Patients' attitudes toward electronic health information exchange: qualitative study

Evaluating perceived technology self-efficacy and telehealth acceptance in optometry students

CLINICAL RELEVANCE

Constant technological improvements require practitioners to be open to adopting technologies such as telehealth for enhanced patient care. Understanding the barriers and facilitators of telehealth adoption will guide stakeholders in making decisions for safe and effective implementation of telehealth.

BACKGROUND

Effective use of telehealth improves patient outcomes. It is unclear if optometry students feel supported in using and/or are accepting of telehealth. This study evaluated telehealth acceptance of optometry students, its association with their technology self-efficacy, and whether telehealth training alters this relationship.

METHODS

Final-year optometry students at the University of Melbourne were invited to participate in a telehealth course. A 22-item online survey adapted from the Technology Proficiency Self-Assessment for twenty-first Century Learning was used to evaluate technology self-efficacy pre- and post-learning. Telehealth acceptance was evaluated using a 34-item survey according to the Unified Theory of Acceptance and Use of Technology-2. A 5-point Likert scale was used for each item, yielding two total scores. Respondent demographics, frequency of usage and number of devices were recorded. Descriptive statistics, ANOVA and Pearson correlation were used to analyse demographic variables and relationship between technology self-efficacy and telehealth acceptance.

RESULTS

58 (68%) and 49 (58%) students participated in the pre- and post-learning surveys. Majority were 20-29-year-old females. Students used between two and four devices for online activities, with 62% being online at least hourly. Technology self-efficacy scores (average ± SD) pre- and post-learning were 83.8% ± 8.2 and 87.8% ± 7.1. Telehealth acceptance scores pre- and post-learning were 66.1% ± 9.6 and 73.98% ± 9.9. There was no association with gender, number of devices and frequency of online use for all scores. Correlation between technology self-efficacy and telehealth acceptance was insignificant pre-learning (p = 0.3) but was significant post-learning (p = 0.04).

CONCLUSION

Optometry students demonstrated high technology self-efficacy compared to telehealth acceptance. Telehealth training resulted in marked improvement in telehealth acceptance.

A study on user willingness to participate in an adverse drug event information sharing system

BACKGROUND

To prevent the recurrence of Adverse Drug Events (ADEs), particularly drug allergies, it is essential to avoid re-exposure to causative drugs. Awareness of previous ADEs is crucial for patients because they can share accurate information with healthcare providers (HCPs). This study aims to assess users' willingness to share ADE information and evaluate the factors related to this willingness by utilizing a prospective ADE information-sharing system currently under consideration in South Korea.

METHODS

In September 2023, a self-administered questionnaire was collected from a sex-, age-, and regionally stratified nationwide convenience sample of adults recruited through a commercial panel in South Korea. Factors contributing to the willingness to share ADE information and create electronic ADE cards (e-ADE cards) were investigated using multivariate logistic regression analysis.

RESULTS

Among the 1,000 respondents, 458 (45.8%) were willing to share ADE information, and 521 (52.1%) were willing to create e-ADE cards. The willingness to share personal ADE information and create e-ADE cards was positively associated with the perceived benefits of sharing ADE, trust in HCPs and positive experiences. Notably, older adult patients demonstrated a higher willingness to share information and use e-ADE cards, with rates of 56% and 62%, respectively.

CONCLUSIONS

Our findings indicate that the approach to sharing personal ADE information should be distinct from that of sharing comprehensive health information. Notably, users are likely to willingly disclose their personal information even if they are not anonymized, owing to the significant perceived benefits of sharing. The findings of this study can enhance awareness about sharing personal ADE information and contribute to the successful establishment of an ADE information-sharing system, thereby improving the patient safety environment.

Community perspectives on the use of electronic health data to support reflective practice by health professionals

BACKGROUND

Electronic health records and other clinical information systems have crucial roles in health service delivery and are often utilised for patient care as well as health promotion and research. Government agencies and healthcare bodies are gradually shifting the focus on how these data systems can be harnessed for secondary uses such as reflective practice, professional learning and continuing professional development. Whilst there has been a presence in research around the attitudes of health professionals in employing clinical information systems to support their reflective practice, there has been very little research into consumer attitudes towards these data systems and how they would like to interact with such structures. The study described in this article aimed to address this gap in the literature by exploring community perspectives on the secondary use of Electronic Health Data for health professional learning and practice reflection.

METHODS

A qualitative methodology was used, with data being collected via semi-structured interviews. Interviews were conducted via phone and audio recordings, before being transcribed into text for analysis. Reflective thematic analysis was undertaken to analyse the data.

RESULTS

Fifteen Australians consented to participate in an interview. Analysis of interview data generated five themes: (1) Knowledge about health professional registration and professional learning; (2) Secondary uses of Electronic Health Data; (3) Factors that enable the use of Electronic Health Data for health professional learning; (4) Challenges using Electronic Health Data for health professional learning and (5) Expectations around consent to use Electronic Health Data for health professional learning.

CONCLUSIONS

Australians are generally supportive of health professionals using Electronic Health Data to support reflective practice and learning but identify several challenges for data being used in this way.

Putting patients at the center of health information exchange design: An exploration of patient preferences for data sharing

BACKGROUND

Despite the many benefits of Health Information Exchange (HIE), Studies reported patients concerns about the privacy and security of sharing their health information. To address these concerns, it is important to understand their needs, preferences, and priorities in the design and implementing HIE systems.

OBJECTIVE

The aim of this study is to investigate patients' preferences for HIE consent option and examine the extent to which they are comfortable sharing the different parts of their medical records.

METHOD

A self-administered survey was conducted. The survey was administrated online and the total number of respondents was 660 participants.

RESULTS

The most popular option selected by participants for sharing HIE information was to share information with their permission once when they register (33.3%) followed by the option to share their information temporarily on demand during their clinical visit (23.8%). The types of information which participants were willing to share the most were general data such as age, weight, height, and gender, followed closely by data needed for medical emergency. In contrast, the information which participants were less likely to share were data related to financial status or income, followed by data related to sexual disease, and mental illnesses.

Feasibility and Design Factors for Home-Based Pulmonary Rehabilitation of Patients With Chronic Obstructive Pulmonary Disease and Chronic Lung Diseases Based on a People-Object-Environment Framework: Qualitative Interview Study

BACKGROUND

The feasibility of implementing home-based pulmonary rehabilitation (PR) can be assessed from the perspectives of patients with chronic lung disease and health care professionals involved in PR.

OBJECTIVE

Through a qualitative inquiry using interviews and the adoption of the people-object-environment framework, this study aims to understand the influences of interpersonal, environmental, and situational factors on the perceptions and considerations of individuals involved in home-based PR for patients with chronic lung disease.

METHODS

One-on-one interviews were conducted with 20 patients with chronic lung disease and 20 health care professionals for investigating their attitudes and opinions based on their experiences regarding home-based PR as well as for identifying the key factors affecting the benefits and drawbacks of such therapies. This study further evaluates the feasibility of using digital tools for medical diagnosis and treatment by examining the technology usage of both parties.

RESULTS

The 4 key issues that all participants were the most concerned about were as follows: distance to outpatient medical care, medical efficiency, internet connectivity and equipment, and physical space for diagnosis and treatment. Interviews with patients and health care professionals revealed that the use of technology and internet was perceived differently depending on age and area of residence. Most participants reported that digital tools and internet connectivity had many benefits but still could not solve all the problems; moreover, these same digital tools and network transmission could lead to problems such as information security and digital divide concerns. This study also emphasizes the significant impact of human behavior and thinking on shaping the design of health care interventions and technologies. Understanding user perspectives and experiences is crucial for developing effective solutions for unmet needs.

CONCLUSIONS

The results of this study indicate that despite the different perspectives of patients and health care professionals, their considerations of the key issues are very similar. Therefore, the implementation of plans related to telemedicine diagnosis, treatment, or rehabilitation should take the suggestions and considerations of both parties into account as crucial factors for telehealth care design.

The viewpoints of parents of children with mental disorders regarding the confidentiality and security of their children's information in the Iranian national electronic health record system

INTRODUCTION

Electronic health records help collect and communicate patient information among healthcare providers. The confidentiality of information, especially for patients with mental disorders, is paramount due to its profound impacts on individuals' lives' social and personal aspects. This study aimed to investigate the viewpoints and concerns of parents of children with mental disorders regarding the confidentiality and security of their children's information in the Iranian National Electronic Health Record System (IEHRS).

