Patterns in Patient Access and Utilization of Online Medical Records: Analysis of MyChart

A Medical Student-Led Multipronged Initiative to Close the Digital Divide in Outpatient Primary Care

BACKGROUND

 The coronavirus disease 2019 pandemic accelerated the use of telehealth. However, this also exacerbated health care disparities for vulnerable populations.

OBJECTIVES

 This study aimed to explore the feasibility and effectiveness of a medical student-led initiative to identify and address gaps in patient access to digital health resources in adult primary care clinics at an academic safety-net hospital.

METHODS

 Medical students used an online HIPAA-compliant resource directory to screen for digital needs, connect patients with resources, and track outcome metrics. Through a series of Plan-Do-Study-Act (PDSA) cycles, the program grew to offer services such as information and registration for subsidized internet and phone services via the Affordable Connectivity Program (ACP) and Lifeline, assistance setting up and utilizing MyChart (an online patient portal for access to electronic health records), orientation to telehealth applications, and connection to community-based digital literacy training.

RESULTS

 Between November 2021 and March 2023, the program received 608 assistance requests. The most successful intervention was MyChart help, resulting in 83% of those seeking assistance successfully signing up for MyChart accounts and 79% feeling comfortable navigating the portal. However, subsidized internet support, digital literacy training, and telehealth orientation had less favorable outcomes. The PDSA cycles highlighted numerous challenges such as inadequate patient outreach, time-consuming training, limited in-person support, and unequal language assistance. To overcome these barriers, the program evolved to utilize clinic space for outreach, increase flier distribution, standardize training, and enhance integration of multilingual resources.

CONCLUSION

 This study is, to the best of our knowledge, the first time a medical student-led initiative addresses the digital divide with a multipronged approach. We outline a system that can be implemented in other outpatient settings to increase patients' digital literacy and promote health equity, while also engaging students in important aspects of nonclinical patient care.

Getting More Out of Clinical Documentation: Can Clinical Dashboards Yield Clinically Useful Information?

This study investigated coded data retrieved from clinical dashboards, which are decision-support tools that include a graphical display of clinical progress and clinical activities. Data were extracted from clinical dashboards representing 256 youth (M age = 11.9) from 128 practitioners who were trained in the Managing and Adapting Practice (MAP) system (Chorpita & Daleiden in BF Chorpita EL Daleiden 2014 Structuring the collaboration of science and service in pursuit of a shared vision. 43(2):323 338. 2014, Chorpita & Daleiden in BF Chorpita EL Daleiden 2018 Coordinated strategic action: Aspiring to wisdom in mental health service systems. 25(4):e12264. 2018) in 55 agencies across 5 regional mental health systems. Practitioners labeled up to 35 fields (i.e., descriptions of clinical activities), with the options of drawing from a controlled vocabulary or writing in a client-specific activity. Practitioners then noted when certain activities occurred during the episode of care. Fields from the extracted data were coded and reliability was assessed for Field Type, Practice Element Type, Target Area, and Audience (e.g., Caregiver Psychoeducation: Anxiety would be coded as Field Type = Practice Element; Practice Element Type = Psychoeducation; Target Area = Anxiety; Audience = Caregiver). Coders demonstrated moderate to almost perfect interrater reliability. On average, practitioners recorded two activities per session, and clients had 10 unique activities across all their sessions. Results from multilevel models showed that clinical activity characteristics and sessions accounted for the most variance in the occurrence, recurrence, and co-occurrence of clinical activities, with relatively less variance accounted for by practitioners, clients, and regional systems. Findings are consistent with patterns of practice reported in other studies and suggest that clinical dashboards may be a useful source of clinical information. More generally, the use of a controlled vocabulary for clinical activities appears to increase the retrievability and actionability of healthcare information and thus sets the stage for advancing the utility of clinical documentation.

Patient Portal Enrollment for Discharged Pediatric Emergency Department Patients: A Multidisciplinary Quality Improvement Project

Introduction

Patient portal enrollment following pediatric emergency department (ED) visits allows access to critical results, physician documentation, and telehealth follow-up options. Despite these advantages, there are many challenges to portal invitation and enrollment. Our primary objective was to improve patient portal enrollment rates for discharged pediatric ED patients.

