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

Toward Personalized Care and Patient Empowerment and Perspectives on a Personal Health Record in Hemophilia Care: Qualitative Interview Study

BACKGROUND

To enable personalized treatment and shared decision-making in chronic care, relevant health information is collected. However, health information is often fragmented across hospital information systems, digital health apps, and questionnaire portals. This also pertains to hemophilia care, in which scattered information hampers integrated care. We intend to co-design a nationwide digital personal health record (PHR) for patients to help manage their health information. For this, user perspectives are crucial.

OBJECTIVE

This study aims to assess patients' and health care providers' perspectives regarding the use of a PHR in hemophilia care in the Netherlands, required functionalities, and expectations and concerns.

METHODS

In this semistructured interview study, 19 pediatric and adult persons with hemophilia, parents, and women with other inherited bleeding disorders, as well as 18 health care providers working within and outside of hemophilia treatment centers, participated. Perspectives of patients and providers were explored separately. To explore requirements, participants were asked to prioritize functionalities.

RESULTS

Participants expected a PHR would increase the transparency of health information, improve patients' understanding of their illness, and help the coordination of care between health care providers and institutions. Prioritized functionalities included the integration of relevant health information and patient-entered data. Formulated expectations and concerns focused on 4 themes: usability, safety, inclusiveness, and implementation. While patients expressed worries over medicalization (ie, more confrontational reminders of their illness), providers were concerned about an increased workload.

CONCLUSIONS

People with hemophilia, their parents, and health care providers welcomed the development of a PHR, as they expected it would result in better coordinated care. Formulated expectations and concerns will contribute to the successful development of a PHR for persons with hemophilia, and ultimately, for all persons with a chronic condition.

Integrated personal health record (PHR) security: requirements and mechanisms

BACKGROUND

Personal Health Records (PHRs) are designed to fulfill the goals of electronic health (eHealth) and empower the individual in the process of self-care. Integrated PHR can improve the quality of care, strengthen the patient-healthcare provider relationship, and reduce healthcare costs. Still, the process of PHR acceptance and use has been slow and mainly hindered by people's concerns about the security of their personal health information. Thus, the present study aimed to identify the Integrated PHR security requirements and mechanisms.

METHODS

In this applied study, PHR security requirements were identified with a literature review of (library sources, research articles, scientific documents, and reliable websites). The identified requirements were classified, and a questionnaire was developed accordingly. Thirty experts completed the questionnaire in a two-round Delphi technique, and the data were analyzed by descriptive statistics.

RESULTS

The PHR security requirements were identified and classified into seven dimensions confidentiality, availability, integrity, authentication, authorization, non-repudiation, and right of access, each dimension having certain mechanisms. On average, the experts reached an agreement about the mechanisms of confidentiality (94.67%), availability (96.67%), integrity (93.33%), authentication (100%), authorization (97.78%), non-repudiation (100%), and right of access (90%).

CONCLUSION

Integrated PHR security is a requirement for its acceptance and use. To design a useful and reliable integrated PHR, system designers, health policymakers, and healthcare organizations must identify and apply security requirements to guarantee the privacy and confidentiality of data.

Patient-Centered Digital Health Records and Their Effects on Health Outcomes: Systematic Review

BACKGROUND

eHealth tools such as patient portals and personal health records, also known as patient-centered digital health records, can engage and empower individuals with chronic health conditions. Patients who are highly engaged in their care have improved disease knowledge, self-management skills, and clinical outcomes.

OBJECTIVE

We aimed to systematically review the effects of patient-centered digital health records on clinical and patient-reported outcomes, health care utilization, and satisfaction among patients with chronic conditions and to assess the feasibility and acceptability of their use.

METHODS

We searched MEDLINE, Cochrane, CINAHL, Embase, and PsycINFO databases between January 2000 and December 2021. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Eligible studies were those evaluating digital health records intended for nonhospitalized adult or pediatric patients with a chronic condition. Patients with a high disease burden were a subgroup of interest. Primary outcomes included clinical and patient-reported health outcomes and health care utilization. Secondary outcomes included satisfaction, feasibility, and acceptability. Joanna Briggs Institute critical appraisal tools were used for quality assessment. Two reviewers screened titles, abstracts, and full texts. Associations between health record use and outcomes were categorized as beneficial, neutral or clinically nonrelevant, or undesired.