METHODS

This is a survey study on parents or guardians of children with mental disorders who visited Kerman's specialised child psychiatry treatment centres. The data collection tool was a researcher-made questionnaire with 28 questions organised in seven sections, including demographic information of parents, children's medical history, Internet use, knowledge about IEHRS, the necessity of data collection, IEHRS security concerns, and privacy concerns. The data were analysed in SPSS 24 software using descriptive statistics and logistic and ordinal regressions to assess the relationship between parents' demographic characteristics and their viewpoints regarding information security and confidentiality concerns.

RESULTS

The results showed that more than 85 % of the parents believed that the security of their children's information in IEHRS was moderate to high. More than two-thirds (71 %) of the parents also believed that IEHRS should tighten its privacy policies. Most participants (87 %) were concerned about their children's information security in IEHRS. In this study, the parents' concerns about the privacy and security of information in IEHRS were not significantly associated with their age, gender, or knowledge about IEHRS.

CONCLUSIONS

Most parents of children with mental disorders were concerned about the security and confidentiality of their children's information in IEHRS. Thus, health policymakers should maintain a high level of security and establish appropriate privacy and confidentiality rules in IEHRS. In addition, they should be transparent about the system's security mechanisms and confidentiality regulations to win public trust.

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

Objective

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

Methods

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

Results

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

Conclusions

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

The relationship between e-health literacy and information technology acceptance, and the willingness to share personal and health information among pregnant women

BACKGROUND

Many factors may affect pregnant women's willingness to accept information (IT) technology and share their personal and health information. One of these factors is their e-health literacy level.

OBJECTIVE

To investigate the relationship between e-health literacy and IT acceptance, as well as the willingness of pregnant women to share their information.

METHODS

This survey was conducted among pregnant women visiting hospitals and private physicians' offices in Zahedan, Iran in 2019. Data were collected using a 4-part questionnaire with 66 questions. The data were analyzed using descriptive (frequency, percentage, mean and standard deviation) and inferential (Pearson correlation coefficient and linear regression) statistics.

RESULTS

The mean scores of electronic health literacy, information technology acceptance, and willingness of pregnant women to share personal and health information were 27.43 ± 5.82, 145.49 ± 25.72, and 19.16 ± 5.47, respectively. There was a significant relationship between IT acceptance and information sharing, which means that with increasing IT acceptance, people were more willing to share their information. Also, the results showed that with the decrease in economic well-being, the willingness to share personal and health information decreases.

CONCLUSION

This study showed that with the increase in e-health literacy of pregnant women, their IT acceptance grows. Increasing IT acceptance improves their willingness to share their information. Setting and updating information-sharing rules and security mechanisms with the participation of people can help reduce concerns and increase public trust. Healthcare policymakers can encourage the use of health IT in the prevention and treatment of diseases by providing relevant education and informing people.

Trust and Health Information Exchanges: Qualitative Analysis of the Intent to Share Personal Health Information

BACKGROUND

Digital health has the potential to improve the quality of care, reduce health care costs, and increase patient satisfaction. Patient acceptance and consent are a prerequisite for effective sharing of personal health information (PHI) through health information exchanges (HIEs). Patients need to form and retain trust in the system(s) they use to leverage the full potential of digital health. Germany is at the forefront of approving digital treatment options with cost coverage through statutory health insurance. However, the German population has a high level of technology skepticism and a low level of trust, providing a good basis to illuminate various facets of eHealth trust formation.

OBJECTIVE

In a German setting, we aimed to answer the question, How does an individual form a behavioral intent to share PHI with an HIE platform? We discussed trust and informed consent through (1) synthesizing the main influence factor models into a complex model of trust in HIE, (2) providing initial validation of influence factors based on a qualitative study with patient interviews, and (3) developing a model of trust formation for digital health apps.

METHODS

We developed a complex model of the formation of trust and the intent to share PHI. We provided initial validation of the influence factors through 20 qualitative, semistructured interviews in the German health care setting and used a deductive coding approach to analyze the data.

RESULTS

We found that German patients show a positive intent to share their PHI with HIEs under certain conditions. These include (perceived) information security and a noncommercial organization as the recipient of the PHI. Technology experience, age, policy and regulation, and a disposition to trust play an important role in an individual's privacy concern, which, combined with social influence, affects trust formation on a cognitive and emotional level. We found a high level of cognitive trust in health care and noncommercial research institutions but distrust in commercial entities. We further found that in-person interactions with physicians increase trust in digital health apps and PHI sharing. Patients' emotional trust depends on disposition and social influences. To form their intent to share, patients undergo a privacy calculus. Hereby, the individual's benefit (eg, convenience), benefits for the individual's own health, and the benefits for public welfare often outweigh the perceived risks of sharing PHI.

CONCLUSIONS

With the higher demand for timely PHI, HIE providers will need to clearly communicate the benefits of their solutions and their information security measures to health care providers (physicians, nursing and administrative staff) and patients and include them as key partners to increase trust. Offering easy access and educational measures as well as the option for specific consent may increase patients' trust and their intention to share PHI.

Measuring the willingness to share personal health information: a systematic review

Background

In the age of digitalization and big data, personal health information is a key resource for health care and clinical research. This study aimed to analyze the determinants and describe the measurement of the willingness to disclose personal health information.

Methods

The study conducted a systematic review of articles assessing willingness to share personal health information as a primary or secondary outcome. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol. English and Italian peer-reviewed research articles were included with no restrictions for publication years. Findings were narratively synthesized.

Results

The search strategy found 1,087 papers, 89 of which passed the screening for title and abstract and the full-text assessment.

Conclusion

No validated measurement tool has been developed for willingness to share personal health information. The reviewed papers measured it through surveys, interviews, and questionnaires, which were mutually incomparable. The secondary use of data was the most important determinant of willingness to share, whereas clinical and socioeconomic variables had a slight effect. The main concern discouraging data sharing was privacy, although good data anonymization and the high perceived benefits of sharing may overcome this issue.

Sharing intention of electronic health records in online health communities: Patients' behavioral decisions in the context of privacy protection measures

Online health communities (OHCs) have become more important to people's daily lives on the foundation of the voluntary sharing of electronic health records (EHRs). However, no in-depth investigation has been conducted concerning the influence of the perceptions of privacy protection among patients on their willingness to share EHRs. To fill the knowledge gap, by combining and modifying the theory of planned behavior (TPB) and the health belief model in the context of the privacy protection models implemented by OHCs, an empirical research method using a questionnaire approach is conducted to validate the hypotheses. The results indicate that the more positive a patient's attitude toward medical information sharing behavior is, the higher that patient's level of perceived behavioral control; in addition, the greater the social rewards obtained from this process, the more willing the patient is to share his or her EHRs after privacy protection measures are implemented by OHCs. Meanwhile, the effects of past positive experiences and disease severity have also been tested. The findings of this study can be used to promote patients' full participation in OHCs from a privacy perspective and offer theoretical and practical suggestions to promote the development of OHCs.

The Patient Role in a Federal National-Scale Health Information Exchange

The federal Trusted Exchange Framework and Common Agreement (TEFCA) aims to reduce fragmentation of patient records by expanding query-based health information exchange with nationwide connectivity for diverse purposes. TEFCA provides a common agreement and security framework allowing clinicians, and possibly insurance company staff, public health officials, and other authorized users, to query for health information about hundreds of millions of patients. TEFCA presents an opportunity to weave information exchange into the fabric of our national health information economy. We define 3 principles to promote patient autonomy and control within TEFCA: (1) patients can query for data about themselves, (2) patients can know when their data are queried and shared, and (3) patients can configure what is shared about them. We believe TEFCA should address these principles by the time it launches. While health information exchange already occurs on a large scale today, the launch of TEFCA introduces a major, new, and cohesive component of 21st-century US health care information infrastructure. We strongly advocate for a substantive role for the patient in TEFCA, one that will be a model for other systems and policies.

Observation and Patients' Perceptions of Incorporating Their Photograph Into the Electronic Health Record

OBJECTIVES

Wrong-patient errors are common and have the potential to cause serious harm. The Office of the National Coordinator for Health Information Technology Patient Identification SAFER Guide recommends displaying patient photographs in electronic health record (EHR) systems to facilitate patient identification and reduce wrong-patient errors. A potential barrier to implementation is patient refusal; however, patients' perceptions about having their photograph captured during registration and integrated into the EHR are unknown.

METHODS

The study was conducted in an emergency department (ED) and primary care outpatient clinic within a large integrated health system in New York City. The study consisted of 2 components: (1) direct observation of the registration process to quantify the frequency of patient refusals and (2) semistructured interviews to elicit patients' feedback on perceived benefits and barriers to integrating their photograph into the EHR.