Methods

A multidisciplinary team of staff from two ED sites developed successful portal enrollment interventions through sequential Plan-Do-Study-Act cycles from October 2020 to October 2021. Interventions included a new invitation process, changes to patient paperwork on ED arrival, staff portal education, and changes to discharge paperwork and the portal website. The team utilized statistical process control charts to track the percentage of eligible discharged patients who received a portal invitation (process measure) and enrolled in the patient portal.

Results

Before the study's initiation, less than 1% of eligible patients received patient portal invites or enrolled in the patient portal. Statistical process control charts revealed significant changes in enrollment and baseline shift at both a large academic ED campus and a satellite ED site by May 2021. Improvements in invitation rates were also observed at both campuses. Changes were sustained for over 6 months at both locations.

Conclusions

High-reliability interventions and a multidisciplinary approach allowed for significant and sustained improvement in patient portal invitation and enrollment rates in eligible pediatric ED patients. Future study will examine enrollment patterns across patient demographics and further high-reliability interventions.

Depression and coronary heart disease: mechanisms, interventions, and treatments

Coronary heart disease (CHD), a cardiovascular condition that poses a significant threat to human health and life, has imposed a substantial economic burden on the world. However, in contrast to conventional risk factors, depression emerges as a novel and independent risk factor for CHD. This condition impacts the onset and progression of CHD and elevates the risk of adverse cardiovascular prognostic events in those already affected by CHD. As a result, depression has garnered increasing global attention. Despite this growing awareness, the specific mechanisms through which depression contributes to the development of CHD remain unclear. Existing research suggests that depression primarily influences the inflammatory response, Hypothalamic-pituitary-adrenocortical axis (HPA) and Autonomic Nervous System (ANS) dysfunction, platelet activation, endothelial dysfunction, lipid metabolism disorders, and genetics, all of which play pivotal roles in CHD development. Furthermore, the effectiveness and safety of antidepressant treatment in CHD patients with comorbid depression and its potential impact on the prognosis of CHD patients have become subjects of controversy. Further investigation is warranted to address these unresolved questions.

Patient and Health Care Provider Perspectives on Patient Access to Test Results via Web Portals: Scoping Review

BACKGROUND

A frequently used feature of electronic patient portals is the viewing of test results. Research on patient portals is abundant and offers evidence to help portal implementers make policy and practice decisions. In contrast, no comparable comprehensive summary of research addresses the direct release of and patient access to test results.

OBJECTIVE

This scoping review aims to analyze and synthesize published research focused on patient and health care provider perspectives on the direct release of laboratory, imaging, and radiology results to patients via web portals.

METHODS

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Searches were conducted in CINAHL, MEDLINE, and other databases. Citations were screened in Covidence using the inclusion and exclusion criteria. Primary studies that focused on patient and health care provider perspectives on patient access to laboratory and imaging results via web portals were included. An updated search was conducted up to August 2023. Our review included 27 articles-20 examining patient views, 3 examining provider views, and 4 examining both patient and provider views. Data extraction and inductive data analysis were informed by sensitizing concepts from sociomaterial perspectives, and 15 themes were generated.

RESULTS

Patient perspectives (24 papers) were synthesized using nine themes: (1) patterns of use and patient characteristics; (2) emotional response when viewing the results and uncertainty about their implications; (3) understanding test results; (4) preferences for mode and timing of result release; (5). information seeking and patients' actions motivated by viewing results via a portal; (6) contemplating changes in behavior and managing own health; (7) benefits of accessing test results via a portal; (8) limitations of accessing test results via a portal; and (9) suggestions for portal improvement. Health care provider perspectives (7 papers) were synthetized into six themes: (1) providers' view of benefits of patient access to results via the portal; (2) effects on health care provider workload; (3) concerns about patient anxiety; (4) timing of result release into the patient portal; (5) the method of result release into the patient portal: manual versus automatic release; and (6) the effects of hospital health information technology system on patient quality outcomes.

CONCLUSIONS

The timing of the release of test results emerged as a particularly important topic. In some countries, the policy context may motivate immediate release of most tests directly into patient portals. However, our findings aim to make policy makers, health administrators, and other stakeholders aware of factors to consider when making decisions about the timing of result release. This review is sensitive to the characteristics of patient populations and portal technology and can inform result release framework policies. The findings are timely, as patient portals have become more common internationally.

