Impact of electronic messaging on the patient-physician interaction

Demographics and clinical features associated with rates of electronic message utilization in the primary care setting

INTRODUCTION

Electronic messages are growing as an important form of patient-provider communication, particularly in the primary care setting. However, adoption of healthcare technology has been under-utilized by underserved patient populations. The purpose of this study was to describe how adoption and utilization of electronic messaging occurred within a large primary care urban-based patient population.

METHODS

In this retrospective study, the frequency of electronic messages initiated by adult outpatient primary care patients was observed. Patients were classified as either non-portal adopters, non-message utilizers, low message utilizers, and high message utilizers. Logistic regression modeling was used to compare factors associated with message utilization rates to determine disparities in access.

RESULTS

Among a sample of 27,453 ethnically diverse adult patients from the Houston, Texas Metropolitan area, 33,497 unique messages were sent (1.22 messages/patient). Message burden was predominantly derived by a small number of high utilizers (individuals who sent 3 or more messages), who comprised 15.7 % of the study population (n = 4302) but accounted for 77 % of the message volume (n = 25,776). These high utilizers were typically older, White, English speaking, from middle to upper income zip codes, had higher number of comorbidities, and a higher number of clinical visits.

CONCLUSIONS

Most inbox messages were generated by a small number of patients. While it was reassuring to see older and sicker individuals utilizing electronic messaging, patients from minority and/or lower income background utilized electronic messaging much less. This may propagate systematic bias and decrease the level of care for traditionally underserved patients.

Changes in Management at the Postoperative Visit After In-Office Wide Awake Local Anesthetic No Tourniquet Carpal Tunnel Release

PURPOSE

Patients are commonly seen for two postoperative visits following carpal tunnel release (CTR), the first visit being at 1-2 weeks and the second at approximately 6 weeks. Our study aimed to determine if these visits led to changes in postoperative medical management.

METHODS

A retrospective review was conducted of 748 procedures performed in an in-office procedure room under wide awake local anesthetic no tourniquet between August 2020 and December 2022. Charts were reviewed for changes in management related to the patient's CTR. Management changes involving a separate diagnosis or solely an additional follow-up visit were classified as unrelated to postoperative CTR care.

RESULTS

A total of 730 patients returned for follow-up. There were 100 patients (13.7 %) who had a CTR-related change in management at the first postoperative visit. Most management changes at this timepoint were due to superficial surgical site infection. There were 29 patients (4.0 %) who had a CTR-related change in management at their second postoperative visit, most commonly a referral to therapy for stiffness or hypersensitivity.

CONCLUSIONS

While postoperative visits for CTR may have intangible benefits, changes in CTR-related care occur only in 17.7% of patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Examining the Intervening Roles of Patient-Centered Care and Patient Activation in the Health Impacts of Offline Healthcare Obstacles and Online Health Consultations Among Deaf and Hard-of-Hearing Patients

Deaf and hard-of-hearing (DHH) patients often encounter difficulties in effective communication with healthcare professionals and are less likely to receive quality medical care. However, DHH populations are understudied in health communication research. This study examined how offline healthcare obstacles and online health consultation impact DHH patients' health, and the mediating roles of patient-centered care (PCC) and patient activation. Data from 323 DHH patients were analyzed using structural equation modeling to test the hypothesized mediation pathway model. Results indicate that offline healthcare obstacles negatively affect DHH patients' perception of patient-centeredness, which reduces their ability and confidence in self-care (conceptualized as patient activation in this study). This reduced patient activation may jeopardize DHH patients' physical and psychological health. Meanwhile, online health consultation is positively associated with PCC, and higher levels of PCC can increase patient activation, contributing to better physical and psychological health. Testing the same model with hearing-abled participants (n = 3542) revealed significant differences in these intervening relationships. Overall, this study provides valuable insights into the relationship between DHH patients' healthcare experience and their health outcomes. The findings support interventions that focus on enhancing PCC and patient activation to improve the physical and psychological health outcomes of DHH patients.

How Online Patient-Provider Communication Impacts Quality of Life: Examining the Role of Patient-Centered Care and Health Competence

The question of how patient-provider communication affects health outcomes has been a longstanding concern for health communication scholarship and practice. As patient-provider communication becomes increasingly mediated by digital technologies, much research has sought to compare online patient-provider communication (OPPC) with that conducted in-person, weighing its relative merits against its costs and barriers. This line of inquiry has mostly focused on the comparative benefits of OPPC for service delivery with little attempt to link these benefits to the wider health implications of OPPC. Consequently, the mechanisms that explain the impacts of OPPC on patients' overall wellbeing have been underexamined. Through a survey of 681 participants in China, this study examined the direct and indirect pathways between OPPC and quality of life (i.e., sleep, exercise, social activities, and psychological wellbeing). Our results demonstrate statistically significant direct relationships between OPPC and the four quality-of-life constructs examined as well as the mediation effects of patient-centered care and health competence in these relationships. The findings call for greater attention to the longer-term contributions of OPPC in empowering patients, especially those who are underserved by the healthcare system.

Communication technology practices used by midwives with pregnant women/people in Aotearoa New Zealand to ensure quality maternal and newborn care

INTRODUCTION

Communication technology such as texting is commonly used for sending appointment reminders and reinforcing health messages. Midwives have identified concerns with privacy of information or information taken out of context within an online format. How this technology is used to ensure quality maternal care within a continuity model of midwifery care is unknown.

AIM

To describe midwives' experiences of using communication technology with pregnant women/people in Aotearoa New Zealand.

METHODS

A mixed methods design was used to collect online survey data from Lead Maternity Carer midwives. Recruitment was through closed midwifery Facebook groups in Aotearoa New Zealand. Survey questions were informed by the Quality Maternal & Newborn Care framework & findings and an integrative literature review. Quantitative data was analysed using descriptive statistics, and qualitative comments analysed using thematic analysis.

FINDINGS

104 midwives responded to the online survey. Phone calls, texting and emails were commonly used by midwives to reinforce health messages and decision making. Communication technology supported, and enhanced relationships midwives develop with their pregnant clients. Texting enhanced documentation of care and enabled midwives to work efficiently. Midwives, however identified concerns when managing expectations around urgent and non-urgent communication.

DISCUSSION

Midwives are bound by regulations to ensure they provide safe care to pregnant women/people. Negotiating and understanding expectations around use of communication technology is vitally important to ensure that communications and connections are undertaken in a safe manner.

Impact of COVID-19 lockdown on patient-provider electronic communications

BACKGROUND

SARS CoV-2 virus (COVID-19) impacted the practice of healthcare in the United States, with technology being used to facilitate access to care and reduce iatrogenic spread. Since then, patient message volume to primary care providers has increased. However, the volume and trend of electronic communications after lockdown remain poorly described in the literature.

METHODS

All incoming inbox items (telephone calls, refill requests, and electronic messages) sent to providers from patients amongst four primary care clinics were collected. Inbox item rates were calculated as a ratio of items per patient encountered each week. Trends in inbox rates were assessed during 12 months before and after lockdown (March 1st, 2020). Logistic regression was utilized to examine the effects of the lockdown on inbox item rate post-COVID-19 lockdown as compared to the pre-lockdown period.

RESULTS

Before COVID-19 lockdown, 2.07 new inbox items per encounter were received, which increased to 2.83 items after lockdown. However, only patient-initiated electronic messages increased after lockdown and stabilized at a rate higher than the pre-COVID-19 period (aRR 1.27, p-value < 0.001). In contrast, prescription refill requests and telephone calls quickly spiked, then returned to pre-lockdown levels.

CONCLUSION

Based on our observations, providers experienced a quick increase in all inbox items. However, only electronic messages had a sustained increase, exacerbating the workload of administrators, staff, and clinical providers. This study directly correlates healthcare technology adoption to a significant disruptive event but also shows additional challenges to the healthcare system that must be considered with these changes.

Determining the readiness of patients with renal failure to use health information technology

INTRODUCTION

Using information technology (IT) for purposes such as patient education and disease prevention and management is effective when patients are ready to use it. The objective of this study was to determine the readiness of patients with renal failure to use health IT.

METHODS

This study was performed on all dialysis patients in South Khorasan province (n = 263) using a 28-item questionnaire. The questionnaire consisted of (1) demographic information of participants and (2) questions concerning eight main factors including the need for information, desire to receive information, ability to use computers and the Internet, computers and the Internet anxiety, communication with physicians, using mobile phones and concerns about security and confidentiality of information. Descriptive statistics and Mann-Whitney and Kruskal-Wallis statistical tests were used to analyze the data.