RESULTS

Of 172 registrations where patients were asked to take a photograph for patient identification, 0 refusals were observed (ED, 0 of 87; primary care outpatient clinic, 0 of 85). A convenience sample of 30 patients were interviewed (female, 70%; age ≥55 years, 43%; Hispanic/Latino, 67%; Black, 23%). Perceived benefits of integrating patient photographs into the EHR included improved security (40%), improved patient identification (23%), and ease of registration (17%). A small proportion of patients raised privacy concerns.

CONCLUSIONS

Patient refusal was not found to be a barrier to implementation of patient photographs in the EHR. Efforts to identify and address other potential barriers would help ensure that the highest proportion of patients has photographs in their medical record.

Needs of Lung Cancer Patients Receiving Immunotherapy and Acceptance of Digital and Sensor-Based Scenarios for Monitoring Symptoms at Home—A Qualitative-Explorative Study

Background: The development of immunotherapy in the treatment for lung cancer has changed the outlook for both patients and health care practitioners. However, reporting and management of side effects are crucial to ensure effectiveness and safety of treatment. The aim of this study was to learn about the subjective experiences of patients with lung cancer receiving immunotherapy and to explore their potential acceptance of digital and sensor-based systems for monitoring treatment-related symptoms at home. Methods: A qualitative-explorative interview study with patients with lung cancer (n = 21) applying qualitative content analysis. Results: Participants had trouble to classify and differentiate between symptoms they experienced and it seemed challenging to assess whether symptoms are serious enough to be reported and to figure out the right time to report symptoms to health care practitioners. We identified four basic needs: (1) the need to be informed, (2) the need for a trustful relationship, (3) the need to be taken seriously, and (4) the need for needs-oriented treatment concepts. The idea of digital and sensor-based monitoring initially provoked rejection, but participants expressed more differentiated attitudes during the interviews, which could be integrated into a preliminary model to explain the acceptance of digital and sensor-based monitoring scenarios. Conclusions: Supporting lung cancer patients and their health care providers in communicating about treatment-related symptoms is important. Technology-based monitoring systems are considered to be potentially beneficial. However, in view of the many unfulfilled information needs and the unsatisfactory reporting of symptoms, it must be critically questioned what these systems can and should compensate for, and where the limits of such monitoring lie.

Electronic health record adopters: a typology based on patients' privacy concerns and perceived benefits

OBJECTIVES

Patients' adoption of electronic health records (EHRs) varies substantially. Although some countries, such as Estonia and Denmark, are sufficiently advanced in terms of EHR generalisation, others, such as France, are figuring out how to implement and disseminate EHRs. These governments must respond to patients' disparities to achieve the expected performance for healthcare systems and improve the quality of care delivery. This study investigates patients' perceived benefits and privacy concerns related to EHRs to develop a typology of patients, identify the characteristics of different clusters and propose practical measures for public policy-makers.

STUDY DESIGN

We conducted a cross-sectional study using online questionnaires.

METHODS

An online quantitative survey was carried out in France. The final sample of EHR non-users (N = 1076) was fitted to be representative of the French population by age and gender, region and socioprofessional status. Hierarchical and non-hierarchical cluster analyses were performed. Several robustness check analyses were also performed.

RESULTS

Cluster analyses identified four patient clusters: the worried, who show the highest mean privacy concern and risk levels related to health data disclosure; the ready adopters, who lack privacy concerns and risk and are the most motivated by EHR benefits; the concerned adopters, who express far fewer privacy concerns and perceive EHR benefits more favourably than the worried adopters; and the balanced adopters, who are relatively similar to the ready adopters in their EHR motives and are still concerned about their health data, suggesting a segment that is easier to convince. Comparing clusters regarding the intentions to create EHRs and willingness to disclose health data confirms that ready adopters, followed by balanced adopters, are more likely to create an EHR and disclose health data. The concerned adopters and, finally, the worried exhibit the lowest intentions for EHR creation and data disclosure.

CONCLUSIONS

The results provide meaningful insights into patient profiles and expectations. The findings underscore the need to implement targeting policies for each cluster and design concrete solutions for improving EHR performance.

Passive Data Use for Ethical Digital Public Health Surveillance in a Postpandemic World

There is a fundamental need to establish the most ethical and effective way of tracking disease in the postpandemic era. The ubiquity of mobile phones is generating large amounts of passive data (collected without active user participation) that can be used as a tool for tracking disease. Although discussions of pragmatism or economic issues tend to guide public health decisions, ethical issues are the foremost public concern. Thus, officials must look to history and current moral frameworks to avoid past mistakes and ethical pitfalls. Past pandemics demonstrate that the aftermath is the most effective time to make health policy decisions. However, an ethical discussion of passive data use for digital public health surveillance has yet to be attempted, and little has been done to determine the best method to do so. Therefore, we aim to highlight four potential areas of ethical opportunity and challenge: (1) informed consent, (2) privacy, (3) equity, and (4) ownership.

Fitness Tracker Information and Privacy Management: Empirical Study

Background

Fitness trackers allow users to collect, manage, track, and monitor fitness-related activities, such as distance walked, calorie intake, sleep quality, and heart rate. Fitness trackers have become increasingly popular in the past decade. One in five Americans use a device or an app to track their fitness-related activities. These devices generate massive and important data that could help physicians make better assessments of their patients’ health if shared with health providers. This ultimately could lead to better health outcomes and perhaps even lower costs for patients. However, sharing personal fitness information with health care providers has drawbacks, mainly related to the risk of privacy loss and information misuse.

Objective

This study investigates the influence of granting users granular privacy control on their willingness to share fitness information.

Methods

The study used 270 valid responses collected from Mtrurkers through Amazon Mechanical Turk (MTurk). Participants were randomly assigned to one of two groups. The conceptual model was tested using structural equation modeling (SEM). The dependent variable was the intention to share fitness information. The independent variables were perceived risk, perceived benefits, and trust in the system.

Results

SEM explained about 60% of the variance in the dependent variable. Three of the four hypotheses were supported. Perceived risk and trust in the system had a significant relationship with the dependent variable, while trust in the system was not significant.

Conclusions

The findings show that people are willing to share their fitness information if they have granular privacy control. This study has practical and theoretical implications. It integrates communication privacy management (CPM) theory with the privacy calculus model.

Patients' moral attitudes toward electronic health records: Survey study with vignettes and statements

Patient access to electronic health records gives rise to ethical questions related to the patient-doctor-computer relationship. Our study aims to examine patients' moral attitudes toward a shared EHR, with a focus on autonomy, information access, and responsibility. A de novo self-administered questionnaire containing three vignettes and 15 statements was distributed among patients in four different settings. A total of 1688 valid questionnaires were collected. Patients' mean age was 51 years, 61% was female, 50% had a higher degree (college or university), and almost 50% suffered from a chronic illness. Respondents were hesitant to hide sensitive information electronically from their care providers. They also strongly believed hiding information could negatively affect the quality of care provided. Participants preferred to be informed about negative test results in a face-to-face conversation, or would have every patient decide individually how they want to receive results. Patients generally had little experience using patient portal systems and expressed a need for more information on EHRs in this survey. They tended to be hesitant to take up control over their medical data in the EHR and deemed patients share a responsibility for the accuracy of information in their record.

Routinely collected data and patient-centred research in anaesthesia and peri-operative care: a narrative review

Randomised controlled trials are the gold standard in clinical research, but remain rare due to their expense and a perceived lack of 'real-world' applicability. At the same time, there has been an exponential increase in routinely collected data which presents opportunities for audit, quality improvement, adverse event reporting and more efficient clinical research. Registry-based research benefits from reduced cost, large sample size and real-world applicability, with methodological developments, particularly registry-based randomised controlled trials and causal inference techniques, showing promise. Limitations include data quality and validity, the need for data linkage, the restrictions of fixed data fields, regulatory barriers, and privacy and security concerns. However, the principal factor hampering current efforts is a lack of anaesthesia-specific datasets in the UK and the fact that most surgical registries do not collect any anaesthetic data. This presents an opportunity for anaesthetists, through enhanced engagement and collaboration, to influence and improve the design of these datasets and increase the value and volume of data collected. Better datasets, coupled with a growing appreciation of new analysis methodologies, would allow significant progress towards realising the potential of routinely collected data for patient benefit. At the same time, work should begin on the development of a minimum dataset for anaesthesia to underpin new data sharing networks and, ideally, a national registry of anaesthesia.