The Impact of Fertility Goals on Long-term Quality of Life in Reproductive-aged Women Who Underwent Myomectomy versus Hysterectomy for Uterine Fibroids

STUDY OBJECTIVE

The objective of this study is to compare quality of life (QOL) for myomectomy with hysterectomy 1 to 5 years after surgical management for fibroids. This study evaluated the difference in QOL in a population of women of reproductive age, including those who desire fertility.

DESIGN

A retrospective cohort study.

INTERVENTIONS

Not applicable.

SETTING

A large academic hospital.

PATIENTS

A total of 142 women who underwent hysterectomy or myomectomy in 2015 to 2020. Included patients were women aged 18 years or older who underwent surgical intervention owing to uterine fibroids.

MEASUREMENTS AND MAIN RESULTS

The 36-Item Short Form Health Survey (SF-36) provides a total score as a single measure of health-related QOL. The Uterine Fibroid Symptom Quality of Life Questionnaire for Hysterectomy and Myomectomy (UFS-QOL) is a patient-reported outcome measure of fibroid symptoms and health-related QOL after hysterectomy and myomectomy. There was no significant difference in SF-36 QOL scores in women after myomectomy who desired fertility compared with those who did not desire fertility, except in the social functioning domain (p = .025). UFS-QOL scores in women after myomectomy who desired fertility were not significantly different compared with women after myomectomy who did not desire fertility (p = .37). There were no significant differences between women who underwent myomectomy and hysterectomy in overall QOL scores on the SF-36 (p = .13) and UFS-QOL scores (p = .16).

CONCLUSION

Myomectomy is not associated with significant differences in measures of general health and QOL compared with hysterectomy, making it a viable fibroid management option for women who desire fertility. Our study highlights the importance of discussing fertility goals and QOL when counseling patients for surgical fibroid treatment.

Impact of a switch to immediate release on the patient viewing of diagnostic test results in an online portal at an academic medical center

Patient portals allow patients to access their personal health information. The 21st Century Cures Act in the United States sought to eliminate 'information blocking', requiring timely release upon request of electronic health information including diagnostic test results. Some health systems, including the one in the present study, chose a systematic switch to immediate release of all or nearly all diagnostic test results to patient portals as part of compliance with the Cures Act. Our primary objective was to study changes in the time to view test results by patients before and after implementation of Cures Act-related changes. This retrospective pre-post study included data from two 10-month time periods before and after implementation of Cures Act-related changes at an academic medical center. The study included all patients (adult and pediatric) with diagnostic testing (laboratory and imaging) performed in the outpatient, inpatient, or emergency department settings. Between February 9, 2020 and December 9, 2021, there was a total of 3 809 397 diagnostic tests from 204 605 unique patients (3 320 423 tests for adult patients; 488 974 for pediatric patients). Overall, 56.5% (115 627) of patients were female, 84.1% (172 048) white, and 96.5% (197 517) preferred English as primary language. The odds of viewing test results within 1 and 30 days after portal release increased monthly throughout both time periods before and after the Cures Act for all patients. The rate of increase was significantly higher after implementation only in the subgroup of tests belonging to adult patients with active MyChart accounts. Immediate release shifted a higher proportion of result/report release to weekends (3.2% pre-Cures vs 15.3% post-Cures), although patient viewing patterns by day of week and time of day were similar before and after immediate release changes. The switch to immediate release of diagnostic test results to the patient portal resulted in a higher fraction of results viewed within 1 day across outpatient, inpatient, and emergency department settings.

Technological Innovations and Data-Driven Support for Older Adults

Entering a new digital era where novel devices and emerging technologies, including artificial intelligence, are playing an incredible role with significant impact on health and health care delivery, JMIR Aging commits to supporting the community of patients and families, clinicians, and scientists to improve the efficiency, equity, and effectiveness of older adult care through the dissemination of cutting-edge evidence.

Pain points in parents' interactions with newborn screening systems: a qualitative study

Background & Objectives

This study aims to explore and elucidate parents’ experience of newborn screening [NBS], with the overarching goal of identifying desiderata for the development of informatics-based educational and health management resources.

