Real-Time Access to Electronic Health Record via a Patient Portal: Is it Harmful? A Retrospective Observational Study

Capture of real-time data from electronic health records: scenarios and solutions

Background

The integration of real-time data (RTD) in the electronic health records (EHRs) is transforming the healthcare of tomorrow. In this work, the common scenarios of capturing RTD in the healthcare from EHRs are studied and the approaches and tools to implement real-time solutions are investigated.

Methods

Delivering RTD by representational state transfer (REST) application programming interfaces (APIs) is usually accomplished through a Publish-Subscribe approach. Common technologies and protocols used for implementing subscriptions are REST hooks and WebSockets. Polling is a straightforward mechanism for obtaining updates; nevertheless, it may not be the most efficient or scalable solution. In such cases, other approaches are often preferred. Database triggers and reverse proxies can be useful in RTD scenarios; however, they should be designed carefully to avoid performance bottlenecks and potential issues.

Results

The implementation of subscriptions through REST hooks and WebSocket notifications using a Fast Healthcare Interoperability Resources (FHIR) REST API, as well as the design of a reverse proxy and database triggers is described. Reference implementations of the solutions are provided in a GitHub repository. For the reverse proxy implementation, the Go language (Golang) was used, which is specialized for the development of server-side networking applications. For FHIR servers a python script is provided to create a sample Subscription resource to send RTD when a new Observation resource for specific patient id is created. The sample WebSocket client is written using the "websocket-client" python library. The sample RTD endpoint is created using the "Flask" framework. For database triggers a sample structured query language (SQL) query for Postgres to create a trigger when an INSERT or UPDATE operation is executed on the FHIR resource table is available. Furthermore, a use case clinical example, where the main actors are the healthcare providers (hospitals, physician private practices, general practitioners and medical laboratories), health information networks and the patient are drawn. The RTD flow and exchange is shown in detail and how it could improve healthcare.

Conclusions

Capturing RTD is undoubtedly vital for health professionals and successful digital healthcare. The topic remains unexplored especially in the context of EHRs. In our work for the first time the common scenarios and problems are investigated. Furthermore, solutions and reference implementations are provided which could support and contribute to the development of real-time applications.

Patients' choices regarding online access to laboratory, radiology and pathology test results on a hospital patient portal

The disclosure of online test results (i.e., laboratory, radiology and pathology results) on patient portals can vary from immediate disclosure (in real-time) via a delay of up to 28 days to non-disclosure. Although a few studies explored patient opinions regarding test results release, we have no insight into actual patients' preferences. To address this, we allowed patients to register their choices on a hospital patient portal. Our research question was: When do patients want their test results to be disclosed on the patient portal and what are the reasons for these choices? We used a mixed methods sequential explanatory design that included 1) patient choices on preferred time delay to test result disclosure on the patient portal for different medical specialties (N = 4592) and 2) semi-structured interviews with patients who changed their mind on their initial choice (N = 7). For laboratory (blood and urine) results, 3530 (76.9%) patients chose a delay of 1 day and 912 (19.9%) patients chose a delay of 7 days. For radiology and pathology results 4352 (94.8%) patients chose a delay of 7 days. 43 patients changed their mind about when they wanted to receive their results. By interviewing seven patients (16%) from this group we learned that some participants did not remember why they made changes. Four participants wanted a shorter delay to achieve transparency in health-related information and communication; to have time to process bad results; for reassurance; to prepare for a medical consultation; monitoring and acting on deviating results to prevent worsening of their disease; and to share results with their general practitioner. Three participants extended their chosen delay to avoid the disappointment about the content and anxiety of receiving incomprehensible information. Our study indicates that most patients prefer transparency in health-related information and want their test results to be disclosed as soon as possible.

Rapid On-site Evaluation Practice Variability Appraisal (ROSE PETAL) survey

BACKGROUND

Rapid on-site evaluation (ROSE) is frequently used during diagnostic procedures in patients with or suspected to have lung cancer. There is variation in ROSE use among bronchoscopists, and discussion of ROSE results can have significant consequences for patients. This study was performed to define ROSE practice and result disclosure patterns among bronchoscopists.

METHODS

This cross-sectional study was performed using an electronic survey disseminated to the members of the American Association for Bronchology and Interventional Pulmonology and the Society for Advanced Bronchoscopy. The questions centered around ROSE availability, utilization, barriers, and discussion of results with patients.