Barriers to the Digitization of Health Information: A Qualitative and Quantitative Study in Kenya and Lao PDR Using a Cloud-Based Maternal and Child Registration System

Digitalization of health information can assist patient information management and improve health services even in low middle-income countries. We have implemented a mother and child health registration system in the study areas of Kenya and Lao PDR to evaluate barriers to digitalization. We conducted in-depth interviews with 20 healthcare workers (HCWs) who used the system and analyzed it qualitatively with thematic framework analysis. Quantitatively, we analyzed the quality of recorded data according to missing information by the logistic regression analysis. The qualitative analysis identified six themes related to digitalization: satisfaction with the system, mothers’ resistance, need for training, double work, working environment, and other resources. The quantitative analysis showed that data entry errors improved around 10% to 80% based on odds ratios in subsequent quarters compared to first quarter periods. The number of registration numbers was not significantly related to the data quality, but the motivation, including financial incentives among HCWs, was related to the registration behavior. Considering both analysis results, workload and motivation to maintain high performance were significant obstacles to implementing a digital health system. We recommend enhancing the scope and focus on human needs and satisfaction as a significant factor for digital system durability and sustainability.

Genetic counselors, patients', and carers' views on an Australian clinical genetics service information system

The Genetic Information System (GIS) is an Australian database of family genetic information. This health information technology system has been used by all 31 publicly operated clinical genetics services across New South Wales (NSW) and the Australian Capital Territory (ACT) for over a decade. As these services are separated geographically, the linkage engendered by the GIS facilitates the services to operate as a virtual state-wide service. This study aimed to explore the views of genetic counselors, patients, and carers on the use and storage of family genetic information in the GIS. Data were collected using audio-recorded semi-structured telephone interviews with genetic counselors experienced with using the GIS and focus groups with past patients/carers of the services. Using thematic analysis, four themes were identified from genetic counselor participant interviews (n = 12): (a) Shared information is valuable; (b) inconsistent data entry provides a challenge; (c) perceived need for the GIS to be current and integrated with other health systems; and (d) future challenges and strategies for the GIS. Three themes were identified following three focus groups with consumer participants (n = 14): (a) access to family genetic information provides a 'clearer picture'; (b) support, but caution, concerning use of information for relatives' health care; and (c) stewardship of family information. Genetic counselors and consumers identified similar advantages and privacy concerns regarding the sharing of family genetic information and all participants wanted patients/carers to be better informed about the GIS early in the genetic counseling process. Consumers were reassured by genetics health professionals' stewardship of their information, but surprised the GIS was not available nationally or for private geneticists or certain non-genetic specialists. These findings may inform further development of the GIS and other clinical genetic databases and lead to increased patient/carer knowledge through education and resource development.

Vulnerable patients' attitudes towards sharing medical data and granular control in patient portal systems: an interview study

BACKGROUND

The collection, storage and exchange of medical information are becoming increasingly complex. More parties are involved in this process, and the data are expected to serve many different purposes beside patient care. This raises several ethical questions regarding privacy, data ownership, security and confidentiality. It is vital to consider patients' moral attitudes and preferences in this digital information exchange. The voice of vulnerable patients is rarely heard in research addressing these questions. This study aims to address this void.

METHOD

Fourteen vulnerable patients without prior experience with patient portal systems were interviewed for this study. First, participants were introduced to the portal and given time to read their personal medical data. Afterwards, semi-structured interviews were conducted and analysed thematically to explore participants' first experience with the portal and their views on sharing medical information with care providers and other parties.

RESULTS

Data analysis resulted in four themes: barriers to and benefits of portal access, emotional responses to reading medical information, diverging views on sharing information with third parties and balancing granular control and the best possible care. First, participants appreciated access to their health information in the portal despite experiencing obstacles. Second, reading medical information online could evoke emotional responses. Third, patients were generally unaware of the meaning and value of medical data to third parties, resulting in inconsistent views on data sharing. Finally, although patients generally supported granular control, they were willing to give up on their autonomy if that would ensure them to receive the best possible care.

CONCLUSIONS

Patient portal design should take into consideration the obstacles that discourage vulnerable patients' access and hamper meaningful use. There is a need for more transparency on secondary use of medical data by third parties. Patients should be better informed about the potential consequences of sharing data with them.

Assessing the quality of mobile applications in chronic disease management: a scoping review

While there has been a rapid growth of digital health apps to support chronic diseases, clear standards on how to best evaluate the quality of these evolving tools are absent. This scoping review aims to synthesize the emerging field of mobile health app quality assessment by reviewing criteria used by previous studies to assess the quality of mobile apps for chronic disease management. A literature review was conducted in September 2017 for published studies that use a set of quality criteria to directly evaluate two or more patient-facing apps supporting promote chronic disease management. This resulted in 8182 citations which were reviewed by research team members, resulting in 65 articles for inclusion. An inductive coding schema to synthesize the quality criteria utilized by included articles was developed, with 40 unique quality criteria identified. Of the 43 (66%) articles that reported resources used to support criteria selection, 19 (29%) used clinical guidelines, and 10 (15%) used behavior change theory. The most commonly used criteria included the presence of user engagement or behavior change functions (97%, n = 63) and technical features of the app such as customizability (20%, n = 13, while Usability was assessed by 24 studies (36.9%). This study highlights the significant variation in quality criteria employed for the assessment of mobile health apps. Future methods for app evaluation will benefit from approaches that leverage the best evidence regarding the clinical impact and behavior change mechanisms while more directly reflecting patient needs when evaluating the quality of apps.

Leadership Perspectives on Implementing Health Information Exchange: Qualitative Study in a Tertiary Veterans Affairs Medical Center

Background

The US Department of Veterans Affairs (VA) seeks to achieve interoperability with other organizations, including non-VA community and regional health information exchanges (HIEs).

Objective

This study aims to understand the perspectives of leaders involved in implementing information exchange between VA and non-VA providers via a community HIE.

Methods

We interviewed operational, clinical, and information technology leaders at one VA facility and its community HIE partner. Respondents discussed their experiences with VA-HIE, including barriers and facilitators to implementation, and the associated impact on health care providers. Transcribed interviews were coded and analyzed using immersion-crystallization methods.

Results

VA and community HIE leaders found training to be a key factor when implementing VA-HIE and worked cooperatively to provide several styles and locations of training. During recruitment, a high-touch approach was successfully used to enroll patients and overcome their resistance to opting in. Discussion with leaders revealed the high levels of complexity navigated by VA providers and staff to send and retrieve information. Part of the complexity stemmed from the interconnected web of information systems and human teams necessary to implement VA-HIE information sharing. These interrelationships must be effectively managed to guide organizational decision making.

Conclusions

Organizational leaders perceived information sharing to be of essential value in delivering high-quality, coordinated health care. The VA continues to increase access to outside care through the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act. Along with this increase in non-VA medical care, there is a need for greater information sharing between VA and non-VA health care organizations. Insights by leaders into barriers and facilitators to VA-HIE can be applied by other national and regional networks that seek to achieve interoperability across health care delivery systems.

Privacy Concerns About Health Information Disclosure in Mobile Health: Questionnaire Study Investigating the Moderation Effect of Social Support

Background

Mobile health (mHealth) provides a new opportunity for disease prediction and patient health self-management. However, privacy problems in mHealth have drawn significant attention to patients’ online health information disclosure and to the possibility that privacy concerns may hinder mHealth development.

Objective

Privacy calculus theory (PCT) has been widely used to understand personal information disclosure behaviors with the basic assumption of a rational and linear decision-making process. However, cognitive behavior processes are complex and mutual. In an attempt to gain a fuller understanding of information disclosure behavior, we further optimize a PCT-based information disclosure model by identifying the mutual relationship between costs (privacy concerns) and benefits. Social support, which has been proven to be a distinct and significant disclosure benefit of mHealth, was chosen as the representative benefit of information disclosure.

Methods

We examine a structural equation model that incorporates privacy concerns, health information disclosure intention in mHealth, and social support from mHealth, all at the individual level.

Results

A validated questionnaire was completed by 253 randomly selected participants. The result indicated that perceived health information sensitivity positively enhances patients’ privacy concern (beta path coefficient 0.505, P<.001), and higher privacy concern levels will decrease their health information disclosure intention (beta path coefficient –0.338, P<.001). Various individual characteristics influence perceived health information sensitivity in different ways. One dimension of social support, informational support, negatively moderates the effect of the relationship between perceived health information sensitivity and privacy concerns (beta path coefficient –0.171, P=.092) and the effect of the relationship between privacy concerns and health information disclosure intention (beta path coefficient –0.105, P=.092). However, another dimension, emotional support, has no direct moderation effect on the relationship between privacy concerns and health information disclosure intention.

