The Impact of Patient Online Access to Computerized Medical Records and Services on Type 2 Diabetes: Systematic Review

The impact of eHealth on relationships and trust in primary care: a review of reviews

BACKGROUND

Given the increasing integration of digital health technologies in team-based primary care, this review aimed at understanding the impact of eHealth on patient-provider and provider-provider relationships.

METHODS

A review of reviews was conducted on three databases to identify papers published in English from 2008 onwards. The impact of different types of eHealth on relationships and trust and the factors influencing the impact were thematically analyzed.

RESULTS

A total of 79 reviews were included. Patient-provider relationships were discussed more frequently as compared to provider-provider relationships. Communication systems like telemedicine were the most discussed type of technology. eHealth was found to have both positive and negative impacts on relationships and/or trust. This impact was influenced by a range of patient-related, provider-related, technology-related, and organizational factors, such as patient sociodemographics, provider communication skills, technology design, and organizational technology implementation, respectively.

CONCLUSIONS

Recommendations are provided for effective and equitable technology selection, application, and training to optimize the impact of eHealth on relationships and trust. The review findings can inform providers' and policymakers' decision-making around the use of eHealth in primary care delivery to facilitate relationship-building.

An Assessment of Patient Portal Messaging Use by Patients With Multiple Chronic Conditions Living in Rural Communities: Retrospective Analysis

BACKGROUND

Patient portals can facilitate the delivery of health care services and support self-management for patients with multiple chronic conditions. Despite their benefits, the evidence of patient portal use among patients with multimorbidity in rural communities is limited.

OBJECTIVE

This study aimed to explore the factors associated with portal messaging use by rural patients.

METHODS

We assessed patient portal use among patients with ≥1 chronic diagnoses who sent or received messages via the Epic MyChart (Epic Systems Corporation) portal between January 1, 2015, and November 9, 2021. Patient portal use was defined as sending or receiving a message through the portal during the study period. We fit a zero-inflated negative binomial model to predict portal use based on the patient's number of chronic conditions, sex, race, age, marital status, and insurance type. County-level characteristics, based on the patient's home address, were also included in the model to assess the influence of community factors on portal use. County-level factors included educational attainment, smartphone ownership, median income, and primary care provider density.

RESULTS

A total of 65,178 patients (n=38,587, 59.2% female and n=21,454, 32.92% Black) were included in the final data set, of which 38,380 (58.88%) sent at least 1 message via the portal during the 7-year study period. As the number of chronic diagnoses increased, so did portal messaging use; however, this relationship was driven primarily by younger patients. Patients with 2 chronic conditions were 1.57 times more likely to send messages via the portal than those with 1 chronic condition (P<.001). In comparison, patients with ≥7 chronic conditions were approximately 11 times more likely to send messages than patients with 1 chronic condition (P<.001). A robustness check confirmed the interaction effect of age and the number of diagnoses on portal messaging. In the model including only patients aged <65 years, there was a significant effect of increased portal messaging corresponding to the number of chronic conditions (P<.001). Conversely, this relationship was not significant for the model consisting of older patients. Other significant factors associated with increased portal use include being female; White; married; having private insurance; and living in an area with a higher average level of educational attainment, greater medical provider density, and a lower median income.

CONCLUSIONS

Patients' use of the portal to send messages to providers was incrementally related to their number of diagnoses. As the number of chronic diagnoses increased, so did portal messaging use. Patients of all ages, particularly those living in rural areas, could benefit from the convenience and cost-effectiveness of portal communication. Health care systems and providers are encouraged to increase the use of patient portals by implementing educational interventions to promote the advantages of portal communication, particularly among patients with multimorbidity.

Unintended consequences of patient online access to health records: a qualitative study in UK primary care

BACKGROUND

Health systems are seeking to harness digital tools to promote patient autonomy and increase the efficiency of care worldwide. The NHS Long Term Plan created the right for patients to access 'digital first' primary care by 2023-2024, including online patient access to full medical records.

AIM

To identify and understand the unintended consequences of online patient access to medical records.

DESIGN AND SETTING

Qualitative interview study in 10 general practices in South West and North West England.

METHOD

Semi-structured individual interviews with 13 patients and 16 general practice staff with experience of patient online access to health records.

