Tracing the Decisions That Shaped the Development of MyChart, an Electronic Patient Portal in Alberta, Canada: Historical Research Study

Retrospective analysis of the human-centered design process used to develop a clinical decision support in the emergency department: PE Dx Study Part 2

With the growing implementation and use of health IT such as Clinical Decision Support (CDS), there is increasing attention on the potential negative impact of these technologies on patients (e.g., medication errors) and clinicians (e.g., increased workload, decreased job satisfaction, burnout). Human-Centered Design (HCD) and Human Factors (HF) principles are recommended to improve the usability of health IT and reduce its negative impact on patients and clinicians; however, challenges persist. The objective of this study is to understand how an HCD process influences the usability of health IT. We conducted a systematic retrospective analysis of the HCD process used in the design of a CDS for pulmonary embolism diagnosis in the emergency department (ED). Guided by the usability outcomes (e.g., barriers and facilitators) of the CDS use "in the wild" (see Part 1 of this research in the accompanying manuscript), we performed deductive content analysis of 17 documents (e.g., design session transcripts) produced during the HCD process. We describe if and how the design team considered the barriers and facilitators during the HCD process. We identified 7 design outcomes of the HCD process, for instance designing a workaround and making a design change to the CDS. We identify gaps in the current HCD process and demonstrate the need for a continuous health IT design process.

Why developers matter: The case of patient portals

Existing studies on patient data portals are informative with respect to the patient and physician perspectives, yet relatively little attention has been paid to the role of developers. This case study focuses on how developers view the meaning and purpose of patient portals and how their perspective differs from that of physicians. The findings show that developers and physicians have different views on whether and how the portals can help achieve transparency, efficiency, and patient empowerment. This misalignment emerges because each group makes sense of the portal through a different frame of how they see patient data, medical work, and patient behavior. The study also finds that developers cope with the frame differences by engaging in practices of coproducing, bypassing, and reframing. The implication of the study is that technological frame analysis needs to incorporate the growing complexity and institutional character of modern technology, the diversity of target groups it serves, and their corresponding frames. The study also suggests that developers, instead of being seen as mere operational IT support, may need to be seen as strategically important actor groups for healthcare organizations-since their practices matter for the strategic agenda of transforming healthcare into a more patient-centric practice.

Leadership in the Context of Digital Health Services: A Concept Analysis

AIM

To define and clarify the concept of leadership in the context of digital health services using Walker's and Avant's concept analysis model.

BACKGROUND

Conceptualizing leadership in the context of digital health services is needed to deliver higher quality services and advance research.

METHOD

Searches were conducted of MEDLINE (Ovid), Scopus, CINAHL (EBSCO), and ProQuest (ABI/INFORM). Empirical articles were included if they reported attributes, antecedents, or consequences of leadership in the study context. A total of 4,037 references were identified; 23 were included.

RESULTS

Leadership attributes concerned leaders' behavior, roles, and qualities. Antecedents concerned informatics skills and competence, information and tools, understanding care systems and their complexity, and education. Consequences related to organization, professionals, and patient and care.

CONCLUSION

Based on our results, the term 'e-leadership' should be more widely utilized in nursing practice and research.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse leaders need to be strong leaders; they need to be visionary and use strategic thinking to develop existing and new digital solutions. By becoming e-leaders, nurse leaders may increase the successful development and implementation of eHealth, and benefit clinicians and patients.

Clinician based decision tool to guide recommended interval between colonoscopies: development and evaluation pilot study

Background

Optimal intervals between repeat colonoscopies could improve patient outcomes and reduce costs. We evaluated: (a) concordance between clinician and guideline recommended colonoscopy screening intervals in Winnipeg, Manitoba, (b) clinician opinions about the utility of an electronic decision-making tool to aid in recommending screening intervals, and (c) the initial use of a decision-making smartphone/web-based application.

Methods

Clinician endoscopists and primary care providers participated in four focus groups (N = 22). We asked participating clinicians to evaluate up to 12 hypothetical scenarios and compared their recommended screening interval to those of North American guidelines. Fisher’s exact tests were used to assess differences in agreement with guidelines. We developed a decision-making tool and evaluated it via a pilot study with 6 endoscopists.

Result

53% of clinicians made recommendations that agreed with guidelines in ≤ 50% of the hypothetical scenarios. Themes from focus groups included barriers to using a decision-making tool: extra time to use it, less confidence in the results of the tool over their own judgement, and having access to the information required by the tool (e.g., family history). Most were willing to try a tool if it was quick and easy to use. Endoscopists participating in the tool pilot study recommended screening intervals discordant with guidelines 35% of the time. When their recommendation differed from that of the tool, they usually endorsed their own over the guideline.

Conclusions

Endoscopists are overconfident and inconsistent with applying guidelines in their polyp surveillance interval recommendations. Use of a decision tool may improve knowledge and application of guidelines. A change in practice may require that the tool be coupled with continuing education about evidence for improved outcomes if guidelines are followed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01872-z.

Oncology Patients' Experiences With Novel Electronic Patient Portals to Support Care and Treatment: Qualitative Study With Early Users and Nonusers of Portals in Alberta, Canada

Background

With the current proliferation of clinical information technologies internationally, patient portals are increasingly being adopted in health care. Research, conducted mostly in the United States, shows that oncology patients have a keen interest in portals to gain access to and track comprehensive personal health information. In Canada, patient portals are relatively new and research into their use and effects is currently emerging. There is a need to understand oncology patients’ experiences of using eHealth tools and to ground these experiences in local sociopolitical contexts of technology implementation, while seeking to devise strategies to enhance portal benefits.