Conclusions

The results indicate that social support can be regarded as a disutility reducer. That is, on the one hand, it reduces patients’ privacy concerns; on the other hand, it also reduces the negative impact of privacy concerns on information disclosure intention. Moreover, the moderation effect of social support is partially supported. Informational support, one dimension of social support, is significant (beta path coefficient –0.171, P=.092), while the other dimension, emotional support, is not significant (beta path coefficient –0.137, P=.146), in mHealth. Furthermore, the results are different among patients with different individual characteristics. This study also provides specific theoretical and practical implications to enhance the development of mHealth.

The role of patient engagement in patient-centric health information exchange (HIE) initiatives: an empirical study in the United States

Purpose

Patient-centric exchanges, a major type of Health Information Exchange (HIE), empower patients to aggregate and manage their health information. This exchange model helps patients access, modify and share their medical information with multiple healthcare organizations. Although existing studies examine patient engagement, more research is required to investigate patients' attitudes and willingness to play an active role in patient-centered information exchange. The study's main objective is to develop a model based on the belief-attitude-intention paradigm to empirically examine the effects of patients' attitudes toward engagement in care on their willingness to participate in patient-centric HIE.

Design/methodology/approach

The authors conducted an online survey study to identify the antecedents and consequences of patients' attitudes toward engagement in care. To empirically test the research model, the authors collected data from a national sample (n = 357) of individuals in the United States. The data were analyzed using structural equation modeling (SEM).

Findings

The proposed model categorizes the antecedents to patients' attitudes toward engagement in patient-related and healthcare system factors. The results show that patient-related factors (perceived health literacy and perceived coping ability) and health system factors (perceived experience with the healthcare organization and perceived patient-provider interaction) significantly shape patient attitude toward care management engagement. The results indicate that patients' attitudes toward engaging in their healthcare significantly contribute to their willingness to participate in medical information sharing through patient-centric HIE initiatives. Moreover, the authors’ findings also demonstrate that the link between patient engagement and willingness to participate in HIE is stronger for individuals who perceive lower levels of privacy and security concerns.

Originality/value

The authors validate the proposed model explaining patients' perceptions about their characteristics and the healthcare system significantly influence their attitude toward engaging in their care. This study also suggests that patients' favorable attitude toward engagement can bring patient-centric HIE efforts onto a path to success. The authors’ research attempts to shed light on the importance of patients' roles in adopting patient-centric HIE initiatives. Theoretical and practical contributions of this study are noticeable since they could result in a deeper understanding of the concept of patient engagement and how it may affect healthcare services in an evolving digital world. The authors’ findings can help healthcare organizations provide public citizen-centric services by introducing user-oriented approaches in healthcare delivery systems.

Ethical issues related to eHealth: An integrative review

BACKGROUND

Identifying and safeguarding ethics in eHealth services from the service users' perspective in social care and healthcare is important. The use of eHealth services should not prejudice the quality of services or the social interaction required in care. There is a lack of studies about the ethics of eHealth services from the service users' perspective.

AIM

The aim of this study is to identify and analyse ethical issues related to eHealth in social care and healthcare from the service users' perspective.

RESEARCH DESIGN

An integrative literature review.

ETHICAL CONSIDERATIONS

The review followed good scientific conduct.

RESEARCH CONTEXT AND DATA SOURCES

A systematic literature search was performed using CINAHL, Scopus, PubMed/MEDLINE, Web of Science, Cochrane Library and Academic Search Premier to find relevant empirical studies published in English from their earliest up to 30 November 2018. In addition, reference lists from the identified research papers were searched. A quality appraisal of each paper included in the review was conducted before thematic analysis.

RESULTS

In total, 26 studies were included in the review, and from these four ethical themes were identified: (1) privacy in eHealth, (2) beneficence and nonmaleficence in eHealth, (3) justice in eHealth and (4) trust in eHealth. The ethical issues within these themes were related to information sharing; ownership; access to information and data protection; informed consent; defence of rights; and equity, equality and proportionality of response.

CONCLUSION

eHealth inequality occurs in social care and healthcare. eHealth service designers and social care and healthcare professionals need to act to maintain and improve user access and data accuracy and provide different levels of security in eHealth services, relative to the information stored. There is a need for further research about ethical issues of eHealth from the user's perspective, including the customer-oriented availability and usability of eHealth services which avoid discrimination.

Security and Privacy Requirements for Cloud Computing in Healthcare

Cloud computing promises essential improvements in healthcare delivery performance. However, its wide adoption in healthcare is yet to be seen, one main reason being patients’ concerns for security and privacy of their sensitive medical records. These concerns can be addressed through corresponding security and privacy requirements within the system engineering process. Despite a plethora of related research, security and privacy requirements for cloud systems and services have seldomly been investigated methodically so far, whereas their individual priorities to increase the system success probability have been neglected. Against this background, this study applies a systematic requirements engineering process: First, based on a systematic literature review, an extensive initial set of security and privacy requirements is elicited. Second, an online survey based on the best-worst scaling method is designed, conducted, and evaluated to determine priorities of security and privacy requirements.

Our results show that confidentiality and integrity of medical data are ranked at the top of the hierarchy of prioritized requirements, followed by control of data use and modification, patients’ anonymity, and patients’ control of access rights. Availability, fine-grained access control, revocation of access rights, flexible access, clinicians’ anonymity, as well as usability, scalability, and efficiency of the system complete the ranking. The level of agreement among patients is rather small, but statistically significant at the 0.01 level.

The main contribution of the present research comprises the study method and results highlighting the role of strong security and privacy and excluding any trade-offs with system usability. Enabling a richer understanding of patients’ security and privacy requirements for adopting cloud computing in healthcare, these are of particular importance to researchers and practitioners interested in supporting the process of security and privacy engineering for health-cloud solutions. It further represents a supplement that can support time-intensive negotiation meetings between the requirements engineers and patients.

Non-Hispanic White Mothers' Willingness to Share Personal Health Data With Researchers: Survey Results From an Opt-in Panel

Background

Advances in information communication technology provide researchers with the opportunity to access and collect continuous and granular data from enrolled participants. However, recruiting study participants who are willing to disclose their health data has been challenging for researchers. These challenges can be related to socioeconomic status, the source of data, and privacy concerns about sharing health information, which affect data-sharing behaviors.

Objective

This study aimed to assess healthy non-Hispanic white mothers’ attitudes in five areas: motivation to share data, concern with data use, desire to keep health information anonymous, use of patient portal and willingness to share anonymous data with researchers.

Methods

This cross-sectional study was conducted on 622 healthy non-Hispanic white mothers raising healthy children. From a Web-based survey with 51 questions, we selected 15 questions for further analysis. These questions focused on attitudes and beliefs toward data sharing, internet use, interest in future research, and sociodemographic and health questions about mothers and their children. Data analysis was performed using multivariate logistic regressions to investigate the factors that influence mothers’ willingness to share their personal health data, their utilization of a patient portal, and their interests in keeping their health information anonymous.

Results

The results of the study showed that the majority of mothers surveyed wanted to keep their data anonymous (440/622, 70.7%) and use patient portals (394/622, 63.3%) and were willing to share their data from Web-based surveys (509/622, 81.8%) and from mobile phones (423/622, 68.0%). However, 36.0% (224/622) and 40.5% (252/622) of mothers were less willing to share their medical record data and their locations with researchers, respectively. We found that the utilization of patient portals, their attitude toward keeping data anonymous, and their willingness to share different data sources were dependent on the mothers’ health care provider status, their motivation, and their privacy concerns. Mothers’ concerns about the misuse of personal health information had a negative impact on their willingness to share sensitive data (ie, electronic medical record: adjusted odds ratio [aOR] 0.43, 95% CI 0.25-0.73; GPS: aOR 0.4, 95% CI 0.27-0.60). In contrast, mothers’ motivation to share their data had a positive impact on disclosing their data via Web-based surveys (aOR 5.94, 95% CI 3.15-11.2), apps and devices designed for health (aOR 5.3, 95% CI 2.32-12.1), and a patient portal (aOR 4.3, 95% CI 2.06-8.99).

Conclusions

The findings of this study suggest that mothers’ privacy concerns affect their decisions to share sensitive data. However, mothers’ access to the internet and the utilization of patient portals did not have a significant effect on their willingness to disclose their medical record data. Finally, researchers can use our findings to better address their study subjects concerns and gain their subjects trust to disclose data.