RESULTS

Online access generated unintended consequences that negatively impacted patients' understanding of their health care, with patients finding surprising or difficult to interpret information. Online access impacted GPs' documentation practices, such as when GPs pre-emptively attempted to minimise potential misunderstandings to aid patient understanding of their health care. In other cases, this negatively impacted the quality of the records and patient safety when GPs avoided documenting speculations or concerns. Contrary to assumptions that workload would be reduced, online access introduced extra work, such as managing and monitoring access, and taking measures to prevent possible harm to patients.

CONCLUSION

The unintended consequences described by both staff and patients show that, to achieve the intended consequences set out in NHS policy, additional work is necessary to prepare records for sharing and to prepare patients about what to expect. It is crucial that practices are adequately supported and resourced to manage the unintended consequences of online access, now that it is the default position. A table of potential unintended consequences and mitigation measures is provided to aid practice managers and clinicians implementing online access.

Patient Portals: Useful for Whom and for What? A Cross-Sectional Analysis of National Survey Data

BACKGROUND

Patients who use patient portals may be more engaged and empowered in their care; however, differences in who accesses patient portals remain. The characteristics of who uses patient portals more frequently and who perceives them as useful may also differ, as well as which functions people use.

OBJECTIVE

We assessed the characteristics of patient portal users to examine who uses them more frequently and who perceives them as useful. In addition, we wanted to see if those who use them more frequently or perceive them to be more useful use different functions or more functions of patient portals.

METHODS

Pooled cross-sectional data from 2017 to 2018 Health Information National Trends Survey (HINTS) were used. Ordinal regression models were developed to assess frequency of use and perceived usefulness by demographics, and multivariable logistic regression models were used to examine the association between the use of 10 patient portal functions and frequency of use and perceived usefulness of patient portals.

RESULTS

The odds of using patient portals more frequently were higher among those with Bachelor's degrees, incomes between $35,000 and $75,000, and those with two or more chronic conditions. Respondents with three or more chronic conditions had higher odds of rating patient portals as useful. Those who used their patient portal 10 or more times in the past year had higher odds of using all functions except for viewing test results compared with those who used their patient portal one to two times per year. Those who rated patient portals as "very useful" had higher odds of using seven of the functions compared with those who rated them "not very"/"not at all useful."

CONCLUSION

It is important to continue to assess usefulness, frequency of use, and overall patient portal function use to identify opportunities to increase patient engagement with patient portals.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Adult patient access to electronic health records

BACKGROUND

To support patient-centred care, healthcare organisations increasingly offer patients access to data stored in the institutional electronic health record (EHR).

OBJECTIVES

Primary objective 1. To assess the effects of providing adult patients with access to electronic health records (EHRs) alone or with additional functionalities on a range of patient, patient-provider, and health resource consumption outcomes, including patient knowledge and understanding, patient empowerment, patient adherence, patient satisfaction with care, adverse events, health-related quality of life, health-related outcomes, psychosocial health outcomes, health resource consumption, and patient-provider communication. Secondary objective 1. To assess whether effects of providing adult patients with EHR access alone versus EHR access with additional functionalities differ among patient groups according to age, educational level, or different status of disease (chronic or acute).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, and Scopus in June 2017 and in April 2020.

SELECTION CRITERIA

Randomised controlled trials and cluster-randomised trials of EHR access with or without additional functionalities for adults with any medical condition.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures.