Methods

We conducted four focus groups and four one-on-one qualitative interviews with a total of 35 participants between March and September 2020. Participants were grouped into three types: parents who had received true positive newborn screening results; parents who had received false positive results; and soon-to-be parents who had no direct experience of the screening process. Interview data were subjected to analysis using an inductive, constant comparison approach.

Results

Results are divided into five sections: (1) experiences related to the process of receiving NBS results and prior knowledge of the NBS program; (2) approaches to the management of a child’s medical data; (3) sources of additional informational and emotional support; (4) barriers faced by parents navigating the health system; and (5) recommendations and suggestions for new parents experiencing the NBS process.

Conclusion

Our analysis revealed a wide range of experiences of, and attitudes towards the newborn screening program and the wider newborn screening system. While parents’ view of the screening process was – on the whole – positive, some participants reported experiencing substantial frustration, particularly related to how results are initially communicated and difficulties in accessing reliable, timely information. This frustration with current information management and education resources indicates a role for informatics-based approaches in addressing parents’ information needs.

Effects of Patient-Generated Health Data: Comparison of Two Versions of Long-Term Mobile Personal Health Record Usage Logs

Patient-generated health data (PGHD) can be managed easily by a mobile personal health record (mPHR) and can increase patient engagement. This study investigated the effect of PGHD functions on mPHR usage. We collected usage log data from an mPHR app, My Chart in My Hand (MCMH), for seven years. We analyzed the number of accesses and trends for each menu by age and sex according to the version-up. Generalized estimating equation (GEE) analysis was used to determine the likelihood of continuous app usage according to the menus and version-up. The total number of users of each version were 15,357 and 51,553, respectively. Adult females under 50 years were the most prevalent user group (30.0%). The “My Chart” menu was the most accessed menu, and the total access count increased by ~10 times after the version-up. The “Health Management” menu designed for PGHD showed the largest degree of increase in its likelihood of continuous usage after the version-up (1.245; p < 0.0001) across menus (range: 0.925–1.050). Notably, improvement of PGHD management in adult females over 50 years is needed.

Audience of Academic Otolaryngology on Twitter: Cross-sectional Study

BACKGROUND

Despite the ubiquity of social media, the utilization and audience reach of this communication method by otolaryngology-head and neck surgery (OHNS) residency programs has not been investigated.

OBJECTIVE

The purpose of this study was to evaluate the content posted to a popular social media platform (Twitter) by OHNS residency programs.

METHODS

In this cross-sectional study, we identified Twitter accounts for accredited academic OHNS residency programs. Tweets published over a 6-month period (March to August 2019) were extracted. Tweets were categorized and analyzed for source (original versus retweet) and target audience (medical versus layman). A random sample of 100 tweets was used to identify patterns of content, which were then used to categorize additional tweets. We quantified the total number of likes or retweets by health care professionals.

RESULTS

Of the 121 accredited programs, 35 (28.9%) had Twitter accounts. Of the 2526 tweets in the 6-month period, 1695 (67.10%) were original-content tweets. The majority of tweets (1283/1695, 75.69%) were targeted toward health care workers, most of which did not directly contain medical information (954/1283, 74.36%). These tweets contained information about the department's trainees and education (349/954, 36.6%), participation at conferences (263/954, 27.6%), and research publications (112/954, 11.7%). Two-thirds of all tweets did not contain medical information. Medical professionals accounted for 1249/1362 (91.70%) of retweets and 5616/6372 (88.14%) of likes on original-content tweets.

CONCLUSIONS

The majority of Twitter usage by OHNS residency programs is for intra and interprofessional communication, and only a minority of tweets contain information geared toward the public. Communication and information sharing with patients is not the focus of OHNS departments on Twitter.

Functionalities and Issues in the Implementation of Personal Health Records: Systematic Review

Background

Functionalities of personal health record (PHR) are evolving, and continued discussions about PHR functionalities need to be performed to keep it up-to-date. Technological issues such as nonfunctional requirements should also be discussed in the implementation of PHR.

Objective

This study systematically reviewed the main functionalities and issues in implementing the PHR.