A Patient-Centric Health Information Exchange Framework Using Blockchain Technology

Health Information Exchange (HIE) exhibits remarkable benefits for patient care such as improving healthcare quality and expediting coordinated care. The Office of the National Coordinator (ONC) for Health Information Technology is seeking patient-centric HIE designs that shift data ownership from providers to patients. There are multiple barriers to patient-centric HIE in the current system, such as security and privacy concerns, data inconsistency, timely access to the right records across multiple healthcare facilities. After investigating the current workflow of HIE, this paper provides a feasible solution to these challenges by utilizing the unique features of blockchain, a distributed ledger technology which is considered "unhackable". Utilizing the smart contract feature, which is a programmable self-executing protocol running on a blockchain, we developed a blockchain model to protect data security and patients' privacy, ensure data provenance, and provide patients full control of their health records. By personalizing data segmentation and an "allowed list" for clinicians to access their data, this design achieves patient-centric HIE. We conducted a large-scale simulation of this patient-centric HIE process and quantitatively evaluated the model's feasibility, stability, security, and robustness.

Adoption of an Electronic Patient Record Sharing Pilot Project: Cross-Sectional Survey

BACKGROUND

The Public Private Interface-Electronic Patient Record (PPI-ePR) system was implemented as a new electronic platform to facilitate collaboration between the public and private sectors in Hong Kong. However, its barriers to participate and benefits have not been comprehensively assessed.

OBJECTIVE

This study aimed to evaluate the awareness, acceptance, perceived benefits, and obstacles to participation among private doctors and the general public.

METHODS

From December 2012 to January 2013, 2435 telephone interviews were performed by trained interviewers to survey randomly selected patients who were enrolled or not enrolled in the PPI-ePR system. In addition, self-administered surveys were sent by postal mail to 4229 registered doctors in Hong Kong. The questionnaires for both patients and doctors contained questions on subjects' awareness, acceptance, and perceptions of the PPI-ePR, perceived benefits and obstacles of participating in the program, reasons for not using the system after enrolling, and perceived areas for service improvement of the system.

RESULTS

More than 53.1% (266/501) of enrolled patients believed that the PPI-ePR system would improve health care quality by reducing duplicate tests and treatments, while more than 76.8% (314/409) of enrolled doctors emphasized timely access to patients' medical records as the biggest benefit of their enrollment. Among nonenrolled patients, unawareness of the project was the most popular obstacle to enrolling in the PPI-ePR system (483/1200, 40.3%). Regarding nonenrolled doctors, the complicated registration process hindered them from participating in the program the most (95/198, 48.0%). Television, newspaper, and magazine advertisements and medical profession newsletters or journals were suggested as the most effective means to encourage participation in the program among surveyed patients (1297/1701, 76.2%) and doctors (428/610, 70.2%), respectively. Lack of clinical indication requiring data extraction from other hospitals was the main reason for low level of PPI-ePR use.

CONCLUSIONS

This study comprehensively assessed the popularity, perceived benefits, and hindering factors of enrolling in the PPI-ePR system in Hong Kong. Low levels of awareness, few privacy concerns, and inactive use of the PPI-ePR system were among the key features for patients and physicians. Public promotions, simplified logistics, and a user-friendly online interface were suggested to improve the coverage and effectiveness of health information exchange between private and public health care sectors.

Informed consent within a learning health system: A scoping review

INTRODUCTION

A major consideration for the implementation of a learning health system (LHS) is consent from participants to the use of their data for research purposes. The main objective of this paper was to identify in the literature which types of consent have been proposed for participation in research observational activities in a LHS. We were particularly interested in understanding which approaches were seen as most feasible and acceptable and in which context, in order to inform the development of a Quebec-based LHS.

METHODS

Using a scoping review methodology, we searched scientific and legal databases as well as the gray literature using specific terms. Full-text articles were reviewed independently by two authors on the basis of the following concepts: (a) LHS and (b) approach to consent. The selected papers were imported in NVivo software for analysis in the light of a conceptual framework that distinguishes various, largely independent dimensions of consent.

RESULTS

A total of 93 publications were analysed for this review. Several studies reach opposing conclusions concerning the best approach to consent within a LHS. However, in the light of the conceptual framework we developed, we found that many of these results are distorted by the conflation between various characteristics of consent. Thus, when these characteristics are distinguished, the results mainly suggest the prime importance of the communication process, by contrast to the scope of consent or the kind of action required by participants (opt-in/opt-out). We identified two models of consent that were especially relevant for our purpose: metaconsent and dynamic consent.

CONCLUSIONS

Our review shows the importance of distinguishing carefully the various features of the consent process. It also suggests that the metaconsent model is a valuable model within a LHS, as it addresses many of the issues raised with regards to feasibility and acceptability. We propose to complement this model by adding the modalities of the information process to the dimensions relevant in the metaconsent process.

Improving Self-Care in Patients With Coexisting Type 2 Diabetes and Hypertension by Technological Surrogate Nursing: Randomized Controlled Trial

BACKGROUND

Technological surrogate nursing (TSN) derives from the idea that nurse-caregiver substitutes can be created by technology to support chronic disease self-care.

OBJECTIVE

This paper begins by arguing that TSN is a useful and viable approach to chronic disease self-care. The analysis then focuses on the empirical research question of testing and demonstrating the effectiveness and safety of prototype TSN supplied to patients with the typical complex chronic disease of coexisting type 2 diabetes and hypertension. At the policy level, it is shown that the data allow for a calibration of TSN technology augmentation, which can be readily applied to health care management.

METHODS

A 24-week, parallel-group, randomized controlled trial (RCT) was designed and implemented among diabetic and hypertensive outpatients in two Hong Kong public hospitals. Participants were randomly assigned to an intervention group, supplied with a tablet-based TSN app prototype, or to a conventional self-managing control group. Primary indices-hemoglobin A1c, systolic blood pressure, and diastolic blood pressure-and secondary indices were measured at baseline and at 8, 12, 16, and 24 weeks after initiation, after which the data were applied to test TSN effectiveness and safety.

RESULTS

A total of 299 participating patients were randomized to the intervention group (n=151) or the control group (n=148). Statistically significant outcomes that directly indicated TSN effectiveness in terms of hemoglobin 1c were found in both groups but not with regard to systolic and diastolic blood pressure. These findings also offered indirect empirical support for TSN safety. Statistically significant comparative changes in these primary indices were not observed between the groups but were suggestive of an operational calibration of TSN technology augmentation. Statistically significant changes in secondary indices were obtained in one or both groups, but not between the groups.

CONCLUSIONS

The RCT's strong behavioral basis, as well as the importance of safety and effectiveness when complex chronic illness is proximately self-managed by layperson patients, prompted the formulation of the empirical joint hypothesis that TSN would improve patient self-care while satisfying the condition of patient self-safety. Statistical and decision analysis applied to the experimental outcomes offered support for this hypothesis. Policy relevance of the research is demonstrated by the derivation of a data-grounded operational calibration of TSN technology augmentation with ready application to health care management.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02799953; https://clinicaltrials.gov/ct2/show/NCT02799953.

Opt-in consent policies: potential barriers to hospital health information exchange

OBJECTIVES

To (1) assess whether hospitals in states requiring explicit patient consent ("opt-in") for health information exchange (HIE) are more likely to report regulatory barriers to HIE and (2) analyze whether these policies correlate with hospital volume of HIE.

STUDY DESIGN

Cross-sectional analysis of US nonfederal acute care hospitals in 2016.

METHODS

We combined legal scholarship surveying HIE-relevant state laws with the American Hospital Association Annual Information Technology Supplement for regulatory barriers and hospital characteristics. Data from CMS reports for hospitals attesting to Meaningful Use stage 2 (MU2; renamed "Promoting Interoperability" in 2018) in 2016 captured hospital HIE volume. We used multivariate logistic regression and linear regression to estimate the association of opt-in state consent policies with reported regulatory barriers and HIE volume, respectively.

RESULTS

Hospitals in states with opt-in consent policies were 7.8 percentage points more likely than hospitals in opt-out states to report regulatory barriers to HIE (P = .03). In subgroup analyses, this finding held among hospitals that did not attest to MU2 (7.7 percentage points; P = .02). Among hospitals attesting, we did not find a relationship between opt-in policies and regulatory barriers (8.0 percentage points; P = .13) or evidence of a relationship between opt-in policies and HIE volume (β = 0.56; P = .76).