RESULTS

About 15% of the participants stated that they do not want to receive information from the Internet. Anxiety and concern about Internet security and confidentiality were higher in women, married people, people over 60, villagers, and illiterate people (p < 0.05). Married people and people over 60 years had a higher desire to get information (p < 0.05). The rate of computer anxiety and Internet privacy concern was higher than average (p < 0.001). Most patients (34.2%) could only send text messages using mobile phones.

CONCLUSION

Despite the need of most patients to online health information, they do not use this information due to a lack of skills and experience to use IT. Therefore, the ability of users should be considered when developing IT-based interventions. Due to patients' concerns about Internet privacy, it is required to teach patients how to protect their privacy while using the Internet.

Early-Stage Lung Cancer Patients’ Perceptions of Presurgical Discussions

Background

Patients with early-stage non–small-cell lung cancer (NSCLC) have high survival rates, but patients often say they did not anticipate the effect of the surgery on their postsurgical quality of life (QoL). This study adds to the literature regarding patient and surgeon interactions and highlights the areas where the current approach is not providing good communication.

Design

Since its start in 2016, the Initiative for Early Lung Cancer Research on Treatment (IELCART), a prospective cohort study, has enrolled 543 patients who underwent surgery for stage I NSCLC within the Mount Sinai Health System. Presurgical patient and surgeon surveys were available for 314 patients, postsurgical surveys for 420, and both pre- and postsurgical surveys for 285.

Results

Of patients with presurgical surveys, 31.2% said that their surgeon recommended multiple types of treatment. Of patients with postsurgical surveys, 85.0% felt very well prepared and 11.4% moderately well prepared for their postsurgical recovery. The median Functional Assessment of Cancer Therapy–Lung Cancer score and social support score of the patients who felt very well prepared was significantly higher than those moderately or not well prepared (24.0 v. 22.0, P < 0.001) and (5.0 [interquartile range: 4.7–5.0] v. 5.0 [IQR: 4.2–5.0], p = 0.015).

Conclusions

This study provides insight into the areas where surgeons are communicating well with their patients as well as the areas where patients still feel uninformed. Most surgeons feel that they prepare their patients well or very well for surgical recovery, whereas some patients still feel that their surgeons did not prepare them well for postsurgical recovery. Surgeons may want to spend additional time emphasizing postsurgical recovery and QoL with their patients or provide their patients with additional avenues to get their questions and concerns addressed.

Highlights

Compassionate nursing care and the use of digital health technologies: A scoping review

BACKGROUND

Compassion is an essential component of quality patient-centered care and a core value in nursing practice. Although much work has been done to enhance nurses' informatics competency, there is limited understanding of how nurses can use, express, and preserve compassion when they use digital health technologies in the provision of patient care.

PURPOSE

This study aimed to explore the nursing literature on how nurses provide compassionate care when they use digital health technologies. A secondary aim was to identify best practices that could be used to guide nursing education and practice toward enhancing compassionate care in digital environment.

METHOD

A scoping review was conducted to address the following research question: What is known about compassionate care in relation to the use of digital health technologies within the nursing literature? A comprehensive search strategy was applied to CINAHL Plus with full text, Ovid Medline, Ovid HealthStar, Embase, APAPsychINFO, Scopus, and ProQuest Dissertations and Theses. In addition, a search of selected organizational websites and a hand search of reference lists of included studies were conducted. The eligibility of articles was determined by two reviewers independently. Descriptive and content analyses were applied. Findings were presented narratively and in a tabular format.

RESULTS

Twenty-eight articles were included in this review. Most of this research was published between 2004 and 2020, using mostly qualitative methods. Narrative results were organized into three themes: 1) evolving understanding of compassionate nursing care in relation to use of digital health technology, 2) compassionate nursing care in relation to the type of digital health technology, and 3) strategies and interventions to improve education and competence relevant to digital health and compassionate nursing care.

CONCLUSION

The use of technology influences how nurses do their work and interact with patients. As advances in digital health continue to evolve, future research should aim to expand understanding of compassion relevant to digital health by articulating its characteristics and associated competencies for nurses to further enhance their ability to provide compassionate care when digital health technologies and services are used to support care delivery. Tweetable abstract: A scoping review that identified how nurses can provide compassionate nursing care in technologically rich practice environments.

Analyzing Trend for U.S. Immigrants' e-Health Engagement from 2008 to 2013

Our study examines the trend of U.S. immigrants' engagement in various e-health activities and how immigrants' use of e-health technologies is associated with their cultural characteristics over years. Aggregating three national representative samples of U.S. immigrants from the Health Information National Trends Survey (HINTS) conducted between 2008 and 2013, our results from trend analyses and logistic regressions revealed that the U.S. immigrants exhibited an increasing trend on two types of e-health engagement: tracking personal health information online and communicating with a doctor online. But we did not find any significant change in the other two e-health activities throughout these years: the percentage of immigrants who sought a health provider online remained moderate (about 37%), whereas the percentage of immigrants who joined an online support group kept low (about 5%). Furthermore, immigrants of different race/ethnicity or length of residence in the United States showed different trends of e-health engagement. Asian immigrants and immigrants with 13-34 years of residence were more proactive to engage in various e-health activities. Our study informs the practice aiming to enhance U.S. immigrants' Internet use for better health-related outcomes.

Characteristics of Future Models of Integrated Outpatient Care

Replacement of fee-for-service with capitation arrangements, forces physicians and institutions to minimize health care costs, while maintaining high-quality care. In this report we described how patients and their families (or caregivers) can work with members of the medical care team to achieve these twin goals of maintaining-and perhaps improving-high-quality care and minimizing costs. We described how increased self-management enables patients and their families/caregivers to provide electronic patient-reported outcomes (i.e., symptoms, events) (ePROs), as frequently as the patient or the medical care team consider appropriate. These capabilities also allow ongoing assessments of physiological measurements/phenomena (mHealth). Remote surveillance of these communications allows longer intervals between (fewer) patient visits to the medical-care team, when this is appropriate, or earlier interventions, when it is appropriate. Systems are now available that alert medical care providers to situations when interventions might be needed.

Telephone Consultation and Prescription in Pediatrics: Contributing Factors and Impact on Clinical Outcomes

Objectives: To evaluate phone-based consultation practices and drug prescription profiles in pediatrics and to highlight their possible uses, contributing factors, and effects on clinical outcomes. Background: The ownership and everyday use of cell phones are increasing worldwide. Telehealth is gaining the support of health professionals for the delivery of simple healthcare measures to more complex management decisions. Despite this, in our country, doctors have been advised by concerned authorities to avoid any phone-based medical activity as the safety of such practices is still not well-established, especially among vulnerable pediatric patients. Patients and Methods: This cross-sectional study was conducted on a national level over 5 months. Phone consultations and prescription behaviors data were collected through a self-administrated questionnaire. The target population consisted of pediatric-trained physicians with at least 1 year of experience. Factors influencing telephone prescriptions were assessed using bivariate analysis. Results: Of among 120 included physicians (75.0% male), 64.2% were general pediatricians, 77.5% practiced in private clinics, and 27.5% had more than 20 years of work experience. All participants gave medical advice over the phone; 61.7% considered that they should be reimbursed for these activities and 29.2% of them reviewed 50% of their patients for the same complaint. A total of 109 participants (90.8%) prescribed drugs using a direct phone call (80.7%), SMS (27.5%), or WhatsApp application (61.5%). Antipyretics (97.2%) and cough suppressants (48.1%) were the most frequently prescribed drugs. Pharmacists' corrective interventions were seen in 40.4% of prescriptions. Fever was the only symptom that was statistically associated with phone prescriptions. Prescribers seemed to be less experienced and were more likely to consider phone-based practices as reimbursable activities. Conclusions: Consultations and prescriptions through mobile phones are extremely frequent in pediatric practices, even when restricted by responsible authorities. Our results highlight the frequency of medical prescription errors and the need for corrective interventions by pharmacists. The current practice of telemedicine may not ensure the patient's safety but exists rather as a convenience. There is a need for proper oversight with a regulatory framework and input from all stakeholders, including pediatricians and pharmacists.

Caring electronically for young outpatients who have epilepsy

PURPOSE

The purpose of this study was to review electronic tools that might improve the delivery of epilepsy care, reduce medical care costs, and empower families to improve self-management capability.