RESULTS

Of the 7716 unique publications examined, 81 (1%) met the eligibility criteria, with a total of 1,639,556 participants across all studies. The most commonly studied diseases included diabetes mellitus (37/81, 46%), cardiopulmonary conditions (21/81, 26%), and hematology-oncology conditions (14/81, 17%). One-third (24/81, 30%) of the studies were randomized controlled trials. Of the 81 studies that met the eligibility criteria, 16 (20%) were of high methodological quality. Reported outcomes varied across studies. The benefits of patient-centered digital health records were most frequently reported in the category health care utilization on the "use of recommended care services" (10/13, 77%), on the patient-reported outcomes "disease knowledge" (7/10, 70%), "patient engagement" (13/28, 56%), "treatment adherence" (10/18, 56%), and "self-management and self-efficacy" (10/19, 53%), and on the clinical outcome "laboratory parameters," including HbA1c and low-density lipoprotein (LDL; 16/33, 48%). Beneficial effects on "health-related quality of life" were seen in only 27% (4/15) of studies. Patient satisfaction (28/30, 93%), feasibility (15/19, 97%), and acceptability (23/26, 88%) were positively evaluated. More beneficial effects were reported for digital health records that predominantly focus on active features. Beneficial effects were less frequently observed among patients with a high disease burden and among high-quality studies. No unfavorable effects were observed.

CONCLUSIONS

The use of patient-centered digital health records in nonhospitalized individuals with chronic health conditions is potentially associated with considerable beneficial effects on health care utilization, treatment adherence, and self-management or self-efficacy. However, for firm conclusions, more studies of high methodological quality are required.

TRIAL REGISTRATION

PROSPERO (International Prospective Register of Systematic Reviews) CRD42020213285; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=213285.

Empowering Patients Through Virtual Care Delivery: Qualitative Study With Micropractice Clinic Patients and Health Care Providers

BACKGROUND

Prior to the wider adoption of digital health technologies during the COVID-19 pandemic, applications of virtual care were largely limited to specialist visits and remote care using telehealth (phone or video) applications. Data sharing approaches using tethered patient portals were mostly built around hospitals and larger care systems. These portals offer opportunities for improved communication, but despite a belief that care has improved, they have so far shown few outcome improvements beyond medication adherence. Less is known about use of virtual care and related tools in the outpatient context and particularly in rural community contexts.

OBJECTIVE

This study aims to reflect on the opportunities and barriers for sustainable virtual care through an example of a digitally enabled rural micropractice, which has provided 10%-15% virtual care since 2016 and 70% virtual care since March 2020.

METHODS

Three focus groups, 1 with providers (physician and medical office manager) and 2 with a total of 8 patients from a rural micropractice in British Columbia, were conducted in November 2020 and December 2020. Virtual care delivery was explored through the topics of communication approach, mixing virtual and in-person care, the practice team's journey in developing these approaches, and provider and patient satisfaction with the care model. Interviews were transcribed, checked for accuracy against recordings, and thematically analyzed.

RESULTS

Both patients and providers reported ease of communication and high satisfaction. Either could initiate communication, and patients found the ability to share health information asynchronously through the portal allowed time to reflect and prepare their thoughts. Patients were highly engaged and reported feeling empowered and true partners in their health care, although they noted limited care coordination with specialists. The mix of virtual and in-person visits was highly regarded by patients and providers, and patients reported feeling safe and cared for 24/7, although both expressed concern about work spilling into the provider's home life. The physician worried about missed diagnoses with virtual care. With respect to establishing the micropractice, solutions took about 5 years to optimize, with providers noting a learning curve requiring technical support for both themselves and their patients and a willingness to respond to patient feedback to identify the best solutions. Despite a mature virtual practice, patients reported deferred care due to COVID-19.

CONCLUSIONS

The micropractice's hybrid care model encouraged patients to be true partners in their care and resulted in high patient engagement and satisfaction; yet, success may rely on the patient population being willing to engage and being comfortable with technology. Barriers lie in gaps in care coordination and provider fear that signs or symptoms more evident with an in-person exam could be missed. Even in this setting, deferral of care in light of COVID-19 was present, and opportunities to address care gaps should be sought.