Methods

This systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The search is performed using the online databases Scopus, ScienceDirect, IEEE, MEDLINE, CINAHL, and PubMed for English journal articles and conference proceedings published between 2015 and 2020.

Results

A total of 105 articles were selected in the review. Seven function categories were identified in this review, which is grouped into basic and advanced functions. Health records and administrative records were grouped into basic functions. Medication management, communication, appointment management, education, and self-health monitoring were grouped into advanced functions. The issues found in this study include interoperability, security and privacy, usability, data quality, and personalization.

Conclusions

In addition to PHR basic and advanced functions, other supporting functionalities may also need to be developed based on the issues identified in this study. This paper provides an integrated PHR architectural model that describes the functional requirements and data sources of PHRs.

Factors Affecting Public Adoption of COVID-19 Prevention and Treatment Information During an Infodemic: Cross-sectional Survey Study

BACKGROUND

With the spread of COVID-19, an infodemic is also emerging. In public health emergencies, the use of information to enable disease prevention and treatment is incredibly important. Although both the information adoption model (IAM) and health belief model (HBM) have their own merits, they only focus on information or public influence factors, respectively, to explain the public's intention to adopt online prevention and treatment information.

OBJECTIVE

The aim of this study was to fill this gap by using a combination of the IAM and the HBM as the framework for exploring the influencing factors and paths in public health events that affect the public's adoption of online health information and health behaviors, focusing on both objective and subjective factors.

METHODS

We carried out an online survey to collect responses from participants in China (N=501). Structural equation modeling was used to evaluate items, and confirmatory factor analysis was used to calculate construct reliability and validity. The goodness of fit of the model and mediation effects were analyzed.

RESULTS

The overall fitness indices for the model developed in this study indicated an acceptable fit. Adoption intention was predicted by information characteristics (β=.266, P<.001) and perceived usefulness (β=.565, P<.001), which jointly explained nearly 67% of the adoption intention variance. Information characteristics (β=.244, P<.001), perceived drawbacks (β=-.097, P=.002), perceived benefits (β=.512, P<.001), and self-efficacy (β=.141, P<.001) jointly determined perceived usefulness and explained about 81% of the variance of perceived usefulness. However, social influence did not have a statistically significant impact on perceived usefulness, and self-efficacy did not significantly influence adoption intention directly.

CONCLUSIONS

By integrating IAM and HBM, this study provided the insight and understanding that perceived usefulness and adoption intention of online health information could be influenced by information characteristics, people's perceptions of information drawbacks and benefits, and self-efficacy. Moreover, people also exhibited proactive behavior rather than reactive behavior to adopt information. Thus, we should consider these factors when helping the informed public obtain useful information via two approaches: one is to improve the quality of government-based and other official information, and the other is to improve the public's capacity to obtain information, in order to promote truth and fight rumors. This will, in turn, contribute to saving lives as the pandemic continues to unfold and run its course.

Quantifying Patient Portal Use: Systematic Review of Utilization Metrics

BACKGROUND

Use of patient portals has been associated with positive outcomes in patient engagement and satisfaction. Portal studies have also connected portal use, as well as the nature of users' interactions with portals, and the contents of their generated data to meaningful cost and quality outcomes. Incentive programs in the United States have encouraged uptake of health information technology, including patient portals, by setting standards for meaningful use of such technology. However, despite widespread interest in patient portal use and adoption, studies on patient portals differ in actual metrics used to operationalize and track utilization, leading to unsystematic and incommensurable characterizations of use. No known review has systematically assessed the measurements used to investigate patient portal utilization.

OBJECTIVE

The objective of this study was to apply systematic review criteria to identify and compare methods for quantifying and reporting patient portal use.

METHODS

Original studies with quantifiable metrics of portal use published in English between 2014 and the search date of October 17, 2018, were obtained from PubMed using the Medical Subject Heading term "Patient Portals" and related keyword searches. The first search round included full text review of all results to confirm a priori data charting elements of interest and suggest additional categories inductively; this round was supplemented by the retrieval of works cited in systematic reviews (based on title screening of all citations). An additional search round included broader keywords identified during the full-text review of the first round. Second round results were screened at abstract level for inclusion and confirmed by at least two raters. Included studies were analyzed for metrics related to basic use/adoption, frequency of use, duration metrics, intensity of use, and stratification of users into "super user" or high utilizers. Additional categories related to provider (including care team/administrative) use of the portal were identified inductively. Additional analyses included metrics aligned with meaningful use stage 2 (MU-2) categories employed by the US Centers for Medicare and Medicaid Services and the association between the number of portal metrics examined and the number of citations and the journal impact factor.