METHOD

We reviewed the epilepsy-specific literature about self-management, electronic patient-reported or provider-reported outcomes, on-going remote surveillance, and alerting/warning systems.

CONCLUSIONS

The improved care delivery system that we envision includes self-management, electronic patient (or provider)-reported outcomes, on-going remote surveillance, and alerting/warning systems. This system and variants have the potential to reduce seizure burden through improved management, keep children out of the emergency department and hospital, and even reduce the number of outpatient visits.

Communicating laboratory results through a Web site: Patients' priorities and viewpoints

BACKGROUND

Patients can access laboratory results using various technologies. The aim of this study was to integrate the laboratory results into the hospital Web site based on patients' viewpoints and priorities and to measure patients' satisfaction.

METHODS

This descriptive-analytical study was conducted in 2015. First, a questionnaire was distributed among 200 patients to assess patients' priorities to receive laboratory results through the Web site. Second, those who agreed (n = 95) to receive their laboratory results through the Web site were identified. Then, the required changes were made to the hospital Web site based on patients' viewpoints and priorities. Third, patients were divided into two groups. The first group received their laboratory results through the Web site on the date had been announced during their visit to the laboratory. The second group was informed by SMS once their results were shown on the Web site. After receiving laboratory results, patients' satisfaction was evaluated.

RESULTS

More than half of the participants (n = 53, 55.8%) were highly satisfied with receiving the results electronically. The higher number of people in SMS group (n = 9, 20.9%) reported that they were satisfied with time-saving compared to other group (n = 2, 3.8%) (P = .04). Participants after receiving the results through the Web site considered the functionalities of reprinting (P < .0001) and timeliness (P = .017) more important.

CONCLUSION

Integrating laboratory results into the hospital Web site based on the patients' viewpoints and priorities can improve patient satisfaction and lower the patients' concern regarding confidentiality of their results.

Ethical implications of digital communication for the patient-clinician relationship: analysis of interviews with clinicians and young adults with long term conditions (the LYNC study)

BACKGROUND

Digital communication between a patient and their clinician offers the potential for improved patient care, particularly for young people with long term conditions who are at risk of service disengagement. However, its use raises a number of ethical questions which have not been explored in empirical studies. The objective of this study was to examine, from the patient and clinician perspective, the ethical implications of the use of digital clinical communication in the context of young people living with long-term conditions.

METHODS

A total of 129 semi-structured interviews, 59 with young people and 70 with healthcare professionals, from 20 United Kingdom (UK)-based specialist clinics were conducted as part of the LYNC study. Transcripts from five sites (cancer, liver, renal, cystic fibrosis and mental health) were read by a core team to identify explicit and implicit ethical issues and develop descriptive ethical codes. Our subsequent thematic analysis was developed iteratively with reference to professional and ethical norms.

RESULTS

Clinician participants saw digital clinical communication as potentially increasing patient empowerment and autonomy; improving trust between patient and healthcare professional; and reducing harm because of rapid access to clinical advice. However, they also described ethical challenges, including: difficulty with defining and maintaining boundaries of confidentiality; uncertainty regarding the level of consent required; and blurring of the limits of a clinician's duty of care when unlimited access is possible. Paradoxically, the use of digital clinical communication can create dependence rather than promote autonomy in some patients. Patient participants varied in their understanding of, and concern about, confidentiality in the context of digital communication. An overarching theme emerging from the data was a shifting of the boundaries of the patient-clinician relationship and the professional duty of care in the context of use of clinical digital communication.

CONCLUSIONS

The ethical implications of clinical digital communication are complex and go beyond concerns about confidentiality and consent. Any development of this form of communication should consider its impact on the patient-clinician-relationship, and include appropriate safeguards to ensure that professional ethical obligations are adhered to.

Patients' Perceptions of Applying Information and Communication Technology Tools in Self-care and Factors Affecting It

Introduction:

In recent years patient self-care has emerged as an important component of disease management programs. The ICT tools facilitate the self-care process with improved access to information resources, effective communication between patients and healthcare professionals, and social support services.

Aim:

The purpose of this study was identifying the perception of patients from the application of information communication technology in self-care in educational centers of Urmia University of Medical Sciences.

Material and Methods:

This is a descriptive cross-sectional study conducted in 2018. The studied population consisted 540 hospitalized patients from educational hospitals affiliated to Urmia university of medical sciences. For data collection, a self-designed questionnaire was developed which valid and reliable instrument to be measured. The statistical analysis of data was done using the SPSS Software.

Results:

more patients’ interest to use of ICT tools in case of social media (34%), computer-based (25%) and the most common applications ICT tools included patient education (34%) and searching health information (23%). The most factors effective in the usage of ICT tools by patients were related to ease of using ICT tools (4.82), ICT tools reliability (4.73) and design ICT tools based on patient needs and preferences (4.68) respectively.

Conclusion:

The ICT tools are critical to patient self- care. To encourage more ICT adoption, patients should be made aware of the benefits of ICT and active involvement in the process of technology development. It seems necessary; ICT tools should be designed user-friendly, easy to use, reliable and usable.

Can Secure Patient-Provider Messaging Improve Diabetes Care?

OBJECTIVE

Internet-based secure messaging between patients and providers through a patient portal is now common in the practice of modern medicine. There is limited evidence on how messaging is associated with use and clinical quality measures among patients with type 2 diabetes. We examine whether messaging with physicians for medical advice is associated with fewer face-to-face visits and better diabetes management.

RESEARCH DESIGN AND METHODS

Patients with diabetes who were enrolled in an online portal of an outpatient health care organization in 2011-2014 were studied (N = 37,762 patient-years). Messages from/to primary care physicians or diabetes-related specialists for medical advice were considered. We estimated the association of messaging with diabetes quality measures, adjusting for patient and provider characteristics and patient-level clustering.

RESULTS

Most patients (72%) used messaging, and those who made frequent visits were also more likely to message. Given visit frequency, no (vs. any) messaging was negatively associated with the likelihood of meeting an HbA_1c target of <8% (64 mmol/mol) (odds ratio [OR] 0.83 [95% CI 0.77, 0.90]). Among message users, additional messages (vs. 1) were associated with better outcome (two more messages: OR 1.17 [95% CI 1.06, 1.28]; three more messages: 1.38 [1.25, 1.53]; four more messages: 1.55 [1.43, 1.69]). The relationship was stronger for noninsulin users. Message frequency was also positively associated, but to a smaller extent, with process measures (e.g., eye examination). Physician-initiated messages had effects similar to those for patient-initiated messages.

CONCLUSIONS

Patients with diabetes frequently used secure messaging for medical advice in addition to routine visits to care providers. Messaging was positively associated with better diabetes management in a large community outpatient practice.

The impact of secure messaging on workflow in primary care: Results of a multiple-case, multiple-method study

INTRODUCTION

Secure messaging is a relatively new addition to health information technology (IT). Several studies have examined the impact of secure messaging on (clinical) outcomes but very few studies have examined the impact on workflow in primary care clinics. In this study we examined the impact of secure messaging on workflow of clinicians, staff and patients.

METHODS

We used a multiple case study design with multiple data collections methods (observation, interviews and survey).

RESULTS

Results show that secure messaging has the potential to improve communication and information flow and the organization of work in primary care clinics, partly due to the possibility of asynchronous communication. However, secure messaging can also have a negative effect on communication and increase workload, especially if patients send messages that are not appropriate for the secure messaging medium (for example, messages that are too long, complex, ambiguous, or inappropriate). Results show that clinicians are ambivalent about secure messaging. Secure messaging can add to their workload, especially if there is high message volume, and currently they are not compensated for these activities. Staff is -especially compared to clinicians- relatively positive about secure messaging and patients are overall very satisfied with secure messaging. Finally, clinicians, staff and patients think that secure messaging can have a positive effect on quality of care and patient safety.

CONCLUSION

Secure messaging is a tool that has the potential to improve communication and information flow. However, the potential of secure messaging to improve workflow is dependent on the way it is implemented and used.

Digital communication between clinician and patient and the impact on marginalised groups: a realist review in general practice

BACKGROUND

Increasingly, the NHS is embracing the use of digital communication technology for communication between clinicians and patients. Policymakers deem digital clinical communication as presenting a solution to the capacity issues currently faced by general practice. There is some concern that these technologies may exacerbate existing inequalities in accessing health care. It is not known what impact they may have on groups who are already marginalised in their ability to access general practice.

AIM

To assess the potential impact of the availability of digital clinician-patient communication on marginalised groups' access to general practice in the UK.