From Digital Health to Digital Well-being: Systematic Scoping Review

Background

Digital health refers to the proper use of technology for improving the health and well-being of people and enhancing the care of patients through the intelligent processing of clinical and genetic data. Despite increasing interest in well-being in both health care and technology, there is no clear understanding of what constitutes well-being, which leads to uncertainty in how to create well-being through digital health. In an effort to clarify this uncertainty, Brey developed a framework to define problems in technology for well-being using the following four categories: epistemological problem, scope problem, specification problem, and aggregation problem.

Objective

This systematic scoping review aims to gain insights into how to define and address well-being in digital health.

Methods

We followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. Papers were identified from 6 databases and included if they addressed the design or evaluation of digital health and reported the enhancement of patient well-being as their purpose. These papers were divided into design and evaluation papers. We studied how the 4 problems in technology for well-being are considered per paper.

Results

A total of 117 studies were eligible for analysis (n=46, 39.3% design papers and n=71, 60.7% evaluation papers). For the epistemological problem, the thematic analysis resulted in various definitions of well-being, which were grouped into the following seven values: healthy body, functional me, healthy mind, happy me, social me, self-managing me, and external conditions. Design papers mostly considered well-being as healthy body and self-managing me, whereas evaluation papers considered the values of healthy mind and happy me. Users were rarely involved in defining well-being. For the scope problem, patients with chronic care needs were commonly considered as the main users. Design papers also regularly involved other users, such as caregivers and relatives. These users were often not involved in evaluation papers. For the specification problem, most design and evaluation papers focused on the provision of care support through a digital platform. Design papers used numerous design methods, whereas evaluation papers mostly considered pre-post measurements and randomized controlled trials. For the aggregation problem, value conflicts were rarely described.

Conclusions

Current practice has found pragmatic ways of circumventing or dealing with the problems of digital health for well-being. Major differences exist between the design and evaluation of digital health, particularly regarding their conceptualization of well-being and the types of users studied. In addition, we found that current methodologies for designing and evaluating digital health can be improved. For optimal digital health for well-being, multidisciplinary collaborations that move beyond the common dichotomy of design and evaluation are needed.

The Acceptance and Use of the e-Health Instrument 'The Personal Health Check' in Four Dutch Municipalities: Lessons Learned

This pilot study assessed the acceptance and use of the e-Health instrument “the Personal Health Check” (PHC) among clients and professionals in primary care settings. By filling in the online PHC instrument, participants were provided insights into their health and lifestyle. When results revealed an increased health risk, participants were advised to undertake additional lab tests measuring blood pressure and haemaglobin levels. Based on the online questionnaire and optional lab tests, participants then received a report that included individually-tailored feedback from the e-Health application about personal health risks and suggestions for health interventions. The PHC was implemented in 2016 in four Dutch municipalities that determined which neighbourhood(s) the PHC targeted and how participants were invited. The Unified Theory of Acceptance and Use of Technology was used as a theoretical framework to address our research questions. Methods used to assess acceptance were: PHC instrument data, data from additional questionnaires completed by PHC participants, focus groups with PHC participants and professionals in primary care, and telephone interviews with non-responders to the invitation to participate in the online PHC. Of the 21,735 invited, 12% participated. Our results showed that participants and professionals in this pilot were predominantly positive about the PHC. Participants reported that they made an effort to apply the PHC lifestyle advice they received. Almost all had the knowledge and resources needed to use the PHC online instrument. Invitations from general practitioners almost doubled participation relative to invitations from the sponsoring municipalities. The overall low response rate, however, suggests that the PHC is unsuitable as a foundation on which to develop local public health policy.

Functionalities and Issues in the Implementation of Personal Health Records: Systematic Review

Background

Functionalities of personal health record (PHR) are evolving, and continued discussions about PHR functionalities need to be performed to keep it up-to-date. Technological issues such as nonfunctional requirements should also be discussed in the implementation of PHR.

Objective

This study systematically reviewed the main functionalities and issues in implementing the PHR.

Methods

This systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The search is performed using the online databases Scopus, ScienceDirect, IEEE, MEDLINE, CINAHL, and PubMed for English journal articles and conference proceedings published between 2015 and 2020.

Results

A total of 105 articles were selected in the review. Seven function categories were identified in this review, which is grouped into basic and advanced functions. Health records and administrative records were grouped into basic functions. Medication management, communication, appointment management, education, and self-health monitoring were grouped into advanced functions. The issues found in this study include interoperability, security and privacy, usability, data quality, and personalization.

