR does not influence their intention to use it and they could not be influenced by self-efficacy in the development of their perception of the ease of use of EHR.

Conclusions

These results may be explained by the fact that secretaries, unlike physicians and nurses, have to follow rules and procedures for their work, including working with EHR. They have less professional autonomy than healthcare professionals and no medical responsibility. This result is also in line with previous literature highlighting that administrators are more motivated by the use of IT in healthcare.

Patient data and patient rights: Swiss healthcare stakeholders' ethical awareness regarding large patient data sets - a qualitative study

Background

There is a growing interest in aggregating more biomedical and patient data into large health data sets for research and public benefits. However, collecting and processing patient data raises new ethical issues regarding patient’s rights, social justice and trust in public institutions. The aim of this empirical study is to gain an in-depth understanding of the awareness of possible ethical risks and corresponding obligations among those who are involved in projects using patient data, i.e. healthcare professionals, regulators and policy makers.

Methods

We used a qualitative design to examine Swiss healthcare stakeholders’ experiences and perceptions of ethical challenges with regard to patient data in real-life settings where clinical registries are sponsored, created and/or used. A semi-structured interview was carried out with 22 participants (11 physicians, 7 policy-makers, 4 ethical committee members) between July 2014 and January 2015. The interviews were audio-recorded, transcribed, coded and analysed using a thematic method derived from Grounded Theory.

Results

All interviewees were concerned as a matter of priority with the needs of legal and operating norms for the collection and use of data, whereas less interest was shown in issues regarding patient agency, the need for reciprocity, and shared governance in the management and use of clinical registries’ patient data. This observed asymmetry highlights a possible tension between public and research interests on the one hand, and the recognition of patients’ rights and citizens’ involvement on the other.

Conclusions

The advocation of further health-related data sharing on the grounds of research and public interest, without due regard for the perspective of patients and donors, could run the risk of fostering distrust towards healthcare data collections. Ultimately, this could diminish the expected social benefits. However, rather than setting patient rights against public interest, new ethical approaches could strengthen both concurrently. On a normative level, this study thus provides material from which to develop further ethical reflection towards a more cooperative approach involving patients and citizens in the governance of their health-related big data.

Electronic supplementary material

The online version of this article (10.1186/s12910-018-0261-x) contains supplementary material, which is available to authorized users.

Conceptual models to guide integration during analysis in convergent mixed methods studies

Methodologists have offered general strategies for integration in mixed-methods studies through merging of quantitative and qualitative data. While these strategies provide researchers in the field general guidance on how to integrate data during mixed-methods analysis, a methodological typology detailing specific analytic frameworks has been lacking. The purpose of this article is to introduce a typology of analytical approaches for mixed-methods data integration in mixed-methods convergent studies. We distinguish three dimensions of data merging analytics: (1) the relational dimension, (2) the methodological dimension, and (3) the directional dimension. Five different frameworks for data merging relative to the methodological and directional dimension in convergent mixed-methods studies are described: (1) the explanatory unidirectional approach, (2) the exploratory unidirectional approach, (3) the simultaneous bidirectional approach, (4) the explanatory bidirectional approach, and (5) the exploratory bidirectional approach. Examples from empirical studies are used to illustrate each type. Researchers can use this typology to inform and articulate their analytical approach during the design, implementation, and reporting phases to convey clearly how an integrated approach to data merging occurred.

Practices in security and confidentiality of HIV/AIDS patients' information: A national survey among staff at HIV outpatient clinics in Vietnam

INTRODUCTION

Breach of confidentiality or invasion of privacy from the collection and use of medical records, particularly those of patients with HIV/AIDS or other diseases sensitive to stigmatization, should be prevented by all related stakeholders in healthcare settings. The main focus of this study was to assess practices regarding security and confidentiality of HIV-related information among staff at HIV outpatient clinics (HIV-OPCs) in Vietnam.

METHODS

A descriptive cross-sectional study was conducted at all 312 HIV-OPCs across the country using an online survey technique.

RESULTS

In general, the staff practices for securing and protecting patient information were at acceptable levels. Most staff had proper measures and practices for maintaining data security; however, the protection of patient confidentiality, particularly for data access, sharing, and transfer still required improvement. Most HIV-OPC staff had good or moderate knowledge and positive perceptions towards security and confidentiality issues. Staff who were not trained in the practice of security measures differed significantly from those who were trained (OR: 3.74; 95%CI: 1.44-9.67); staff needing improved knowledge levels differed significantly from those with good (OR: 5.20; 95%CI: 2.39-11.32) and moderate knowledge levels (OR: 5.10; 95%CI: 2.36-11.00); and staff needing improved perception levels differed significantly from those with good (i.e., with 100% proper practices) and moderate perception levels (OR: 5.67; 95%CI: 2.93-10.95). Staff who were not trained in the protection of data confidentiality differed significantly from those who were trained (OR: 2.18; 95%CI: 1.29-3.65).

CONCLUSIONS

Training is an important factor to help raise the levels of proper practices regarding confidentiality and security, to improve knowledge and raise awareness about change among staff. The operation and management of HIV treatment and care in Vietnam are currently transitioning from separate healthcare clinics (HIV-OPC) into units integrated into general hospitals/healthcare facilities. The findings of this study highlight topics that could be used for improving management and operation of information system and revising guidelines and regulations on protection measures/strategies for data security and confidentiality of HIV/AIDS patients by Vietnam health authorities or other countries facing similar situations. Secure infrastructure and secure measures for data access and use are very important, worthwhile investments. The provision of continuous training and active enforcement and monitoring of the practices of healthcare personnel might lead to an improved understanding and acknowledegement of the importance of national policies/guidelines regarding HIV-related patient information.