DESIGN AND SETTING

Realist review in general practice.

METHOD

A four-step realist review process was used: to define the scope of the review; to search for and scrutinise evidence; to extract and synthesise evidence; and to develop a narrative, including hypotheses.

RESULTS

Digital communication has the potential to overcome the following barriers for marginalised groups: practical access issues, previous negative experiences with healthcare service/staff, and stigmatising reactions from staff and other patients. It may reduce patient-related barriers by offering anonymity and offers advantages to patients who require an interpreter. It does not impact on inability to communicate with healthcare professionals or on a lack of candidacy. It is likely to work best in the context of a pre-existing clinician-patient relationship.

CONCLUSION

Digital communication technology offers increased opportunities for marginalised groups to access health care. However, it cannot remove all barriers to care for these groups. It is likely that they will remain disadvantaged relative to other population groups after their introduction.

Email Between Patient and Provider: Assessing the Attitudes and Perspectives of 624 Primary Health Care Patients

Background

Email between patients and their health care providers can serve as a continuous and collaborative forum to improve access to care, enhance convenience of communication, reduce administrative costs and missed appointments, and improve satisfaction with the patient-provider relationship.

Objective

The main objective of this study was to investigate the attitudes of patients aged 16 years and older toward receiving email communication for health-related purposes from an academic inner-city family health team in Southern Ontario. In addition to exploring the proportion of patients with a functioning email address and interest in email communication with their health care provider, we also examined patient-level predictors of interest in email communication.

Methods

A cross-sectional study was conducted using a self-administered, 1-page survey of attitudes toward electronic communication for health purposes. Participants were recruited from attending patients at the McMaster Family Practice in Hamilton, Ontario, Canada. These patients were aged 16 years and older and were approached consecutively to complete the self-administered survey (N=624). Descriptive analyses were conducted using the Pearson chi-square test to examine correlations between variables. A logistic regression analysis was conducted to determine statistically significant predictors of interest in email communication (yes or no).

Results

The majority of respondents (73.2%, 457/624) reported that they would be willing to have their health care provider (from the McMaster Family Practice) contact them via email to communicate health-related information. Those respondents who checked their personal email more frequently were less likely to want to engage in this electronic communication. Among respondents who check their email less frequently (fewer than every 3 days), 46% (37/81) preferred to communicate with the McMaster Family Practice via email.

Conclusions

Online applications, including email, are emerging as a viable avenue for patient communication. With increasing utility of mobile devices in the general population, the proportion of patients interested in email communication with their health care providers may continue to increase. When following best practices and appropriate guidelines, health care providers can use this resource to enhance patient-provider communication in their clinical work, ultimately leading to improved health outcomes and satisfaction with care among their patients.

Personalized Technologies in Chronic Gastrointestinal Disorders: Self-monitoring and Remote Sensor Technologies

With increased access to high-speed Internet and smartphone devices, patients have started to use mobile applications (apps) for various health needs. These mobile apps are now increasingly used in integration with telemedicine and wearables to support fitness, health education, symptom tracking, and collaborative disease management and care coordination. More recently, evidence (especially around remote patient monitoring) has started to build in some chronic diseases, and some of the digital health technologies have received approval from the Food and Drug Administration. With the changing healthcare landscape and push for value-based care, adoption of these digital health initiatives among providers is bound to increase. Although so far there is a dearth of published evidence about effectiveness of these apps in gastroenterology care, there are ongoing trials to determine whether remote patient monitoring can lead to improvement in process metrics or outcome metrics for patients with chronic gastrointestinal diseases.

Text messaging between clinicians and patients - Hve we got thngs unda cntrl?

INTRODUCTION Patients are interested in receiving text messages (texts) related to their health care. However, anecdotes are emerging of associated problems and it is possible that many of the potential pitfalls are not recognised. AIM To assess clinicians' attitudes and behaviours towards text messaging (texting) with patients. METHODS A voluntary, anonymous, online survey was created and distributed to general practitioners and physiotherapists in New Zealand and to Sports Medicine Fellows and Sports Medicine Registrars in New Zealand and Australia. RESULTS In total, 322 clinicians completed the survey. Texting behaviours relating to accuracy, privacy and security were identified. A range of sensitive and important medical information was frequently conveyed and at times forwarded to third parties. The clinicians generally felt uneasy communicating this way and some felt pressured into it. Most thought that guidelines are insufficient and that they had not received sufficient education on the issues. Most were interested in further education. CONCLUSION This study has demonstrated frequent texting between clinicians and patients. It has highlighted potential risks to the privacy, accuracy and security of medical information. Current guidelines and education may be insufficient. Clinicians were interested in receiving readily available best practice guidelines and education regarding texting.

What Drives Responses to Willingness-to-pay Questions? A Methodological Inquiry in the Context of Hypertension Self-management

Background: The use of economic evaluation to determine the cost-effectiveness of health interventions is recommended by decision-making bodies internationally. Understanding factors that explain variations in costs and benefits is important for policy makers. Objective: This work aimed to test a priori hypotheses defining the relationship between benefits of using self-management equipment (measured using the willingness-to-pay (WTP) approach) and a number of demographic and other patient factors. Methods: Data for this study were collected as part of the first major randomised controlled trial of self-monitoring combined with self-titration in hypertension (TASMINH2). A contingent valuation framework was used with patients asked to indicate how much they were willing to pay for equipment used for self-managing hypertension. Descriptive statistics, simple statistical tests of differences and multivariate regression were used to test six a priori hypotheses. Results: 393 hypertensive patients (204 in the intervention and 189 in the control) were willing to pay for self-management equipment and 85% of these (335) provided positive WTP values. Three hypotheses were accepted: higher WTP values were associated with being male, higher household incomes and satisfaction with the equipment. Prior experiences of using this equipment, age and changes in blood pressure were not significantly related to WTP. Conclusion: The majority of hypertensive patients who had taken part in a self-management study were prepared to purchase the self-monitoring equipment using their own funds, more so for men, those with higher incomes and those with greater satisfaction. Further research based on bigger and more diverse populations is recommended.

Feasibility and success of cell-phone assisted remote observation of medication adherence (CAROMA) in clinical trials

OBJECTIVE

Medication nonadherence is a serious issue in clinical trials, especially in studies of substance abuse disorders. Measuring and confirming adherence is critical to ensuring that collected data is accurate and interpretable. This study evaluated the feasibility and success of a smartphone-based approach (Cellphone Assisted Remote Observation of Medication Adherence [CAROMA]) to visually confirm medication adherence in a clinical trial.

METHOD

Medication adherence was confirmed visually via smartphones provided to participants in a double-blind, randomized, placebo-controlled trial for cannabis dependence. Every morning, subjects (n=20) were video-called by staff who observed consumption of study medication. Adherence was also assessed with weekly face-to-face visits, pill counts and plasma drug levels. Subjects were paid for completing daily CAROMA visits, and for returning the smartphone at study completion.

RESULTS

CAROMA confirmed 96.04% adherence to medication. Concordance between expected and actual remaining study medication counted at weekly study visits was 87.69%. Subjects assigned to active study medication had detectable plasma drug levels, while those assigned to placebo did not. CAROMA was estimated to cost approximately $100 per subject per week - a total of $300.24 per subject for the 3-week outpatient portion of the trial.

CONCLUSION

This pilot study demonstrates the feasibility, success and cost-effectiveness of CAROMA to facilitate and confirm medication adherence in a clinical trial. Preliminary findings support larger and longer studies, and possibly applying this approach to clinical care - especially in other populations with high rates of medication nonadherence.

What Predicts Patients' Willingness to Undergo Online Treatment and Pay for Online Treatment? Results from a Web-Based Survey to Investigate the Changing Patient-Physician Relationship

Background

Substantial research has focused on patients’ health information–seeking behavior on the Internet, but little is known about the variables that may predict patients’ willingness to undergo online treatment and willingness to pay additionally for online treatment.

Objective

This study analyzed sociodemographic variables, psychosocial variables, and variables of Internet usage to predict willingness to undergo online treatment and willingness to pay additionally for online treatment offered by the general practitioner (GP).

Methods

An online survey of 1006 randomly selected German patients was conducted. The sample was drawn from an e-panel maintained by GfK HealthCare. Missing values were imputed; 958 usable questionnaires were analyzed. Variables with multi-item measurement were factor analyzed. Willingness to undergo online treatment and willingness to pay additionally for online treatment offered by the GP were predicted using 2 multiple regression models.