RESULTS

Of 315 distinct search results, 87 met the inclusion criteria. Of the a priori metrics, plus provider use, most studies included either three (26 studies, 30%) or four (23 studies, 26%) metrics. Nine studies (10%) only reported the patient use/adoption metric and only one study (1%) reported all six metrics. Of the US-based studies (n=76), 18 (24%) were explicitly motivated by MU-2 compliance; 40 studies (53%) at least mentioned these incentives, but only 6 studies (8%) presented metrics from which compliance rates could be inferred. Finally, the number of metrics examined was not associated with either the number of citations or the publishing journal's impact factor.

CONCLUSIONS

Portal utilization measures in the research literature can fall below established standards for "meaningful" or they can substantively exceed those standards in the type and number of utilization properties measured. Understanding how patient portal use has been defined and operationalized may encourage more consistent, well-defined, and perhaps more meaningful standards for utilization, informing future portal development.

Data on the activation and utilization of an electronic health record patient portal in an adult inpatient population at an academic medical center

Electronic health record patient portals allow patients to access their own health data online and interact with the healthcare team. Many studies have focused on use of patient portals in the outpatient setting. Relatively less is known about use of patient portals for hospitalized patients. The data in this article include analysis of patient portal activation and utilization for adults hospitalized in 2018 at an academic medical center in a Midwestern state in the United States. Activation was assessed by percentage of patients who had activated their patient portal by the time of data review. Utilization of the patient portal was determined by whether patients or their legal proxies accessed one or more reports from diagnostic testing ordered during inpatient encounter(s) in 2018. The data include 826,843 diagnostic tests on 40,640 unique patients. Patient characteristics include sex, age, whether outpatient diagnostic tests were also performed in 2018, preferred language (English or non-English), health insurance status (private, public, or uninsured), self-declared race (White or non-White), and whether there was a legal proxy for the patient. Association of these covariates with patient portal activation and utilization were analyzed.

A Comparative Analysis of Online Medical Record Utilization and Perception by Cancer Survivorship

BACKGROUND

Cancer survivors face many challenges including coordinating care across multiple providers and maintaining medical records from multiple institutions. Access and utilization of online medical records could help cancer survivors manage this complexity. Here, we examined how cancer survivors differ from those without a history of cancer with regards to utilization and perception of medical records.

METHODS

We conducted a cross-sectional study of 3491 respondents, from the Health Information National Trends survey 5, cycle 2. The association of medical record utilization and perceptions with cancer survivorship was assessed using survey-weighted logistic regression.

RESULTS

Cancer survivors (n=593) were more likely to report that a provider maintains a computerized medical record [adjusted odds ratio (AOR)=2.05; 95% confidence (CI), 1.24-3.41] and were more likely to report confidence in medical record safeguards (AOR=1.44; 95% CI, 1.03-2.03). However, cancer survivors were no more likely to access online medical records than those without a history of cancer (AOR=1.13; 95% CI, 0.69-1.86). Cancer survivors were no more likely to report privacy concerns as a reason for not accessing online medical records, however, survivors were more likely to report a preference for speaking directly with a provider as a reason for not accessing online medical records (AOR=2.24; 95% CI, 0.99-5.05).

CONCLUSIONS

Although cancer survivors are more likely to trust medical record safe guards and do not express increased concerns about online medical record privacy, a preference to speak directly with provider is a barrier of use.

Patient-Initiated Data: Our Experience with Enabling Patients to Initiate Incorporation of Heart Rate Data into the Electronic Health Record

BACKGROUND

Provider organizations increasingly allow incorporation of patient-generated data into electronic health records (EHRs). In 2015, we began allowing patients to upload data to our EHR without physician orders, which we henceforth call patient-initiated data (PAIDA). Syncing wearable heart rate monitors to our EHR allows for uploading of thousands of heart rates per patient per week, including many abnormally low and high rates. Physician informaticists expressed concern that physicians and their patients might be unaware of abnormal heart rates, including those caused by treatable pathology.