RESULTS

There were 137 respondents. Most identified themselves as interventional pulmonologists (109, 80%); most respondents worked in an academic setting (71, 52%). Availability of ROSE was reported by 121 (88%) respondents. Time constraints (28%), availability of cytology (22%), and scheduling conflicts (20%) were the most reported barriers to ROSE use. Endobronchial ultrasound transbronchial needle aspiration (85%) and nonrobotic peripheral bronchoscopy (65%) were the most reported procedures that used ROSE. There was heterogeneity regarding discussion of ROSE results with the patient or their caregiver in the immediate postprocedure setting: yes - always (40, 33%), yes - sometimes (32, 26%), yes - rarely (18, 15%), or no (31, 26%). Thirty-eight respondents reported they believed ROSE was ≥90% concordant with final cytology results.

CONCLUSIONS

The results confirmed the heterogeneity of practice patterns. Estimates of ROSE-final cytology concordance were lower than previously published concordance results. Notably, the discussion of ROSE results varied significantly.

Patients' Experiences of Web-Based Access to Electronic Health Records in Finland: Cross-sectional Survey

Background

Patient portals that provide access to electronic health records offer a means for patients to better understand and self-manage their health. Yet, patient access to electronic health records raises many concerns among physicians, and little is known about the use practices and experiences of patients who access their electronic health records via a mature patient portal that has been available for citizens for over five years.

Objective

We aimed to identify patients’ experiences using a national patient portal to access their electronic health records. In particular, we focused on understanding usability-related perceptions and the benefits and challenges of reading clinical notes written by health care professionals.

Methods

Data were collected from 3135 patient users of the Finnish My Kanta patient portal through a web-based survey in June 2021 (response rate: 0.7%). Patients received an invitation to complete the questionnaire when they logged out of the patient portal. Respondents were asked to rate the usability of the patient portal, and the ratings were used to calculate approximations of the System Usability Scale score. Patients were also asked about the usefulness of features, and whether they had discussed the notes with health professionals. Open-ended questions were used to ask patients about their experiences of the benefits and challenges related to reading health professionals’ notes.

Results

Overall, patient evaluations of My Kanta were positive, and its usability was rated as good (System Usability Scale score approximation: mean 72.7, SD 15.9). Patients found the portal to be the most useful for managing prescriptions and viewing the results of examinations and medical notes. Viewing notes was the most frequent reason (978/3135, 31.2%) for visiting the portal. Benefits of reading the notes mentioned by patients included remembering and understanding what was said by health professionals and the instructions given during an appointment, the convenience of receiving information about health and care, the capability to check the accuracy of notes, and using the information to support self-management. However, there were challenges related to difficulty in understanding medical terminology, incorrect or inadequate notes, missing notes, and usability.

Conclusions

Patients actively used medical notes to receive information to follow professionals' instructions to take care of their health, and patient access to electronic health records can support self-management. However, for the benefits to be realized, improvements in the quality and availability of medical professionals’ notes are necessary. Providing a standard information structure could help patients find the information they need. Furthermore, linking notes to vocabularies and other information sources could also improve the understandability of medical terminology; patient agency could be supported by allowing them to add comments to their notes, and patient trust of the system could be improved by allowing them to control the visibility of the professionals’ notes.

Prevalence and Factors Associated with Patient-Requested Corrections to the Medical Record through Use of a Patient Portal: Findings from a National Survey

BACKGROUND

Providing patients with medical records access is one strategy that health systems can utilize to reduce medical errors. However, how often patients request corrections to their records on a national scale is unknown.

OBJECTIVES

We aimed to develop population-level estimates of patients who request corrections to their medical records using national-level data. We also identified patient-level correlates of requesting corrections.

METHODS

We used the 2017 and 2019 Health Information National Trends Survey and examined all patient portal adopters. We applied jackknife replicate weights to develop population-representative estimates of the prevalence of requesting medical record corrections. We conducted a multivariable logistic regression analysis to identify correlates of requesting corrections while controlling for demographic factors, health care utilization patterns, health status, technology/internet use patterns, and year.

RESULTS

Across 1,657 respondents, 125 (weighted estimate: 6.5%) reported requesting corrections to their medical records. In unadjusted models, greater odds of requesting corrections were observed among patients who reported their race/ethnicity as non-Hispanic black (odds ratio [OR]: 2.20, 95% confidence interval [CI]: 1.10-4.43), had frequent portal visits (OR: 3.92, 95% CI: 1.51-10.23), and had entered data into the portal (OR: 7.51, 95% CI: 4.08-13.81). In adjusted models, we found greater odds of requesting corrections among those who reported frequent portal visits (OR: 3.39, 95% CI: 1.24-9.33) and those who reported entering data into the portal (OR: 6.43, 95% CI: 3.20-12.94). No other significant differences were observed.