Results

Exploratory factor analyses revealed that the disposition of patients’ personality to engage in information-searching behavior on the Internet was unidimensional. Exploratory factor analysis with the variables measuring the motives for Internet usage led to 2 separate factors: perceived usefulness (PU) of the Internet for health-related information searching and social motives for information searching on the Internet. Sociodemographic variables did not serve as significant predictors for willingness to undergo online treatment offered by the GP, whereas PU (B=.092, P=.08), willingness to communicate with the GP more often in the future (B=.495, P<.001), health-related information–seeking personality (B=.369, P<.001), actual use of online communication with the GP (B=.198, P<.001), and social motive (B=.178, P=.002) were significant predictors. Age, gender, satisfaction with the GP, social motive, and trust in the GP had no significant impact on the willingness to pay additionally for online treatment, but it was predicted by health-related information–seeking personality (B=.127, P=.07), PU (B=–.098, P=.09), willingness to undergo online treatment (B=.391, P<.001), actual use of online communication with the GP (B=.192, P=.001), highest education level (B=.178, P<.001), monthly household net income (B=.115, P=.01), and willingness to communicate with the GP online more often in the future (B=.076, P=.03).

Conclusions

Age, gender, and trust in the GP were not significant predictors for either willingness to undergo online treatment or to pay additionally for online treatment. Willingness to undergo online treatment was partly determined by the actual use of online communication with the GP, willingness to communicate online with the GP, health information–seeking personality, and social motivation for such behavior. Willingness to pay extra for online treatment was influenced by the monthly household net income category and education level. The results of this study are useful for online health care providers and physicians who are considering offering online treatments as a viable number of patients would appreciate the possibility of undergoing an online treatment offered by their GP.

Patients' Online Access to Their Primary Care Electronic Health Records and Linked Online Services: Implications for Research and Practice

Online access to medical records and linked services, including requesting repeat prescriptions and booking appointments, enables patients to personalize their access to care. However, online access creates opportunities and challenges for both health professionals and their patients, in practices and in research. The challenges for practice are the impact of online services on workload and the quality and safety of health care. Health professionals are concerned about the impact on workload, especially from email or other online enquiry systems, as well as risks to privacy. Patients report how online access provides a convenient means through which to access their health provider and may offer greater satisfaction if they get a timely response from a clinician. Online access and services may also result in unforeseen consequences and may change the nature of the patient-clinician interaction. Research challenges include: (1) Ensuring privacy, including how to control inappropriate carer and guardian access to medical records; (2) Whether online access to records improves patient safety and health outcomes; (3) Whether record access increases disparities across social classes and between genders; and (4) Improving efficiency. The challenges for practice are: (1) How to incorporate online access into clinical workflow; (2) The need for a business model to fund the additional time taken. Creating a sustainable business model for a safe, private, informative, more equitable online service is needed if online access to records is to be provided outside of pay-for-service systems.

Internet Services for Communicating With the General Practice: Barely Noticed and Used by Patients

Background

The Netherlands is one of the frontrunners of eHealth in Europe. Many general practices offer Internet services, which can be used by patients to communicate with their general practice. In promoting and implementing such services, it is important to gain insight into patients’ actual use and intention toward using.

Objective

The objective of the study is to investigate the actual use and intention toward using Internet services to communicate with the general practice by the general practice population. The secondary objective is to study the factors and characteristics that influence their intention to use such services.

Methods

There were 1500 members of the Dutch Health Care Consumer Panel, age over 18 years, that were invited to participate in this cross-sectional study. People who had contacted their general practitioner at least once in the past year were included. Participants were asked to fill out a questionnaire about the following services: Internet appointment planning, asking questions on the Internet, email reminders about appointments, Internet prescription refill requests, Internet access to medical data, and Internet video consultation. Participants indicated whether they had used these services in the past year, they would like to use them, and whether they thought their general practice had these services. For the first two services, participants rated items based on the unified theory of acceptance and use of technology complemented with additional constructs. These items were divided into six subscales: effort expectancy, performance expectancy, trust, attitude, facilitating conditions, and social influence.

Results

There were 546 participants that were included in the analyses out of 593 who met the inclusion criteria. The participants had a mean age of 53 years (SD 15.4), 43.6% (n=238) were male, and 66.8% (n=365) had at least one chronic illness. Actual use of the services varied between 0% (n=0, video consultation) and 10.4% (n=57, requesting prescription refill by Internet). The proportion of participants with a positive intention to use the service varied between 14.7% (n=80, video consultation) and 48.7% (n=266, Internet access to medical data). For each service, approximately half indicated that they did not know whether the service was available. Univariate logistic regression analyses revealed that all the constructs as well as age, level of education, and Internet usage had a significant association with intention toward using Internet appointment planning and asking questions by Internet.

Conclusions

Internet communication services to contact the general practice are not yet frequently used by this population. Although a substantial number of persons have a positive intention toward using such services, not all people who receive primary care seem willing to use them. The lack of awareness of the availability and functionality of such services might play an important role.

Using the Consolidated Framework for Implementation Research to Identify Barriers and Facilitators for the Implementation of an Internet-Based Patient-Provider Communication Service in Five Settings: A Qualitative Study

Background

Although there is growing evidence of the positive effects of Internet-based patient-provider communication (IPPC) services for both patients and health care providers, their implementation into clinical practice continues to be a challenge.

Objective

The 3 aims of this study were to (1) identify and compare barriers and facilitators influencing the implementation of an IPPC service in 5 hospital units using the Consolidated Framework for Implementation Research (CFIR), (2) assess the ability of the different constructs of CFIR to distinguish between high and low implementation success, and (3) compare our findings with those from other studies that used the CFIR to discriminate between high and low implementation success.

Methods

This study was based on individual interviews with 10 nurses, 6 physicians, and 1 nutritionist who had used the IPPC to answer messages from patients.

Results

Of the 36 CFIR constructs, 28 were addressed in the interviews, of which 12 distinguished between high and low implementation units. Most of the distinguishing constructs were related to the inner setting domain of CFIR, indicating that institutional factors were particularly important for successful implementation. Health care providers’ beliefs in the intervention as useful for themselves and their patients as well as the implementation process itself were also important. A comparison of constructs across ours and 2 other studies that also used the CFIR to discriminate between high and low implementation success showed that 24 CFIR constructs distinguished between high and low implementation units in at least 1 study; 11 constructs distinguished in 2 studies. However, only 2 constructs (patient need and resources and available resources) distinguished consistently between high and low implementation units in all 3 studies.

Conclusions

The CFIR is a helpful framework for illuminating barriers and facilitators influencing IPPC implementation. However, CFIR’s strength of being broad and comprehensive also limits its usefulness as an implementation framework because it does not discriminate between the relative importance of its many constructs for implementation success. This is the first study to identify which CFIR constructs are the most promising to distinguish between high and low implementation success across settings and interventions. Findings from this study can contribute to the refinement of CFIR toward a more succinct and parsimonious framework for planning and evaluation of the implementation of clinical interventions.

ClinicalTrial

Clinicaltrials.gov NCT00971139; http://clinicaltrial.gov/ct2/show/NCT00971139 (Archived by WebCite at http://www.webcitation.org/6cWeqN1uY)

Intervention for Smokers through New Communication Technologies: What Perceptions Do Patients and Healthcare Professionals Have? A Qualitative Study

Background

The use of information and communication technologies (ICTs) in the health service is increasing. In spite of limitations, such as lack of time and experience, the deployment of ICTs in the healthcare system has advantages which include patient satisfaction with secure messaging, and time saving benefits and utility for patients and health professionals. ICTs may be helpful as either interventions on their own or as complementary tools to help patients stop smoking.

Objectives

To gather opinions from both medical professionals and smokers about an email-based application that had been designed by our research group to help smoking cessation, and identify the advantages and disadvantages associated with interventions based on the utilization of ICTs for this purpose.

Methods

A qualitative, descriptive–interpretative study with a phenomenological perspective was performed to identify and interpret the discourses of the participating smokers and primary healthcare professionals. Data were obtained through two techniques: semi-structured individual interviews and discussion groups, which were recorded and later systematically and literally transcribed together with the interviewer’s notes. Data were analyzed with the ATLAS TI 6.0 programme.

Results

Seven individual interviews and four focal groups were conducted. The advantages of the application based on the email intervention designed by our research group were said to be the saving of time in consultations and ease of access for patients who found work timetables and following a programme for smoking cessation incompatible. The disadvantages were thought to be a lack of personal contact with the healthcare professional, and the possibility of cheating/ self-deception, and a greater probability of relapse on the part of the smokers.