MAIN RESULTS

We included 10 studies with 78 to 4500 participants and follow-up from 3 to 24 months. Nine studies assessed the effects of EHR with additional functionalities, each addressing a subset of outcomes sought by this review. Five studies focused on patients with diabetes mellitus, four on patients with specific diseases, and one on all patients. All studies compared EHR access alone or with additional functionalities plus usual care versus usual care only. No studies assessing the effects of EHR access alone versus EHR access with additional functionalities were identified. Interventions required a variety of data within the EHR, such as patient history, problem list, medication, allergies, and lab results. In addition to EHR access, eight studies allowed patients to share self-documented data, seven offered individualised disease management functions, seven offered educational disease-related information, six supported secure communication, and one offered preventive reminders. Only two studies were at low or unclear risk of bias across domains. Meta-analysis could not be performed, as participants, interventions, and outcomes were too heterogeneous, and most studies presented results based on different adjustment methods or variables. The quality of evidence was rated as low or very low across outcomes. Overall differences between intervention and control groups, if any, were small. The relevance of any small effects remains unclear for most outcomes because in most cases, trial authors did not define a minimal clinically important difference. Overall, results suggest that the effects of EHR access alone and with additional functionalities are mostly uncertain when compared with usual care. Patient knowledge and understanding: very low-quality evidence is available from one study, so we are uncertain about effects of the intervention on patient knowledge about diabetes and blood glucose testing. Patient empowerment: low-quality evidence from three studies suggests that the intervention may have little or no effect on patient empowerment measures. Patient adherence: low-quality evidence from two studies suggests that the intervention may slightly improve adherence to the process of monitoring risk factors and preventive services. Effects on medication adherence are conflicting in two studies; this may or may not improve to a clinically relevant degree. Patient satisfaction with care: low-quality evidence from three studies suggests that the intervention may have little or no effect on patient satisfaction, with conflicting results. Adverse events: two small studies reported on mortality; one of these also reported on serious and other adverse events, but sample sizes were too small for small differences to be detected. Therefore, low-quality evidence suggests that the intervention may have little to no effect on mortality and other adverse events. Health-related quality of life: only very low-quality evidence from one study is available. We are uncertain whether the intervention improves disease-specific quality of life of patients with asthma. Health-related outcomes: low-quality evidence from eight studies suggests that the intervention may have little to no effect on asthma control, glycosylated haemoglobin (HbA1c) levels, blood pressure, low-density lipoprotein or total cholesterol levels, body mass index or weight, or 10-year Framingham risk scores. Low-quality evidence from one study suggests that the composite scores of risk factors for diabetes mellitus may improve slightly with the intervention, but there is uncertainty about effects on ophthalmic medications or intraocular pressure. Psychosocial health outcomes: no study investigated psychosocial health outcomes in a more than anecdotal way. Health resource consumption: low-quality evidence for adult patients in three studies suggests that there may be little to no effect of the intervention on different measures of healthcare use. Patient-provider communication: very low-quality evidence is available from a single small study, and we are uncertain whether the intervention improves communication measures, such as the number of messages sent.

AUTHORS' CONCLUSIONS

The effects of EHR access with additional functionalities in comparison with usual care for the most part are uncertain. Only adherence to the process of monitoring risk factors and providing preventive services as well as a composite score of risk factors for diabetes mellitus may improve slightly with EHR access with additional functionalities. Due to inconsistent terminology in this area, our search may have missed relevant studies. As the overall quality of evidence is very low to low, future research is likely to change these results. Further trials should investigate the impact of EHR access in a broader range of countries and clinical settings, including more patients over a longer period of follow-up, as this may increase the likelihood of detecting effects of the intervention, should these exist. More studies should focus on assessing outcomes such as patient empowerment and behavioural outcomes, rather than concentrating on health-related outcomes alone. Future studies should distinguish between effects of EHR access only and effects of additional functionalities, and investigate the impact of mobile EHR tools. Future studies should include information on usage patterns, and consider the potential for widening health inequalities with implementation of EHR access. A taxonomy for EHR access and additional functionalities should be developed to promote consistency and comparability of outcome measures, and facilitate future reviews by better enabling cross-study comparisons.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The State of Evidence in Patient Portals: Umbrella Review

BACKGROUND

Patient portals have emerged as a recognized digital health strategy. To date, research on patient portals has grown rapidly. However, there has been limited evaluation of the growing body of evidence on portal availability, use, clinical or health behavior and outcomes, and portal adoption over time.

OBJECTIVE

This paper aims to comprehensively consolidate the current state of evidence on patient portals using the umbrella review methodology, introduce our approach for evaluating evidence for quantitative and qualitative findings presented in included systematic reviews, and present a knowledge translation tool that can be used to inform all stages of patient portal adoption.

METHODS

For this study, a modified version of the Joanna Briggs Institute umbrella review method was used. Multiple databases were searched for systematic reviews focused on patient portals, and the final sample included 14 reviews. We conducted a meta-level synthesis of findings from quantitative, qualitative, and mixed methods primary studies reported in systematic reviews. We organized the umbrella review findings according to the Clinical Adoption Meta-Model (CAMM). Vote-counting, GRADE (Grading of Recommendations, Assessment, Development, and Evaluations), and CERQual (Confidence in the Evidence from Review of Qualitative Research) were used to assess the umbrella review evidence.