OBJECTIVE

This study aimed to develop a protocol to address millions of unreviewed heart rates.

METHODS

As a quality improvement initiative, we assembled a physician informaticist team to meet monthly for review of abnormally low and high heart rates. By incorporating other data already present in the EHR, lessons learned from reviewing records over time, and from contacting physicians, we iteratively refined our protocol.

RESULTS

We developed (1) a heart rate visualization dashboard to identify concerning heart rates; (2) experience regarding which combinations of heart rates and EHR data were most clinically worrisome, as opposed to representing artifact; (3) a protocol whereby only concerning heart rates would trigger a cardiologist review revealing protected health information; and (4) a generalizable framework for addressing other PAIDA.

CONCLUSION

We expect most PAIDA to eventually require systematic integration and oversight. Our governance framework can help guide future efforts, especially for cases with large amounts of data and where abnormal values may represent concerning but treatable pathology.

Exploring how virtual primary care visits affect patient burden of treatment

BACKGROUND

There is growing emphasis on the role of digital solutions in supporting chronic disease management. This has the potential to increase the burden patients experience in managing their health by offloading care from the health system to patients. This paper explores the effects of virtual visits on patient burden using an explicit framework measuring both the work patients do to care for their health and the challenges they experience that exacerbate burden.

METHODS

This mixed methods study evaluates a large pilot implementation of virtual visits (video, audio, and asynchronous messaging with providers) in primary care in Ontario, Canada. Participants were recruited using convenience sampling from patients using a virtual visit platform to complete a semi-structured interview or a survey including a free-text response. We conducted 17 interviews and reviewed 427 free text responses related to explore patients' perceived value and burden of these visits. We used qualitative analyses to map patients' feedback on their experience to the framework on patient burden.

MAIN FINDINGS

Virtual visits appear to reduce the work patients must do to manage their care by 1) improving access, convenience, and time needed for medical appointments, and 2) making it easier to access information and support for chronic disease management. Virtual visits also alleviate patients' perceived burden by improving continuity of care, experience of care, and providing some cost savings.

CONCLUSIONS

Virtual visits reduced overall patient burden of treatment by decreasing the required patient effort of managing medical appointments and monitoring their health, and by minimizing challenges experienced when accessing care. For regions that want to improve patient experience of care, virtual visits are likely to be of benefit. There is need for further research on the generalizability of the findings herein, particularly for high-needs populations under-represented such as those of low socioeconomic status and those in rural and remote locations.

Artificial Intelligence, Data Sensors and Interconnectivity: Future Opportunities for Heart Failure

A higher proportion of patients with heart failure have benefitted from a wide and expanding variety of sensor-enabled implantable devices than any other patient group. These patients can now also take advantage of the ever-increasing availability and affordability of consumer electronics. Wearable, on- and near-body sensor technologies, much like implantable devices, generate massive amounts of data. The connectivity of all these devices has created opportunities for pooling data from multiple sensors – so-called interconnectivity – and for artificial intelligence to provide new diagnostic, triage, risk-stratification and disease management insights for the delivery of better, more personalised and cost-effective healthcare. Artificial intelligence is also bringing important and previously inaccessible insights from our conventional cardiac investigations. The aim of this article is to review the convergence of artificial intelligence, sensor technologies and interconnectivity and the way in which this combination is set to change the care of patients with heart failure.

Frequency of and Factors Associated with Care Partner Proxy Interaction with Health Care Teams Using Patient Portal Accounts