CONCLUSION

Prior to the Information Blocking Final Rule in April 2021, approximately 6.5% of patients requested corrections of errors in their medical records at the national level. Those who reported higher engagement with their health, as proxied by portal visit frequency and entering data into the portal, were more likely to request corrections.

Implementation Strategies to Improve Engagement With a Multi-Institutional Patient Portal: Multimethod Study

Background

Comprehensive multi-institutional patient portals that provide patients with web-based access to their data from across the health system have been shown to improve the provision of patient-centered and integrated care. However, several factors hinder the implementation of these portals. Although barriers and facilitators to patient portal adoption are well documented, there is a dearth of evidence examining how to effectively implement multi-institutional patient portals that transcend traditional boundaries and disparate systems.

Objective

This study aims to explore how the implementation approach of a multi-institutional patient portal impacted the adoption and use of the technology and to identify the lessons learned to guide the implementation of similar patient portal models.

Methods

This multimethod study included an analysis of quantitative and qualitative data collected during an evaluation of the multi-institutional MyChart patient portal that was deployed in Southwestern Ontario, Canada. Descriptive statistics were performed to understand the use patterns during the first 15 months of implementation (between August 2018 and October 2019). In addition, 42 qualitative semistructured interviews were conducted with 18 administrative stakeholders, 16 patients, 7 health care providers, and 1 informal caregiver to understand how the implementation approach influenced user experiences and to identify strategies for improvement. Qualitative data were analyzed using an inductive thematic analysis approach.

Results

Between August 2018 and October 2019, 15,271 registration emails were sent, with 67.01% (10,233/15,271) registered for an account across 38 health care sites. The median number of patients registered per site was 19, with considerable variation (range 1-2114). Of the total number of sites, 55% (21/38) had ≤30 registered patients, whereas only 2 sites had over 1000 registered patients. Interview participants perceived that the patient experience of the portal would have been improved by enhancing the data comprehensiveness of the technology. They also attributed the lack of enrollment to the absence of a broad rollout and marketing strategy across sites. Participants emphasized that provider engagement, change management support, and senior leadership endorsement were central to fostering uptake. Finally, many stated that regional alignment and policy support should have been sought to streamline implementation efforts across participating sites.

Conclusions

Without proper management and planning, multi-institutional portals can suffer from minimal adoption. Data comprehensiveness is the foundational component of these portals and requires aligned policies and a key base of technology infrastructure across all participating sites. It is important to look beyond the category of the technology (ie, patient portal) and consider its functionality (eg, data aggregation, appointment scheduling, messaging) to ensure that it aligns with the underlying strategic priorities of the deployment. It is also critical to establish a clear vision and ensure buy-ins from organizational leadership and health care providers to support a cultural shift that will enable a meaningful and widespread engagement.

Impact of using wearable devices on psychological Distress: Analysis of the health information national Trends survey

AIM

This study explores the possible impact of wearables on psychological distress and their implications on designs.

METHOD

The study conceptualizes and tests two exploratory models by analyzing the US-based Health Information National Trends Survey of 2019 and 2020. Six variants from the databases were used in the study as predictors. We used models 4 and 6 of the Hayes PROCESS macros to test our conceptual parallel and sequential mediation models, respectively.

RESULTS

The finding indicates significant and negative indirect effects of 'Use of wearable device' on 'Psychological distress.' In parallel mediation models, 'self-care' and 'health perception' were noted to be significant mediators. Wearable devices were associated with improved 'Health perception,' 'Self-care,' and longer 'workout duration,', which in turn helped reduce 'psychological distress' (better mental health). The sequential mediation model captured the indirect effect of 'Use of wearable device' on 'Psychological distress' when sequentially mediated by 'workout duration,' 'BMI,' 'self-care,' and 'health perception' in the given order.

CONCLUSION

As the adoption of digital wearables is increasing due to their growing potential to augment physiological and psychosocial health, it is critical that these technologies are designed to address the needs of users from diverse backgrounds (race, education level, age).