RESULTS

Our knowledge translation tool summarizes the findings in the form of an evidence map. Organized by the CAMM categories, the map describes the following factors that influence portal adoption and effects over time: patient contexts, patient's interest and satisfaction, portal design, facilitators and barriers, providers' attitudes, service utilization, behavioral effects, clinical outcomes, and patient-reported outcomes. The map lists the theories and mechanisms recognized in the included portal research while identifying the need for business models and organizational theories that can inform all stages of portal adoption. Our GRADE and CERQual umbrella review evaluation resulted in the majority of evidence being rated as moderate to low, which reflects methodological issues in portal research, insufficient number of studies, or mixed results in specific focus areas. The 2 findings with a high rating of evidence were patients' interest in using portals for communication and the importance of a simple display of information in the portals. Over 40 portal features were identified in the umbrella review, with communication through secure messaging and appointment booking mentioned in all systematic reviews.

CONCLUSIONS

Our umbrella review provides a meta-level synthesis to make sense of the evidence on patient portals from published systematic reviews. Unsystematic and variable reporting of portal features undermines the ability to evaluate and compare portal effects and overlooks the specific context of portal use. Research designs sensitive to the social, organizational, policy, and temporal dimensions are needed to better understand the underlying mechanisms and context that leverage the identified factors to improve portal use and effects.

Electronic Consultation in Primary Care Between Providers and Patients: Systematic Review

Background

Governments and health care providers are keen to find innovative ways to deliver care more efficiently. Interest in electronic consultation (e-consultation) has grown, but the evidence of benefit is uncertain.

Objective

This study aimed to assess the evidence of delivering e-consultation using secure email and messaging or video links in primary care.

Methods

A systematic review was conducted on the use and application of e-consultations in primary care. We searched 7 international databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, PsycINFO, EconLit, and Web of Science; 1999-2017), identifying 52 relevant studies. Papers were screened against a detailed inclusion and exclusion criteria. Independent dual data extraction was conducted and assessed for quality. The resulting evidence was synthesized using thematic analysis.

Results

This review included 57 studies from a range of countries, mainly the United States (n=30) and the United Kingdom (n=13). There were disparities in uptake and utilization toward more use by younger, employed adults. Patient responses to e-consultation were mixed. Patients reported satisfaction with services and improved self-care, communication, and engagement with clinicians. Evidence for the acceptability and ease of use was strong, especially for those with long-term conditions and patients located in remote regions. However, patients were concerned about the privacy and security of their data. For primary health care staff, e-consultation delivers challenges around time management, having the correct technological infrastructure, whether it offers a comparable standard of clinical quality, and whether it improves health outcomes.

Conclusions

E-consultations may improve aspects of care delivery, but the small scale of many of the studies and low adoption rates leave unanswered questions about usage, quality, cost, and sustainability. We need to improve e-consultation implementation, demonstrate how e-consultations will not increase disparities in access, provide better reassurance to patients about privacy, and incorporate e-consultation as part of a manageable clinical workflow.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Social Media Content Analysis of Public Diabetes Facebook Groups

INTRODUCTION

Relatively little is known about how Facebook groups are used to facilitate diabetes self-management support. This study provides a critical analysis of public diabetes Facebook groups and their content.

METHODS

Two trained researchers independently identified 34 public Facebook diabetes groups. A coding and classification scheme was applied to the 20 most recent "wall posts" within 15 of the 34 (44.1%) largest groups (n = 300 posts). Nonparametric Mann-Whiney U tests examined differences in group characteristics between groups with more (active) and less (inactive) than 50 posts in the past month. Multivariable logistic regressions evaluated associations between group purpose, post types, membership (engagement leader vs regular user), and modality.

RESULTS

We identified 193 458 members of the 34 largest diabetes Facebook groups (Mdn size = 3124 members, IQR = 1298-8523 members). Many groups (20/34, 58.8%) were created to provide instrumental support, while fewer (12/34, 35.8%) aimed to provide emotional support. Nutrition was the only diabetes self-management topic addressed in more than 30% of posts (n = 107). Posts made by engagement leaders were almost five times more likely to appear within inactive compared to active groups.

DISCUSSION

Diabetes Facebook groups are used to share both information and emotional support, with greater emphasis placed on sharing information about nutrition. While engagement leaders should theoretically increase the credibility of online forums, frequent posts by group engagement leaders may actually lead to group decay. Health and diabetes educators should consider how to more effectively leverage social media engagement leaders to disseminate valid health information on diabetes self-management.