CONCLUSIONS

Our findings suggest that opt-in consent laws may carry greater administrative burdens compared with opt-out policies. However, less technologically advanced hospitals may bear more of this burden. Furthermore, opt-in policies may not affect HIE volume for hospitals that have already achieved a degree of technological sophistication. Policy makers should carefully consider the incidence of administrative burdens when crafting laws pertaining to HIE.

A national registry to assess the value of cardiovascular magnetic resonance imaging after primary percutaneous coronary intervention pathway activation: a feasibility cohort study

Background

Cardiovascular magnetic resonance (CMR) is increasingly used in patients who activate the primary percutaneous coronary intervention (PPCI) pathway to assess heart function. It is uncertain whether having CMR influences patient management or the risk of major adverse cardiovascular events in these patients.

Objective

To determine whether or not it is feasible to set up a national registry, linking routinely collected data from hospital information systems (HISs), to investigate the role of CMR in patients who activate the PPCI pathway.

Design

A feasibility prospective cohort study.

Setting

Four 24/7 PPCI hospitals in England and Wales (two with and two without a dedicated CMR facility).

Participants

Patients who activated the PPCI pathway and underwent an emergency coronary angiogram.

Interventions

CMR either performed or not performed within 10 weeks of the index event.

Main outcome measures

A. Feasibility parameters – (1) patient consent implemented at all hospitals, (2) data extracted from more than one HIS and successfully linked for > 90% of consented patients at all four hospitals, (3) HIS data successfully linked with Hospital Episode Statistics (HES) and Patient Episode Database Wales (PEDW) for > 90% of consented patients at all four hospitals and (4) CMR requested and carried out for ≥ 10% of patients activating the PPCI pathway in CMR hospitals. B. Key drivers of cost-effectiveness for CMR (identified from simple cost-effectiveness models) in patients with (1) multivessel disease and (2) unobstructed coronary arteries. C. A change in clinical management arising from having CMR (defined using formal consensus and identified using HES follow-up data in the 12 months after the index event).

Results

A. (1) Consent was implemented (for all hospitals, consent rates were 59–74%) and 1670 participants were recruited. (2) Data submission was variable – clinical data available for ≥ 82% of patients across all hospitals, biochemistry and echocardiography (ECHO) data available for ≥ 98%, 34% and 87% of patients in three hospitals and medications data available for 97% of patients in one hospital. (3) HIS data were linked with hospital episode data for 99% of all consented patients. (4) At the two CMR hospitals, 14% and 20% of patients received CMR. B. In both (1) multivessel disease and (2) unobstructed coronary arteries, the difference in quality-adjusted life-years (QALYs) between CMR and no CMR [‘current’ comparator, stress ECHO and standard ECHO, respectively] was very small [0.0012, 95% confidence interval (CI) –0.0076 to 0.0093 and 0.0005, 95% CI –0.0050 to 0.0077, respectively]. The diagnostic accuracy of the ischaemia tests was the key driver of cost-effectiveness in sensitivity analyses for both patient subgroups. C. There was consensus that CMR leads to clinically important changes in management in five patient subgroups. Some changes in management were successfully identified in hospital episode data (e.g. new diagnoses/procedures, frequency of outpatient episodes related to cardiac events), others were not (e.g. changes in medications, new diagnostic tests).

Conclusions

A national registry is not currently feasible. Patients were consented successfully but conventional consent could not be implemented nationally. Linking HIS and hospital episode data was feasible but HIS data were not uniformly available. It is feasible to identify some, but not all, changes in management in the five patient subgroups using hospital episode data. The delay in obtaining hospital episode data influenced the relevance of some of our study objectives.

Future work

To test the feasibility of conducting the study using national data sets (e.g. HES, British Cardiovascular Intervention Society audit database, Diagnostic Imaging Dataset, Clinical Practice Research Datalink).

Funding

The National Institute for Health Research (NIHR) Health Services and Delivery Research programme. This study was designed and delivered in collaboration with the Clinical Trials and Evaluation Unit, a UK Clinical Research Collaboration-registered clinical trials unit that, as part of the Bristol Trials Centre, is in receipt of NIHR clinical trials unit support funding.

eHealth and telemedicine: Practices and beliefs among healthcare professionals and medical students at a medical university

Digitalization affects almost every aspect of modern daily life including healthcare delivery. Successful adoption and sustainable integration of information technology-based eHealth and telemedicine concepts in clinical practice depend on constant evaluation of end user needs, proficiencies, and preferences. We therefore assessed how current and future healthcare professionals perceived health technology solutions and whether their perceptions differed. We conducted an online survey among a purposive sample of employees and students at the Medical University of Vienna, Austria. The structured questionnaire collected self-reported practices and beliefs in the context of eHealth and telemedicine among 905 participants (59.0% females), of which 48.4% were employees and 51.6% were students. Participants expressed moderate knowledge of eHealth and telemedicine concepts with higher levels among employees compared to students (both: p<0.05). Compared to employees, students were less convinced that online health information improves patient knowledge (p<0.001), but were more optimistic that telemedicine reduces healthcare costs (p<0.05). Participants doubted that telemedicine services would enhance the doctor-patient relationship and raised concerns regarding data security and privacy issues. Accordingly, quantitative context analysis of free text comments revealed that the four most frequently mentioned themes were related to issues concerning data privacy and security, questions of responsibility, doctor-patient interaction, and reliability of information. This study provides valuable insights into how current and future healthcare professionals differ in their perceptions regarding eHealth and telemedicine. These findings raise awareness of the need to bridge the gap between digital age groups and professional groups, especially in clinical healthcare delivery in a clocked-through, strenuous academic setting as found at a medical university.

The Association Between State-Level Health Information Exchange Laws and Hospital Participation in Community Health Information Organizations

Evidence suggests that health information exchange (HIE) is an effective strategy to improve efficiency and quality of care, as well as reduce costs. A complex patchwork of federal and state legislation has developed over time to encourage HIE activity. Hospitals and health systems have adopted various HIE models to meet the requirements of these statutes and regulations. Given the complexity of HIE laws, it is important to understand how these legal levers influence HIE engagement. We combined data from two unique data sources to examine the association between state-level HIE laws and hospital engagement in community HIEs. Our results identified three legal provisions of state laws (HIE authorization, financial & non-financial incentives, opt-out consent) that increased the likelihood of community HIE engagement. Other provisions decreased the likelihood of engagement. This analysis provides foundational evidence about the utility of HIE laws. More research is needed to determine causal relationships.

Challenges and Opportunities of Health Information Exchange (HIE) From Health Consumers' Perspective

The implementation of HIE depends on a number of entities and one of the key participants is health consumers. All potential gains of HIE cannot be achieved without consumers' favorable beliefs and support. However, little is known about the factors affecting consumers to endorse electronic information exchange between healthcare organizations. The primary objective of this article is to identify how and why patients would support HIE used by healthcare providers. The author has conducted an online questionnaire-based survey in the U.S. This study has shown that perceived value of HIE is significantly related to consumers HIE supportive intention. Moreover, perceived value fully mediates the effects of perceived benefit and cost of HIE implementation on consumer tendency to endorse HIE. The findings also provide evidence to highlight that consumers' attitude toward exchange model moderates the relationship between value perception and intention to support HIE. Relying on the results, this study offers several practical and theoretical contributions.

Greater patient health information control to improve the sustainability of health information exchanges

Health information exchanges (HIEs) are multisided platforms that facilitate the sharing of patient health information (PHI) between providers and payers across organizations within a region, community or hospital system. The benefits of HIEs to payers and providers include lower cost, faster services, and better health outcome. However, most HIEs have configured the patient healthcare consent process to give all providers who sign up with the exchange access to PHI for all consenting patients, leaving no control to patients in customized what information to share and with who. This research investigates the impact of granting greater control to patients in sharing their personal health information on consent rates and making them active participants in the HIEs system. This research utilizes a randomized experimental survey design study. The study uses responses from 388 participants and structural equation modeling (SEM) to test the conceptual model. The main findings of this research include that patients consent rate increases significantly when greater control in sharing PHI is offered to the patient. In addition, greater control reduces the negative impact of privacy concern on the intention to consent. Similarly, trust in healthcare professionals leads to higher consent when greater control is offered to the patient. Thus, greater control empowers the role of trust in engaging patients and sustaining HIEs. The paper makes a theoretical contribution to research by extending the unified theory of acceptance and use of technology (UTAUT) model. The findings impact practice by providing insights that will help sustain HIEs.