Conclusions

Both patients and healthcare professionals viewed the email-based application to help patients stop smoking as a complementary aid to face-to-face consultations. Nevertheless, ICTs could not substitute personal contact in the smoking cessation programme.

Rapid growth in surgeons' use of secure messaging in a patient portal

BACKGROUND

Use of secure messaging through patient portals has risen substantially in recent years due to provider incentives and consumer demand. Secure messaging may increase patient satisfaction and improve outcomes, but also adds to physician workload. Most prior studies of secure messaging focused on primary care and medical specialties. We examined surgeons' use of secure messaging and the contribution of messaging to outpatient interactions in a broadly deployed patient portal.

METHODS

We determined the number of clinic visits and secure messages for surgical providers in the first 3 years (2008-2010) after patient portal deployment at an academic medical center. We calculated the proportion of outpatient interaction conducted through messaging for each specialty. Logistic regression models compared the likelihood of message-based versus clinic outpatient interaction across surgical specialties.

RESULTS

Over the study period, surgical providers delivered care in 648,200 clinic visits and received 83,912 messages, with more than 200% growth in monthly message volume. Surgical specialties receiving the most messages were orthopedics/podiatry (25.1%), otolaryngology (20.1%), urology (10.8%), and general surgery (9.6%); vascular surgery (0.8%) and pediatric general surgery (0.2%) received the fewest. The proportion of outpatient interactions conducted through secure messaging increased significantly from 5.4% in 2008 to 15.3% in 2010 (p < 0.001) with all specialties experiencing growth. Heart/lung transplantation (74.9%), liver/kidney/pancreas transplantation (69.5%), and general surgery (48.7%) had the highest proportion of message-based outpatient interaction by the end of the study.

CONCLUSIONS

This study demonstrates rapid adoption of online secure messaging across surgical specialties with significant growth in its use for outpatient interaction. Some specialties, particularly those with long-term follow-up, interacted with patients more through secure messaging than in person. As surgeons devote more time to secure messaging, additional research will be needed to understand the care delivered through online interactions and to develop models for reimbursement.

Growth of Secure Messaging Through a Patient Portal as a Form of Outpatient Interaction across Clinical Specialties

OBJECTIVE

Patient portals are online applications that allow patients to interact with healthcare organizations. Portal adoption is increasing, and secure messaging between patients and healthcare providers is an emerging form of outpatient interaction. Research about portals and messaging has focused on medical specialties. We characterized adoption of secure messaging and the contribution of messaging to outpatient interactions across diverse clinical specialties after broad portal deployment.

METHODS

This retrospective cohort study at Vanderbilt University Medical Center examined use of patient-initiated secure messages and clinic visits in the three years following full deployment of a patient portal across adult and pediatric specialties. We measured the proportion of outpatient interactions (i.e., messages plus clinic visits) conducted through secure messaging by specialty over time. Generalized estimating equations measured the likelihood of message-based versus clinic outpatient interaction across clinical specialties.

RESULTS

Over the study period, 2,422,114 clinic visits occurred, and 82,159 unique portal users initiated 948,428 messages to 1,924 recipients. Medicine participated in the most message exchanges (742,454 messages; 78.3% of all messages sent), followed by surgery (84,001; 8.9%) and obstetrics/gynecology (53,424; 5.6%). The proportion of outpatient interaction through messaging increased from 12.9% in 2008 to 33.0% in 2009 and 39.8% in 2010 (p<0.001). Medicine had the highest proportion of outpatient interaction conducted through messaging in 2008 (23.3% of outpatient interactions in medicine). By 2010, this proportion was highest for obstetrics/gynecology (83.4%), dermatology (71.6%), and medicine (56.7%). Growth in likelihood of message-based interaction was greater for anesthesiology, dermatology, obstetrics/gynecology, pediatrics, and psychiatry than for medicine (p<0.001).

CONCLUSIONS

This study demonstrates rapid adoption of secure messaging across diverse clinical specialties, with messaging interactions exceeding face-to-face clinic visits for some specialties. As patient portal and secure messaging adoption increase beyond medicine and primary care, research is needed to understand the implications for provider workload and patient care.

Patients' online access to their electronic health records and linked online services: a systematic interpretative review

OBJECTIVES

To investigate the effect of providing patients online access to their electronic health record (EHR) and linked transactional services on the provision, quality and safety of healthcare. The objectives are also to identify and understand: barriers and facilitators for providing online access to their records and services for primary care workers; and their association with organisational/IT system issues.

SETTING

Primary care.

PARTICIPANTS

A total of 143 studies were included. 17 were experimental in design and subject to risk of bias assessment, which is reported in a separate paper. Detailed inclusion and exclusion criteria have also been published elsewhere in the protocol.

PRIMARY AND SECONDARY OUTCOME MEASURES

Our primary outcome measure was change in quality or safety as a result of implementation or utilisation of online records/transactional services.

RESULTS

No studies reported changes in health outcomes; though eight detected medication errors and seven reported improved uptake of preventative care. Professional concerns over privacy were reported in 14 studies. 18 studies reported concern over potential increased workload; with some showing an increase workload in email or online messaging; telephone contact remaining unchanged, and face-to face contact staying the same or falling. Owing to heterogeneity in reporting overall workload change was hard to predict. 10 studies reported how online access offered convenience, primarily for more advantaged patients, who were largely highly satisfied with the process when clinician responses were prompt.

CONCLUSIONS

Patient online access and services offer increased convenience and satisfaction. However, professionals were concerned about impact on workload and risk to privacy. Studies correcting medication errors may improve patient safety. There may need to be a redesign of the business process to engage health professionals in online access and of the EHR to make it friendlier and provide equity of access to a wider group of patients. A1 SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42012003091.

Online medicine for pregnant women

Objective. To assess the use of cell phones and email as means of communication between pregnant women and their gynecologists and family physicians. Study Design. A cross-sectional study of pregnant women at routine followup. One hundred and twenty women participated in the study. Results. The mean age was 27.4 ± 3.4 years. One hundred nineteen women owned a cell phone and 114 (95%) had an email address. Seventy-two women (60%) had their gynecologist's cell phone number and 50 women (42%) had their family physician's cell phone number. More women contacted their gynecologist via cell phone or email during pregnancy compared to their family physician (P = 0.005 and 0.009, resp.). Most preferred to communicate with their physician via cell phone at predetermined times, but by email at any time during the day (P < 0.0001). They would use cell phones for emergencies or unusual problems but preferred email for other matters (P < 0.0001). Conclusions. Pregnant women in the Negev region do not have a preference between the use of cell phones or email for medical consultation with their gynecologist or family physician. The provision of the physician's cell phone numbers or email address together with the provision of guidelines and resources could improve healthcare services.

Patient-provider secure messaging in VA: variations in adoption and association with urgent care utilization

BACKGROUND

The Veterans Health Administration has implemented patient to clinical team electronic asynchronous secure messaging (SM). This disruptive technology has the potential to support continuous, coordinated quality care, but limited evidence supports this connection.

OBJECTIVES

The objective of this paper is to (1) measure SM implementation and identify facility characteristics associated with higher rates of adoption and (2) understand the association of SM use and noncontinuity care [ie, urgent care (UC)] utilization rates.

MEASURES

We conducted a retrospective cohort study of 132 VA facilities implementing SM in primary care. We used a combination of cross-sectional survey data on predictors of SM implementation and longitudinal data (July 2010-June 2012) on use of SM and UC.

RESULTS

Human resources (coordinator and staff/volunteer availability to directly assist Veterans), computer resources (computers and computer rooms for Veterans), and leadership support for coordinators were associated with increased SM adoption rates. Higher SM use was associated with lower UC rates; early adopters of SM achieved a greater decrease in UC utilization over time than later adopters.

CONCLUSIONS

In this exploratory analysis of early SM implementation in VA, we found a path of associations linking SM and reductions in UC utilization. These results suggest a need for further examination of the relationship between SM and its effects on health care utilization patterns.

Secure messaging and diabetes management: experiences and perspectives of patient portal users

BACKGROUND

Patient portal use has been associated with favorable outcomes, but we know less about how patients use and benefit from specific patient portal features.

OBJECTIVE

Using mixed-methods, we explored how adults with type 2 diabetes (T2DM) use and benefit from secure messaging (SM) within a patient portal.