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.

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.

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.

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.

High uptake of shared electronic health records among HIV-infected patients at an Australian sexual health clinic

The uptake of an opt-in system for integrating the health information of HIV-infected patients of an Australian sexual health clinic into the regional shared electronic health record (EHR) is described. A medical record audit was performed to determine the number and demographic characteristics of HIV-infected patients in the study's sexual health clinic opting in and out of inclusion in the regional shared EHR. The majority of these HIV-infected patients (70%, 95% CI: 58-79%) took up the option of including their HIV-related records into the regional shared electronic health record.

A cross-sectional survey exploring attitudes towards provincial electronic health record implementation among clients attending the Provincial Sexually Transmitted Infections Clinic in British Columbia

INTRODUCTION

To support control of sexually transmitted infections (STI), British Columbia is exploring data sharing through a provincial electronic health record (EHR). Increased electronic data sharing among healthcare providers may be a barrier for clients of STI clinics where expectations of privacy and confidentiality are heightened.

METHODS

A survey to assess attitudes towards sharing of personal health information through a provincial EHR was conducted with a convenience sample of clients attending an STI clinic in Vancouver. Descriptive statistics and logistic regression were used to examine the association between the primary outcome variable, whether a client would be less likely to take the test for an STI or HIV if their clinic records were made part of a provincial EHR, and independent variables of interest.

RESULTS

A total of 1004 clients completed the survey, and 31% stated that they would be less likely to get tested for STI/HIV if their records were made part of a provincial EHR. Participants who were more likely to agree that they might avoid testing had the expectation that no other clinician would review their chart (adjusted OR (AOR)=3.55), or expected their records would not be shared beyond the clinic (AOR=2.81).

DISCUSSION

While most participants thought an EHR was acceptable, a large minority expressed that they might avoid testing if their records were made part of a provincial EHR. The introduction of a provincial EHR should be considered with caution in STI healthcare settings to ensure that screening, case detection and treatment are not negatively impacted.

Challenges and Opportunities with Empowering Baby Boomers for Personal Health Information Management Using Consumer Health Information Technologies: an Ecological Perspective

"Baby Boomers" (adults born between the years of 1946 and 1964) make up the largest segment of the population in many countries, including the United States (about 78 million Americans) [1]. As Baby Boomers reach retirement age and beyond, many will have increasing medical needs and thus demand more health care resources that will challenge the healthcare system. Baby Boomers will likely accelerate the movement toward patient self-management and prevention efforts. Consumer Health Information Technologies (CHIT) hold promise for empowering health consumers to take an active role in health maintenance and disease management, and thus, have the potential to address Baby Boomers' health needs. Such innovations require changes in health care practice and processes that take into account Baby Boomers' personal health needs, preferences, health culture, and abilities to use these technologies. Without foundational knowledge of barriers and opportunities, Baby Boomers may not realize the potential of these innovations for improving self-management of health and health outcomes. However, research to date has not adequately explored the degree to which Baby Boomers are ready to embrace consumer health information technology and how their unique subcultures affect adoption and diffusion. This position paper describes an ecological conceptual framework for understanding and studying CHIT aimed at satisfying the personal health needs of Baby Boomers. We explore existing literature to provide a detailed depiction of our proposed conceptual framework, which focuses characteristics influencing Baby Boomers and their Personal Health Information Management (PHIM) and potential information problems. Using our ecological framework as a backdrop, we provide insight and implications for future research based on literature and underlying theories represented in our model.

Shifting the paradigm: using HIV surveillance data as a foundation for improving HIV care and preventing HIV infection

CONTEXT

Reducing HIV incidence in the United States and improving health outcomes for people living with HIV hinge on improving access to highly effective treatment and overcoming barriers to continuous treatment. Using laboratory tests routinely reported for HIV surveillance to monitor individuals' receipt of HIV care and contacting them to facilitate optimal care could help achieve these objectives. Historically, surveillance-based public health intervention with individuals for HIV control has been controversial because of concerns that risks to privacy and autonomy could outweigh benefits. But with the availability of lifesaving, transmission-interrupting treatment for HIV infection, some health departments have begun surveillance-based outreach to facilitate HIV medical care.

METHODS

Guided by ethics frameworks, we explored the ethical arguments for changing the uses of HIV surveillance data. To identify ethical, procedural, and strategic considerations, we reviewed the activities of health departments that are using HIV surveillance data to contact persons identified as needing assistance with initiating or returning to care.

FINDINGS

Although privacy concerns surrounding the uses of HIV surveillance data still exist, there are ethical concerns associated with not using HIV surveillance to maximize the benefits from HIV medical care and treatment. Early efforts to use surveillance data to facilitate optimal HIV medical care illustrate how the ethical burdens may vary depending on the local context and the specifics of implementation. Health departments laid the foundation for these activities by engaging stakeholders to gain their trust in sharing sensitive information; establishing or strengthening legal, policy and governance infrastructure; and developing communication and follow-up protocols that protect privacy.

CONCLUSIONS

We describe a shift toward using HIV surveillance to facilitate optimal HIV care. Health departments should review the considerations outlined before implementing new uses of HIV surveillance data, and they should commit to an ongoing review of activities with the objective of balancing beneficence, respect for persons, and justice.