Conclusions

In addition to PHR basic and advanced functions, other supporting functionalities may also need to be developed based on the issues identified in this study. This paper provides an integrated PHR architectural model that describes the functional requirements and data sources of PHRs.

Attitudes towards using electronic health records of patients with psoriasis and dermatologists: a cross-sectional study

BACKGROUND

Electronic health records (EHRs) offer various advantages for healthcare delivery, especially for chronic and complex diseases such as psoriasis. However, both patients' and physicians' acceptability is required for EHRs to unfold their full potential. Therefore, this study compares patients' and physicians' attitudes towards using EHRs in routine psoriasis care.

METHODS

For the purpose of this study, a questionnaire was developed based on literature research and analyses of previously conducted focus groups. Participants completed either a paper-based or an electronic version of the questionnaire. Patient recruitment took place at an dermatological outpatient clinic and via several online pathways (patient associations, and social media). Physicians were recruited via a mailing list of a dermatological association and at a dermatological conference. Patients' and physicians' responses were compared using χ2 tests and Fisher's exact tests.

RESULTS

The study consisted of 187 patients and 44 dermatologists. Patients compared to physicians rated almost all potential EHR uses as significantly more important and expected significantly more potential benefits from EHRs.

CONCLUSIONS

Patients showed positive expectations towards using EHRs, whereas there was more scepticism in the physician sample. This aligns with previous findings. These differences illustrate the necessity to involve all stakeholders, especially patients and physicians, into the process of developing and implementing EHRs.

Design Features for Improving Mobile Health Intervention User Engagement: Systematic Review and Thematic Analysis

Background

Well-designed mobile health (mHealth) interventions support a positive user experience; however, a high rate of disengagement has been reported as a common concern regarding mHealth interventions. To address this issue, it is necessary to summarize the design features that improve user engagement based on research over the past 10 years, during which time the popularity of mHealth interventions has rapidly increased due to the use of smartphones.

Objective

The aim of this review was to answer the question “Which design features improve user engagement with mHealth interventions?” by summarizing published literature with the purpose of guiding the design of future mHealth interventions.

Methods

This review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist. Databases, namely, PubMed, Web of Science, Cochrane Library, Ovid EMBASE, and Ovid PsycINFO, were searched for English and Chinese language papers published from January 2009 to June 2019. Thematic analysis was undertaken to assess the design features in eligible studies. The Mixed Methods Appraisal Tool was used to assess study quality.

Results

A total of 35 articles were included. The investigated mHealth interventions were mainly used in unhealthy lifestyle (n=17) and chronic disease (n=10) prevention programs. Mobile phone apps (n=24) were the most common delivery method. Qualitative (n=22) and mixed methods (n=9) designs were widely represented. We identified the following 7 themes that influenced user engagement: personalization (n=29), reinforcement (n=23), communication (n=20), navigation (n=17), credibility (n=16), message presentation (n=16), and interface aesthetics (n=7). A checklist was developed that contained these 7 design features and 29 corresponding specific implementations derived from the studies.

Conclusions

This systematic review and thematic synthesis identified useful design features that make an mHealth intervention more user friendly. We generated a checklist with evidence-based items to enable developers to use our findings easily. Future evaluations should use more robust quantitative approaches to elucidate the relationships between design features and user engagement.

Emerging health data platforms: From individual control to collective data governance

Health data have enormous potential to transform healthcare, health service design, research, and individual health management. However, health data collected by institutions tend to remain siloed within those institutions limiting access by other services, individuals or researchers. Further, health data generated outside health services (e.g., from wearable devices) may not be easily accessible or useable by individuals or connected to other parts of the health system. There are ongoing tensions between data protection and the use of data for the public good (e.g., research). Concurrently, there are a number of data platforms that provide ways to disrupt these traditional health data siloes, giving greater control to individuals and communities. Through four case studies, this paper explores platforms providing new ways for health data to be used for personal data sharing, self-health management, research, and clinical care. The case-studies include data platforms: PatientsLikeMe, Open Humans, Health Record Banks, and unforgettable.me. These are explored with regard to what they mean for data access, data control, and data governance. The case studies provide insight into a shift from institutional to individual data stewardship. Looking at emerging data governance models, such as data trusts and data commons, points to collective control over health data as an emerging approach to issues of data control. These shifts pose challenges as to how “traditional” health services make use of data collected on these platforms. Further, it raises broader policy questions regarding how to decide what public good data should be put towards.