EVALUATION OF A TELEHEALTH APPLICATION (SEHHA) USED DURING THE COVID-19 PANDEMIC IN SAUDI ARABIA: PROVIDER EXPERIENCE AND SATISFACTION

INTRODUCTION

COVID-19 has drastically transformed healthcare delivery and forced many to utilize telehealth. This study aimed to comprehensively evaluate the telehealth service "Sehha" used during COVID-19 in Saudi Arabia and assess the provider experience and satisfaction with Sehha.

METHODS

A questionnaire was distributed by the Ministry of Health (MoH) to 362 physicians using Sehha. The questionnaire items were adapted from previous studies and then tested for content validity and reliability (α = 0.88).

RESULTS

The findings showed that most of the physicians improved their experience in telehealth because of COVID-19. The majority of the physicians (67.6 percent) reported being satisfied with Sehha. However, the most commonly perceived challenge by the physicians was difficulty in providing accurate medical assessments.

CONCLUSION

COVID-19 has remarkably uncovered numerous benefits of telehealth. Therefore, telehealth should remain a permanent model of healthcare delivery with consideration of further telehealth development initiatives.

Mental Health Care Professionals' Appraisal of Patients' Use of Web-Based Access to Their Electronic Health Record: Qualitative Study

BACKGROUND

Patients in a range of health care sectors can access their medical health records using a patient portal. In mental health care, the use of patient portals among mental health care professionals remains low. Mental health care professionals are concerned that patient access to electronic health records (EHRs) will negatively affect the patient's well-being and privacy as well as the professional's own workload.

OBJECTIVE

This study aims to provide insights into the appraisal work of mental health care professionals to assess and understand patient access to their EHRs through a patient portal.

METHODS

We conducted a qualitative study that included 10 semistructured interviews (n=11) and a focus group (n=10). Participants in both the interviews and the focus group were mental health care professionals from different professional backgrounds and staff employees (eg, team leaders and communication advisors). We collected data on their opinions and experiences with the recently implemented patient portal and their attempts to modify work practices.

RESULTS

Our study provides insights into mental health care professionals' appraisal work to assess and understand patient access to the EHR through a patient portal. A total of four topics emerged from our data analysis: appraising the effect on the patient-professional relationship, appraising the challenge of sharing and registering delicate information, appraising patient vulnerability, and redefining consultation routines and registration practices.

CONCLUSIONS

Mental health care professionals struggle with the effects of web-based patient access and are searching for the best ways to modify their registration and consultation practices. Our participants seem to appraise the effects of web-based patient access individually. Our study signals the lack of systematization and communal appraisal. It also suggests various solutions to the challenges faced by mental health care professionals. To optimize the effects of web-based patient access to EHRs, mental health care professionals need to be involved in the process of developing, implementing, and embedding patient portals.

Development and Validation of a Useful Taxonomy of Patient Portals Based on Characteristics of Patient Engagement

Objective  Taxonomies are classification systems used to reduce complexity and better understand a domain. The present research aims to develop a useful taxonomy for health information managers to classify and compare patient portals based on characteristics appropriate to promote patient engagement. As a result, the taxonomy should contribute to understanding the differences and similarities of the portals. Further, the taxonomy shall support health information managers to more easily define which general type and functionalities of patient portals they need and to select the most suitable solution offered on the market.

Methods  We followed the formal taxonomy-building method proposed by Nickerson et al. Based on a literature review, we created a preliminary taxonomy following the conceptional approach of the model. We then evaluated each taxa's appropriateness by analyzing and classifying 17 patient portals offered by software vendors and 11 patient portals offered by health care providers. After each iteration, we examined the achievement of the determined objective and subjective ending conditions.

Results  After two conceptional approaches to create our taxonomy, and two empirical approaches to evaluate it, the final taxonomy consists of 20 dimensions and 49 characteristics. To make the taxonomy easy to comprehend, we assigned to the dimensions seven aspects related to patient engagement. These aspects are (1) portal design, (2) management, (3) communication, (4) instruction, (5) self-management, (6) self-determination, and (7) data management. The taxonomy is considered finished and useful after all ending conditions that defined beforehand have been fulfilled. We demonstrated that the taxonomy serves to understand the differences and similarities by comparing patient portals. We call our taxonomy “Taxonomy of Patient Portals based on Characteristics of Patient Engagement (TOPCOP).”