METHODS

Adults with T2DM who had used a patient portal participated in a focus group and completed a survey (n=39) or completed a survey only (n=15). We performed thematic analysis of focus group transcripts to identify the benefits of and barriers to using SM within a portal. We also examined the association between use of various patient portal features and patients' glycemic control.

RESULTS

Participants were on average 57.1 years old; 65% were female; 76% were Caucasian/White, and 20% were African American/Black. Self-reported benefits of SM within a portal included enhanced patient satisfaction, enhanced efficiency and quality of face-to-face visits, and access to clinical care outside traditional face-to-face visits. Self-reported barriers to using SM within a portal included preconceived beliefs or rules about SM and prior negative experiences with SM. Participants' assumptions about providers' opinions about SM and providers' instructions about SM also influenced use. Greater self-reported use of SM to manage a medical appointment was significantly associated with patients' glycemic control (ρ=-0.29, p=0.04).

CONCLUSION

SM within a portal may facilitate access to care, enhance the quality of office visits, and be associated with patient satisfaction and clinical outcomes for patients with diabetes, but provider communication about SM is essential.

Effectiveness of an intensive E-mail based intervention in smoking cessation (TABATIC study): study protocol for a randomized controlled trial

BACKGROUND

Intensive interventions on smoking cessation increase abstinence rates. However, few electronic mail (E-mail) based intensive interventions have been tested in smokers and none in primary care (PC) setting. The aim of the present study is to evaluate the effectiveness of an intensive E-mail based intervention in smokers attending PC services.

METHODS/DESIGN

Randomized Controlled Multicentric Trial.

STUDY POPULATION

1060 smokers aged between 18-70 years from Catalonia, Salamanca and Aragón (Spain) who have and check regularly an E-mail account. Patients will be randomly assigned to control or intervention group.

INTERVENTION

Six phase intensive intervention with two face to face interviews and four automatically created and personal E-mail patients tracking, if needed other E-mail contacts will be made. Control group will receive a brief advice on smoking cessation.

OUTCOME MEASURES

Will be measured at 6 and 12 months after intervention: self reported continuous abstinence (confirmed by cooximetry), point prevalence abstinence, tobacco consumption, evolution of stage according to Prochaska and DiClemente's Stages of Change Model, length of visit, costs for the patient to access Primary Care Center.

STATISTICAL ANALYSIS

Descriptive and logistic and Poisson regression analysis under the intention to treat basis using SPSS v.17.

DISCUSSION

The proposed intervention is an E-mail based intensive intervention in smokers attending primary care. Positive results could be useful to demonstrate a higher percentage of short and long-term abstinence among smokers attended in PC in Spain who regularly use E-mail. Furthermore, this intervention could be helpful in all health services to help smokers to quit.

TRIAL REGISTRATION

Clinical Trials.gov Identifier: NCT01494246.

Email for clinical communication between patients/caregivers and healthcare professionals

BACKGROUND

Email is a popular and commonly-used method of communication, but its use in health care is not routine. Where email communication has been demonstrated in health care this has included its use for communication between patients/caregivers and healthcare professionals for clinical purposes, but the effects of using email in this way is not known.This review addresses the use of email for two-way clinical communication between patients/caregivers and healthcare professionals.

OBJECTIVES

To assess the effects of healthcare professionals and patients using email to communicate with each other, on patient outcomes, health service performance, service efficiency and acceptability.

SEARCH METHODS

We searched: the Cochrane Consumers and Communication Review Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2010), MEDLINE (OvidSP) (1950 to January 2010), EMBASE (OvidSP) (1980 to January 2010), PsycINFO (OvidSP) (1967 to January 2010), CINAHL (EbscoHOST) (1982 to February 2010) and ERIC (CSA) (1965 to January 2010). We searched grey literature: theses/dissertation repositories, trials registers and Google Scholar (searched July 2010). We used additional search methods: examining reference lists, contacting authors.

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised trials, controlled before and after studies and interrupted time series studies examining interventions using email to allow patients to communicate clinical concerns to a healthcare professional and receive a reply, and taking the form of 1) unsecured email 2) secure email or 3) web messaging. All healthcare professionals, patients and caregivers in all settings were considered.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias of included studies and extracted data. We contacted study authors for additional information. We assessed risk of bias according to the Cochrane Handbook for Systematic Reviews of Interventions. For continuous measures, we report effect sizes as mean differences (MD). For dichotomous outcome measures, we report effect sizes as odds ratios and rate ratios. Where it was not possible to calculate an effect estimate we report mean values for both intervention and control groups and the total number of participants in each group. Where data are available only as median values it is presented as such. It was not possible to carry out any meta-analysis of the data.

MAIN RESULTS

We included nine trials enrolling 1733 patients; all trials were judged to be at risk of bias. Seven were randomised controlled trials; two were cluster-randomised controlled designs. Eight examined email as compared to standard methods of communication. One compared email with telephone for the delivery of counselling. When email was compared to standard methods, for the majority of patient/caregiver outcomes it was not possible to adequately assess whether email had any effect. For health service use outcomes it was not possible to adequately assess whether email has any effect on resource use, but some results indicated that an email intervention leads to an increased number of emails and telephone calls being received by healthcare professionals. Three studies reported some type of adverse event but it was not clear if the adverse event had any impact on the health of the patient or the quality of health care. When email counselling was compared to telephone counselling only patient outcomes were measured, and for the majority of measures there was no difference between groups. Where there were differences these showed that telephone counselling leads to greater change in lifestyle modification factors than email counselling. There was one outcome relating to harm, which showed no difference between the email and the telephone counselling groups. There were no primary outcomes relating to healthcare professionals for either comparison.

AUTHORS' CONCLUSIONS

The evidence base was found to be limited with variable results and missing data, and therefore it was not possible to adequately assess the effect of email for clinical communication between patients/caregivers and healthcare professionals. Recommendations for clinical practice could not be made. Future research should ideally address the issue of missing data and methodological concerns by adhering to published reporting standards. The rapidly changing nature of technology should be taken into account when designing and conducting future studies and barriers to trial development and implementation should also be tackled. Potential outcomes of interest for future research include cost-effectiveness and health service resource use.

Integration of computer and Internet-based programmes into psychiatric out-patient care of adolescents with depression

The aim of this explorative study was to describe nurses' opportunities to integrate computer and Internet-based programmes in psychiatric out-patient care among adolescents with depression. Therefore, nurses' daily computer use and possible problems related to it were investigated. The data were collected by conducting focus group interviews with Finnish registered nurses (n =12) working at the out-patient clinics of two university central hospitals. The data were analysed using inductive content analysis. The analysis showed that nurses used the computer and Internet in their daily work for data transmission and informal interaction with adolescents. Findings revealed that nurses have good computer skills, a positive attitude towards using the computer and Internet and were motivated to make use of both on a daily basis. Problems faced in daily computer use were a lack of instructions and education, and lack of help and support. We can conclude that nurses have good opportunities to implement computer and Internet-based programmes in adolescent out-patient care. These results are encouraging keeping in mind that adolescents are the most active Internet users in society.

Providing cell phone numbers and e-mail addresses to patients: The patient's perspective, a cross sectional study

Background

Today patients can consult with their treating physician by cell phone or e-mail. These means of communication enhance the quality of medical care and increase patient satisfaction, but they can also impinge on physicians’ free time and their patient schedule while at work. The objective of this study is to assess the attitudes and practice of patients on obtaining the cell phone number or e-mail address of their physician for the purpose of medical consultation.

Methods

Personal interviews with patients, 18 years of age or above, selected by random sampling from the roster of adults insured by Clalit Health Services, Southern Division. The total response rate was 41%. The questionnaire included questions on the attitude and practice of patients towards obtaining their physician’s cell phone number or e-mail address. Comparisons were performed using Chi-square tests to analyze statistically significant differences of categorical variables. Two-tailed p values less than 0.05 were considered statistically significant, with a power of 0.8.

Results

The study sample included 200 patients with a mean age of 46.6 ± 17.1, of whom 110 were women (55%). Ninety-three (46.5%) responded that they would be very interested in obtaining their physician’s cell phone number, and an additional 83 (41.5%) would not object to obtaining it. Of the 171 patients (85.5%) who had e-mail addresses, 25 (14.6%) said they would be very interested in obtaining their physician’s e-mail address, 85 (49.7%) said they would not object to getting it, and 61 (35.7%) were not interested. In practice only one patient had requested the physician’s e-mail address and none actually had it.