Too Important to Ignore: Leveraging Digital Technology to Improve Chronic Illness Management Among Black Men

Health disparities associated with chronic illness experiences of black men demonstrate widespread, systematic failures to meet an urgent need. Well-established social and behavioral determinants that have led to health disparities among black men include racism, discrimination, and stress. While advocacy work that includes community-engagement and tailoring health promotion strategies have shown local impact, evidence shows the gaps are increasing. We suspect that failure to reduce current disparities may be due to conventional public health interventions and programs; therefore, we submit that innovative interventions, ones that embrace digital technologies and their ability to harness naturally occurring social networks within groups, like black men, have particular importance and deserve attention. This commentary characterizes the current literature on chronic illness among black men as well as health interventions that use digital technology, to build a case for expanding research in this area to reduce the overwhelming burden of chronic illness among black men.

Consumer Mobile Health Apps: Current State, Barriers, and Future Directions

This paper discusses the current state, barriers, and future directions of consumer-facing applications (apps). There are currently more than 165,000 mobile health apps publicly available in major app stores, the vast majority of which are designed for patients. The top 2 categories are wellness management and disease management apps, whereas other categories include self-diagnosis, medication reminder, and electronic patient portal apps. Apps specific to physical medicine and rehabilitation also are reviewed. These apps have the potential to provide low-cost, around-the-clock access to high-quality, evidence-based health information to end users on a global scale. However, they have not yet lived up to their potential due to multiple barriers, including lack of regulatory oversight, limited evidence-based literature, and concerns of privacy and security. The future directions may consist of improving data integration into the health care system, an interoperable app platform allowing access to electronic health record data, cloud-based personal health record across health care networks, and increasing app prescription by health care providers. For consumer mobile health apps to fully contribute value to health care delivery and chronic disease management, all stakeholders within the ecosystem must collaborate to overcome the significant barriers.

Developing a UK registry to investigate the role of cardiovascular magnetic resonance (CMR) in patients who activate the primary percutaneous coronary intervention (PPCI) pathway: a multicentre, feasibility study linking routinely collected electronic patient data

OBJECTIVES

To determine whether it is feasible to set up a national registry, linking routinely collected data from hospital information systems (HIS), to investigate the role of cardiovascular magnetic resonance (CMR) in patients who activate the primary percutaneous coronary intervention (PPCI) pathway.

DESIGN

Feasibility prospective cohort study, to establish whether: (1) consent can be implemented; (2) data linkage and extraction from multiple HIS can be achieved for >90% of consented patients; (3) local data can be successfully linked with hospital episode data (Hospital Episode Statistics, HES; Patient Episode Database for Wales, PEDW) for >90% of consented patients and (4) the proportion of patients activating the PPCI pathway who get a CMR scan is ≥10% in hospitals with dedicated CMR facilities.

PARTICIPANTS

Patients from four 24/7 PPCI hospitals in England and Wales (two with and two without a dedicated CMR facility) who activated the PPCI pathway and underwent an emergency coronary angiogram.

RESULTS

Consent was successfully implemented at all hospitals (consent rates ranged from 59% to 74%) and 1670 participants were recruited. Data submission was variable: all hospitals submitted clinical data (for ≥82% of patients); only three hospitals submitted biochemistry data (for ≥98% of patients) and echocardiography data (for 34%-87% of patients); only one hospital submitted medications data (for 97% of patients). At the two CMR centres, 14% and 20% of patients received a CMR scan. Data submitted by hospitals were linked with HES and PEDW for 99% of all consented patients.

CONCLUSION

We successfully consented patients but obtaining individual, opt-in consent would not be feasible for a national registry. Linkage of data from HIS with hospital episode data was feasible. However, data from HIS are not uniformly available/exportable and, in centres with a dedicated CMR facility, some referrals for CMR were for research rather than clinical purposes.

Support needs for medication use and the suitability of eHealth technologies to address these needs: a focus group study of older patients with rheumatoid arthritis

OBJECTIVE

The objectives of this study were to explore the needs of patients with rheumatoid arthritis (RA) regarding support for medication use and to gain insight into their perspective on the suitability of eHealth technologies to address these needs.

METHODS

Three focus groups were conducted with 28 patients with RA. Audio recordings made during the focus groups were transcribed verbatim. Two researchers independently performed an inductive, thematic analysis on the data (ie, the transcripts and field notes).

RESULTS

The following three themes that described support needs of patients with RA for medication use were identified in the data: 1) informational support; 2) practical support; and 3) emotional support. Informational support reflected the provision of information and facts, including advice, suggestions, and feedback from health care providers. Practical support included the reinforcement of practical skills as well as the provision of medication aids and pharmacy services. Emotional support reflected a trusted patient-health care provider relationship, characterized by good communication. Although potential advantages of eHealth technologies to address the patients' support needs were recognized, concerns over matters such as personal interaction with health care providers, privacy and data security, and the quality and reliability of online information were prevalent.

CONCLUSION

Patients with RA have informational, practical, and emotional support needs for medication use. Informational support seems to be most important. From the patients' perspective, eHealth technologies may have the potential to address these needs. However, these technologies are regarded as a complement to, rather than a replacement of, current practices.

Client-Focused Security Assessment of mHealth Apps and Recommended Practices to Prevent or Mitigate Transport Security Issues

Background

Mobile health (mHealth) apps show a growing importance for patients and health care professionals. Apps in this category are diverse. Some display important information (ie, drug interactions), whereas others help patients to keep track of their health. However, insufficient transport security can lead to confidentiality issues for patients and medical professionals, as well as safety issues regarding data integrity. mHealth apps should therefore deploy intensified vigilance to protect their data and integrity. This paper analyzes the state of security in mHealth apps.

Objective

The objectives of this study were as follows: (1) identification of relevant transport issues in mHealth apps, (2) development of a platform for test purposes, and (3) recommendation of practices to mitigate them.

Methods

Security characteristics relevant to the transport security of mHealth apps were assessed, presented, and discussed. These characteristics were used in the development of a prototypical platform facilitating streamlined tests of apps. For the tests, six lists of the 10 most downloaded free apps from three countries and two stores were selected. As some apps were part of these top 10 lists in more than one country, 53 unique apps were tested.

Results

Out of the 53 apps tested from three European App Stores for Android and iOS, 21/53 (40%) showed critical results. All 21 apps failed to guarantee the integrity of data displayed. A total of 18 apps leaked private data or were observable in a way that compromised confidentiality between apps and their servers; 17 apps used unprotected connections; and two apps failed to validate certificates correctly. None of the apps tested utilized certificate pinning. Many apps employed analytics or ad providers, undermining user privacy.

Conclusions

The tests show that many mHealth apps do not apply sufficient transport security measures. The most common security issue was the use of any kind of unprotected connection. Some apps used secure connections only for selected tasks, leaving all other traffic vulnerable.

Putting the Focus Back on the Patient: How Privacy Concerns Affect Personal Health Information Sharing Intentions

Background

Health care providers are driven by greater participation and systemic cost savings irrespective of benefits to individual patients derived from sharing Personal Health Information (PHI). Protecting PHI is a critical issue in the sharing of health care information systems; yet, there is very little literature examining the topic of sharing PHI electronically. A good overview of the regulatory, privacy, and societal barriers to sharing PHI can be found in the 2009 Health Information Technology for Economic and Clinical Health Act.

Objective

This study investigated the factors that influence individuals’ intentions to share their PHI electronically with health care providers, creating an understanding of how we can represent a patient’s interests more accurately in sharing settings, instead of treating patients like predetermined subjects. Unlike privacy concern and trust, patient activation is a stable trait that is not subject to change in the short term and, thus, is a useful factor in predicting sharing behavior. We apply the extended privacy model in the health information sharing context and adapt this model to include patient activation and issue involvement to predict individuals’ intentions.

Methods

This was a survey-based study with 1600+ participants using the Health Information National Trends Survey (HINTS) data to validate a model through various statistical techniques. The research method included an assessment of both the measurement and structural models with post hoc analysis.

Results

We find that privacy concern has the most influence on individuals’ intentions to share. Patient activation, issue involvement, and patient-physician relationship are significant predictors of sharing intention. We contribute to theory by introducing patient activation and issue involvement as proxies for personal interest factors in the health care context.

Conclusions

Overall, this study found that although patients are open to sharing their PHI, they still have concerns over the privacy of their PHI during the sharing process. It is paramount to address this factor to increase information flow and identify how patients can assure that their privacy is protected. The outcome of this study is a set of recommendations for motivating the sharing of PHI. The goal of this research is to increase the health profile of the patients by integrating the testing and diagnoses of various doctors across health care providers and, thus, bring patients closer to the physicians.