Conclusion  We developed the first useful taxonomy for health information managers to classify and compare patient portals. The taxonomy is based on characteristics promoting patient engagement. With 20 dimensions and 49 characteristics, our taxonomy is particularly suitable to discriminate among patient portals and can easily be applied to compare portals. The TOPCOP taxonomy enables health information managers to better understand the differences and similarities of patient portals. Further, the taxonomy may help them to define the type and general functionalities needed. But it also supports them in searching and comparing patient portals offered on the market to select the most suitable solution.

Impact of patient access to their electronic health record: systematic review

Patient access to their own electronic health records (EHRs) is likely to become an integral part of healthcare systems worldwide. It has the potential to decrease the healthcare provision costs, improve access to healthcare data, self-care, quality of care, and health and patient-centered outcomes. This systematic literature review is aimed at identifying the impact in terms of benefits and issues that have so far been demonstrated by providing patients access to their own EHRs, via providers' secure patient portals from primary healthcare centers and hospitals. Searches were conducted in PubMed, MEDLINE, CINHAL, and Google scholar. Over 2000 papers were screened and were filtered based on duplicates, then by reading the titles and finally based on their abstracts or full text. In total, 74 papers were retained, analyzed, and summarized. Papers were included if providing patient access to their own EHRs was the primary intervention used in the study and its impact or outcome was evaluated. The search technique used to identify relevant literature for this paper involved input from five experts. While findings from 54 of the 74 papers showed positive outcome or benefits of patient access to their EHRs via patient portals, 10 papers have highlighted concerns, 8 papers have highlighted both and 2 have highlighted absence of negative outcomes. The benefits range from re-assurance, reduced anxiety, positive impact on consultations, better doctor-patient relationship, increased awareness and adherence to medication, and improved patient outcomes (e.g., improving blood pressure and glycemic control in a range of study populations). In addition, patient access to their health information was found to improve self-reported levels of engagement or activation related to self-management, enhanced knowledge, and improve recovery scores, and organizational efficiencies in a tertiary level mental health care facility. However, three studies did not find any statistically significant effect of patient portals on health outcomes. The main concerns have been around security, privacy and confidentiality of the health records, and the anxiety it may cause amongst patients. This literature review identified some benefits, concerns, and attitudes demonstrated by providing patients' access to their own EHRs. This access is often part of government strategies when developing patient-centric self-management elements of a sustainable healthcare system. The findings of this review will give healthcare providers a framework to analyze the benefits offered by promoting patient access to EHRs and decide on the best approach for their own specialties and clinical setup. A robust cost-benefit evaluation of such initiatives along with its impact on major stakeholders within the healthcare system would be essential in understanding the overall impact of such initiatives. Implementation of patient access to their EHRs could help governments to appropriately prioritize the development or adoption of national standards, whilst taking care of local variations and fulfilling the healthcare needs of the population, e.g., UK Government is aiming to make full primary care records available online to every patient. Ultimately, increasing transparency and promoting personal responsibility are key elements of a sustainable healthcare system for future generations.

Participants' views and experiences from setting up a shared patient portal for primary and specialist health services- a qualitative study

Background

Recently, there has been an increasing focus among healthcare organisations on implementing patient portals. Previous studies have mainly focussed on the experiences of patient portal use. Few have investigated the processes of deciding what content and features to make available, in particular for shared portals across healthcare domains. The aim of the study was to investigate views on content and experiences from the configuration process among participants involved in setting up a shared patient portal for primary and specialist health services.

Methods

A qualitative study including 15 semi-structured interviews with persons participating in patient portal configuration was conducted from October 2019 to June 2020.

Results

Whether a shared patient portal for all the health services in the region should be established was not questioned by any of the informants. It was experienced as a good thing to have numerous participants present in the discussions on configuration, but it also was said to increase the complexity of the work. The informants considered a patient portal to be of great value for patient care, among other things because it would lead to improvements in patient follow-up and increased patient empowerment. Nevertheless, some informants advocated caution as they thought the patient portal possibly could lead to an increase in healthcare providers’ workloads and to anxiety and worries, as well as to inequality in access to health care among patients. The findings were categorized into the themes ‘A tool for increased patient involvement’, ‘Which information should be available for the patient’, ‘Concerns about increased workload’, ‘Too complex to use versus not interesting enough’, ‘Involving all services’ and ‘Patient involvement’.

Conclusions

Establishing a shared patient portal for primary and specialist health services was considered unproblematic. There was, however, variation in opinions on which content and features to include. This variation was related to concerns about increasing the workload for health care providers, causing anxiety and inequality among patients, and ensuring that the solution would be interesting enough to adopt.