Conclusions

Patients favored cell phones over e-mail for consulting with their treating physicians. With new technologies such as cell phones and e-mail in common use, it is important to determine how they can be best used and how they should be integrated into the flow of clinical practice.

Send it: study of e-mail etiquette and notions from doctors in training

OBJECTIVES

Worldwide, more than 247 billion e-mails are sent each day. Little empiric evidence is available to guide how e-mail presentation style, tone, and content affect e-mail recipients and whether these factors impact opinions about the sender and the rapidity of response. In a study of physicians in training assessing a series of 100 e-mail examples, we examined the following: (1) formatting characteristics most and least endorsed, (2) impression of the sender based on the e-mail itself, and (3) factors associated with the decision to respond. We reasoned that our study would provide empiric data to support recommendations for e-mail etiquette, focusing specifically on doctors in training.

DESIGN

Cross-sectional survey study.

SETTING

Division of Orthopaedic Surgery at McMaster University, Hamilton, Ontario, Canada.

PARTICIPANTS

After each e-mail, the participating surgical residents completed a series of questions focusing on their impression of the e-mail appearance, their perception of the sender, and their motivation to respond to the e-mail.

RESULTS

Thirty-two residents participated in this study. The responses indicate that the key negatively endorsed features of the e-mails included the use of colored backgrounds (84%), difficult-to-read font (83%), lack of a subject header (55%), opening salutations without recipient names (50%), or no salutation at all (42%). The senders of negatively endorsed e-mails were perceived by participants as inefficient (p = 0.03), unprofessional (p < 0.001), and irritating (p = 0.007). E-mails with overall positive endorsements were significantly more likely to have the participants perceive the e-mail senders as professional (p < 0.001), pleasant (p = 0.048), and kind (p = 0.059). The participants were 2.6-fold more likely to respond immediately when they perceived e-mails as favorable compared with disliking them (42% vs 16% of responses, respectively, p < 0.001).

CONCLUSION

The e-mails perceived as being disliked overall are likely to result in a negative perception of the sender and delays in response time.

Consistency of patient preferences about a secure Internet-based patient communications portal: contemplating, enrolling, and using

Internet-based secure communication portals (portal) have the potential to enhance patient care via improved patient-provider communications. This study examines differences among primary care patients' perceptions when contemplating using, enrolling to use, and using a portal for health care purposes. A total of 3 groups of patients from 1 Midwestern academic medical center were surveyed at different points in time: (1) Waiting Room survey asking about hypothetical interest in using a portal to communicate with their physicians; (2) patient portal Enrollment survey; and (3) Follow-up postenrollment experience survey. Those who enroll and use a patient portal have different demographic characteristics and interest levels in selected portal functions (eg, e-mailing providers, viewing medical records online, making appointments) and initially perceive only limited improvements in care because of the portal. These differences have potential market implications and provide insight into selecting and maintaining portal functions of greater interest to patients who use the portal.

Physician response time when communicating with patients over the Internet

Background

Patients want to use electronic communication to access health services more easily. Health authorities in several countries see this as a way to improve health care. Physicians appear to have conflicting opinions regarding the suitability of electronic communication in clinical settings.

Objectives

The aim of our study was to measure how long it actually takes physicians to answer questions from patients through an electronic communication channel, and whether some of the questions are especially time consuming.

Methods

We monitored electronic patient–physician communication. A total of 1113 messages from 14 participating physicians from 7 medical offices were analyzed. The length of questions and answers, and the time physicians spent answering the questions were recorded and analyzed.

Results

Physicians spent an average of 2.3 minutes (median 2 minutes) answering questions from patients. The patients’ questions had an average length of 507.1 characters (95% CI 487.4–526.9, SD 336.2), while physicians’ answers averaged 119.9 characters (95% CI 189.8–210.0, SD 172.6). The results show that the influence of patient question length on time spent responding was negligible. For the shortest 25% of the questions the answer time was 2.1 minutes (95% CI 1.9–2.3), while it was 2.4 minutes (95% CI 2.2–2.7) for the longest 25%. Even extremely long questions had a minimal impact on the time spent answering them. A threefold increase in question length from patients resulted in only an 18% increase in physician response time.

Conclusions

The study shows the potential clinical usefulness of electronic communication between patients and health care services by demonstrating the potential for saving time.

Effects of between visit physician-patient communication on Diabetes Recognition Program scores

OBJECTIVE

To determine whether physicians who interact with their patients between office visits using secure messaging and phone provide better care for patients with diabetes when controlling for physician, patient and care center characteristics.

DESIGN

Retrospective study.

SETTING

Kaiser Permanente Mid-Atlantic States.

PARTICIPANTS

174 Primary Care Physicians.

INTERVENTION

We modeled the relationship between communication via secure messaging or phone communication and Diabetes Recognition Program (DRP) scores with a Generalized Estimating Equations model. Covariates included physician age and panel size, patient age, race, income and number of comorbidities, and the population density around the care center.

MAIN OUTCOME MEASURE

DRP scores.

RESULTS

Physicians whose patients were predominantly white or mixed race were more likely than other physicians to use secure messaging and phone with their patients between visits, but there was no significant association between such contacts and DRP scores (P> 0.1). In contrast, physicians with predominantly black or Hispanic patients had significantly higher DRP scores associated with the use of secure messaging (P< 0.01) and higher, though not statistically significant, DRP scores associated with the use of phone (P< 0.1). These associations were strongest for outcome measures such as HbA1c and lipid levels, and were weaker or nonexistent for process measures such as annual foot and eye exams.

CONCLUSIONS

The use of secure messaging, and, to a lesser extent, phone, appears to be associated with higher quality diabetes care, particularly among at-risk populations.

An ask-the-expert service on a rheumatology web site: who were the users and what did they look for?

OBJECTIVE

To analyze the inquiries sent to an online ask-the-rheumatologist service in order to identify the users' needs and requirements.

METHODS

The official web site of the German Competence Network Rheumatology (www.rheumanet.org) provided expert information for patients, relatives, and physicians. We analyzed the content of 1,133 inquiries posted over 5 years and the experts' answers were blinded for analyses.

RESULTS

Patients (60.0%), relatives (24.3%), and physicians (15.7%) addressed the experts. Inquiries were predominantly sent by women (62.2%). Distinct rheumatic diseases were mentioned in 40.5% of the inquiries, and 16.3% reported musculoskeletal symptoms without a definite diagnosis. The number of questions ranged from 1-7 per inquiry (mean±SD 1.58±0.9). Of the inquiries, 33.2% contained personal histories, 24.9% searched for a rheumatologist nearby, and 11.6% asked for a "second opinion." The questions covered a wide range of interests, including medication (30.8%), diagnosis-related issues (15.7%), laboratory tests (6.9%), (treatment) guidelines (6.2%), sexual and reproductive health issues (4.1%), and clinical trials (3.4%). In more than 50% of the inquiries, the information requested from the experts was already at least partly published on the web site. The experts' answers covered the users' questions completely in 91.8%, partly in 6.1%, and not at all in 2.1%.

CONCLUSION

A standardized medical web site providing tailored and trustworthy information for all user groups gains from an ask-the-expert service. Only such an interactive online application is able to satisfy users' actual demands: searching for specific individualized information on the internet. Therefore, an ask-the-expert service contributes to optimized patient care.

Providing cell phone numbers and email addresses to Patients: the physician's perspective

Background

The provision of cell phone numbers and email addresses enhances the accessibility of medical consultations, but can add to the burden of physicians' routine clinical practice and affect their free time. The objective was to assess the attitudes of physicians to providing their telephone number or email address to patients.

Methods

Primary care physicians in the southern region of Israel completed a structured questionnaire that related to the study objective.

Results

The study population included 120 primary care physicians with a mean age of 41.2 ± 8.5, 88 of them women (73.3%). Physicians preferred to provide their cell phone number rather than their email address (P = 0.0007). They preferred to answer their cell phones only during the daytime and at predetermined times, but would answer email most hours of the day, including weekends and holidays (P = 0.001). More physicians (79.7%) would have preferred allotted time for email communication than allotted time for cell phone communication (50%). However, they felt that email communication was more likely to lead to miscommunication than telephone calls (P = 0.0001). There were no differences between male and female physicians on the provision of cell phone numbers or email addresses to patients. Older physicians were more prepared to provide cell phone numbers that younger ones (P = 0.039).

Conclusions

The attitude of participating physicians was to provide their cell phone number or email address to some of their patients, but most of them preferred to give out their cell phone number.