Personal electronic healthcare records: What influences consumers to engage with their clinical data online? A literature review

Background:

Online electronic records such as patient portals and personally controlled electronic health records (PEHRs) have been widely viewed as a key component to modernising the delivery of healthcare but the uptake of such systems has been slow.

Objective:

The purpose of this literature review was to determine what influences consumers to engage and interact with their clinical data online.

Method:

A scoping literature review following PRISMA guidelines was completed. Electronic patient record research published between January 2009 and December 2018 was included. Following screening and full-text reviews, a total of 64 records were included in this review.

Results:

Three key areas of influence on consumer engagement with their clinical data online emerged: demographic factors affecting consumer interaction with PEHRs; consumers’ perceived benefits and detriments of PEHR use; and the influence of PEHR use on consumer empowerment and responsibility.

Discussion:

Consumer motivation and readiness for engaging with their clinical data online and their long-term ongoing use of these systems requires further exploration.

Conclusion:

As worldwide rates of consumer interactions with individual online clinical data remain low, what influences consumer engagement with a PEHR remains unknown. Further research into the consumer perspective of, and interaction with, a PEHR, needs to be undertaken to determine if factors such as frequent usage of the system by consumers leads to improved clinical outcomes.

Persuasive design features within a consumer-focused eHealth intervention integrated with the electronic health record: A mixed methods study of effectiveness and acceptability

INTRODUCTION

eHealth strategies targeting health-related behaviour often incorporate persuasive software design. To further engage patients with their overall health management, consumer-facing web portals may be integrated with data from one or more care providers. This study aimed to explore effectiveness for healthier behaviour of persuasive design characteristics within a web application integrated with the primary health care electronic record; also patient and general practitioner (GP) preferences for future integrated records.

METHODS

Mixed methods study within the Consumer Navigation of Electronic Cardiovascular Tools randomised controlled trial. Participants were patients with moderate-high risk of cardiovascular disease, and their GPs. Survey and web analytic data were analysed with descriptive statistics. Interview and focus group transcripts were recorded, transcribed, coded and analysed for themes.

RESULTS

Surveys (n = 397) received from patients indicated improved medication adherence (31.8%); improved mental health and well-being (40%); higher physical activity (47%); and healthier eating (61%). Users of the interactive features reported benefiting from personalised cardiovascular disease risk score (73%); goal tracking (69%); risk factor self-monitoring (52%) and receipt of motivational health tips (54%). Focus group and interview participants (n = 55) described customisations that would increase portal appeal and relevance, including more provider interaction. Of the GP survey respondents (n = 38), 74% reported increased patient attendance and engagement with their care. For future integrated portals, 94% of GPs were in favour and key themes among interviewees (n = 17) related to design optimisation, impact on workflow and data security.

CONCLUSION

Intervention features reflecting the persuasive design categories of Primary Task support, Dialogue support and System Credibility support facilitated healthier lifestyle behaviour. Patients valued customisable functions and greater patient-provider interactivity. GPs identified system challenges but saw advantages for patients and the health care relationship. Future studies could further elucidate the persuasive design principles that are at play and which may promote adoption of EHR-integrated consumer portals.

Digital networks for laboratory data: potentials, barriers and current initiatives

Medical care is increasingly delivered by multiple providers across healthcare sectors and specialties, leading to a fragmentation of the electronic patient record across organizations and vendor IT systems. The rapid uptake of wearables and connected diagnostic devices adds another source of densely collected data by the patients themselves. Integration of these data sources opens up several potentials: a longitudinal view of laboratory findings would close the gaps between individual provider visits and allow to more closely follow disease progression. Adding non-laboratory data (e.g. diagnoses, procedures) would add context and support clinical interpretation of findings. Case-based reasoning and disease-modelling approaches would allow to identify similar patient groups and classify endotypes. Realization of these potentials is, however, subject to several barriers, including legal and ethical prerequisites of data access, syntactic and semantic integration, comparability of items and user-centered presentation. The German Medical Informatics Initiative is presented as a current undertaking that strives to address these issues by establishing a national infrastructure for the secondary use of routine clinical data.