Objective

The purpose of this study was to explore the experiences of oncology patients and their family caregivers when using electronic patient portals to support their health care needs. We focused on how Alberta’s unique, 2-portal context shapes experiences of early portal adopters and nonadopters, in anticipation of a province-wide rollout of a clinical information system in oncology facilities.

Methods

This qualitative descriptive study employed individual semistructured interviews and demographic surveys with 11 participants. Interviews were audio-recorded and transcribed verbatim. Data were analyzed thematically. The study was approved by the University of Alberta Human Research Ethics Board.

Results

Participants currently living with nonactive cancer discussed an online patient portal as one among many tools (including the internet, phone, videoconferencing, print-out reports) available to make sense of their diagnosis and treatment, maintain connections with health care providers, and engage with information. In the Fall of 2020, most participants had access to 1 of 2 of Alberta’s patient portals and identified ways in which this portal was supportive (or not) of their ongoing health care needs. Four major themes, reflecting the participants’ broader concerns within which the portal use was occurring, were generated from the data: (1) experiencing doubt and the desire for transparency; (2) seeking to become an informed and active member of the health care team; (3) encountering complexity; and (4) emphasizing the importance of the patient–provider relationship.

Conclusions

Although people diagnosed with cancer and their family caregivers considered an online patient portal as beneficial, they identified several areas that limit how portals support their oncology care. Providers of health care portals are invited to recognize these limitations and work toward addressing them.

Creation of a pharmacogenomics patient portal complementary to an existing institutional provider-facing clinical decision support system

Background

Applied pharmacogenomics presents opportunities for improving patient care through precision medicine, particularly when paired with appropriate clinical decision support (CDS). However, a lack of patient resources for understanding pharmacogenomic test results may hinder shared decision-making and patient confidence in treatment. We sought to create a patient pharmacogenomics education and results delivery platform complementary to a CDS system to facilitate further research on the relevance of patient education to pharmacogenomics.

Methods

We conceptualized a model that extended the data access layer of an existing institutional CDS tool to allow for the pairing of decision supports offered to providers with patient-oriented summaries at the same level of phenotypic specificity. We built a two-part system consisting of a secure portal for patient use and an administrative dashboard for patient summary creation. The system was built in an ASP.NET and AngularJS architecture, and all data was housed in a HIPAA-compliant data center, with PHI secure in transit and at rest.

Results

The YourPGx Patient Portal was deployed on the institutional network in June 2019. Fifty-eight unique patient portal summaries have been written so far, which can provide over 4500 results modules to the pilot population of 544 patients. Patient behavior on the portal is being logged for further research.

Conclusions

To our knowledge, this is the first automated system designed and deployed to provide detailed, personalized patient pharmacogenomics education complementary to a clinical decision support system. Future work will expand upon this system to allow for telemedicine and patient notification of new or updated results.

Capturing the Impact of Patient Portals Based on the Quadruple Aim and Benefits Evaluation Frameworks: Scoping Review

Background

Despite extensive and continuing research in the area of patient portals, measuring the impact of patient portals remains a convoluted process.

Objective

This study aims to explore what is known about patient portal evaluations and to provide recommendations for future endeavors. The focus is on mapping the measures used to assess the impact of patient portals on the dimensions of the Quadruple Aim (QA) framework and the Canada Health Infoway’s Benefits Evaluation (BE) framework.

Methods

A scoping review was conducted using the methodological framework of Arksey and O’Malley. Reporting was guided by the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) extension for scoping reviews. A systematic and comprehensive search was conducted using the Ovid platform, and the following databases were searched: Ovid MEDLINE (R) ALL (including epub ahead of print, in-process, and other nonindexed citations), EMBASE, and PsycINFO. CINAHL on the EBSCO platform and Web of Science were searched for studies published between March 2015 and June 2020. A systematic gray literature search was conducted using the Google search engine. Extracted data were tabulated based on a coding template developed to categorize the literature into themes and areas of interest.

Results

A total of 96 studies were included for data extraction. The studies were categorized based on the QA dimensions, with strict adherence to the definitions for each dimension. From the patients’ perspective, it was determined that most evaluations focused on benefits and barriers to access, access to test results, medication adherence, condition management, medical notes, and secure messaging. From the population perspective, the evaluations focused on the increase in population outreach, decrease in disparities related to access to care services, and improvement in quality of care. From the health care workforce perspective, the evaluations focused on the impact of patients accessing medical records, impact on workflow, impact of bidirectional secure messaging, and virtual care. From the health system perspective, the evaluations focused on decreases in no-show appointments, impact on office visits and telephone calls, impact on admission and readmission rates and emergency department visits, and impact on health care use. Overall, 77 peer-reviewed studies were mapped on the expanded version of the BE framework. The mapping was performed using subdimensions to create a more precise representation of the areas that are currently explored when studying patient portals. Most of the studies evaluated more than one subdimension.

Conclusions

The QA and BE frameworks provide guidance in identifying gaps in the current literature by providing a way to show how an impact was assessed. This study highlights the need to appropriately plan how the impact will be assessed and how the findings will be translated into effective adaptations.