Introduction: Proxies can communicate with health care teams through patient portals either by using proxy login credentials or a patient's login credentials. The frequency of proxies using patient login credentials is unknown. Methods: A random selection of 3,000 portal messages sent in through adult patients' own portal account was reviewed for indicators (referring to the patient in the third person) that someone other than the patient was using the patient portal account. Results: Of the reviewed 3,000 portal messages sent through patient portal accounts, 221 (7.4%) appeared to be sent in by a proxy, 2,512 (83.8%) appeared to have been sent in by the patient and for 266 (8.9%) portal messages reviewed it was unclear who sent in the message. There was no difference in mean age between patients who had proxy messages sent through patient portal accounts versus proxy portal accounts. Patients who had proxies send messages through patient accounts were more likely to be married and male. Out of 221 manually reviewed messages apparently sent by proxies through patient portal accounts there were 113 (51%) where the proxy included their name and 56 (25.3%) where they reported their relationship to the patient. During the study period, 0.7% of total messages on adult patients were sent through proxy accounts. Discussion: Proxies appear to use patient portal accounts much more frequently than proxy accounts to communicate with the health care team on adult patients; however, when using patient accounts they only identify themselves approximately half of the time.

Providing Access: Differences in Pediatric Portal Activation Begin at Patient Check-in

BACKGROUND

The patient portal interface with individual electronic health records (EHR) was introduced as a tool to enhance participatory medicine. Recent studies suggest adults from racial and ethnic minorities as well as non-English speakers face disproportionate barriers to adoption; however, little data are available for pediatric patients.

OBJECTIVE

The purpose of this study was to examine patient portal offers and activation patterns among pediatric urology patients at two geographically diverse tertiary pediatric hospitals.

METHODS

Retrospective analysis of 2011 to 2016 electronic portal audit records was conducted among patients aged 18 and younger with at least one outpatient urology clinic visit at two tertiary academic pediatric hospitals and their affiliated networks. Differences in utilization among parents/caregivers and adolescents were examined using multivariate analysis.

RESULTS

Of 44,608 individuals seen in a participating urology department during the study period, 21,815 (48.9%) were offered a code for patient portal activation; of these, 8,605 (19.3% of total eligible individuals) activated portal access. Logistic regression demonstrated associations between an offer and site (p < 0.001), being female (p < 0.001), being Asian or white (p < 0.05), being non-Hispanic (p < 0.001), and reporting English as preferred language (p < 0.001). Activating patient portal access was associated with site (p < 0.001), being Asian or white (p < 0.001), and reporting English as preferred language (p < 0.001).

CONCLUSION

This study found that demographic variations in portal began with demographic differences in which patients were offered an activation code. Fewer than half of those given an access code activated their account. Preferred language, race/ethnicity, and clinic location were associated with likelihood of portal activation. Although patients are increasingly expected to schedule appointments, manage correspondence, request prescription refills, obtain authorizations and referrals, and communicate with the medical team using the portal, this study suggests that in the pediatric specialty setting many patients and caregivers are not offered the opportunity to access these tools.

Applying a User-Centered Approach to Building a Mobile Personal Health Record App: Development and Usability Study

Background

A personal health record (PHR) system encourages patients to engage with their own health care by giving them the ability to manage and keep track of their own health data. Of the numerous PHR systems available in the market, many are Web-based patient portals and a few are mobile apps. They have mainly been created by hospitals and electronic health record (EHR) vendors. One major limitation of these hospital-created PHR systems is that patients can only view specific health data extracted from their EHR. Patients do not have the freedom to add important personal health data they collect in their daily lives into their PHR. Therefore, there is an information gap between clinical visits.

Objective

The aim of this study was to develop and evaluate a new mobile PHR app that can be easily used to manage various types of personal health data to fill the information gap.

Methods

A user-centered approach was used to guide the development and evaluation of the new mobile PHR app. There were three steps in this study: needs assessment, app design and development, and conducting a usability study. First, a large-scale questionnaire study was conducted with the general population to gain an understanding of their needs and expectations with regard to a mobile PHR app. A mobile PHR app for personal medical data tracking and management was then created based on the results of the questionnaire study. End users were actively involved in all stages of the app development. Finally, a usability study was performed with participants to evaluate the usability of the mobile PHR app, which involved asking participants to finish a set of tasks and to respond to a usability questionnaire.

Results

In the questionnaire study for needs assessment, there were 609 participants in total. The answers from these participants revealed that they wanted to manage various types of personal health data in a mobile PHR app. Participants also reported some features they desired to have in the app. On the basis of the needs assessment findings, a new mobile PHR app (PittPHR) was created with 6 major modules: health records, history, trackers, contacts, appointments, and resources. This app allows users to customize the trackers according to their needs. In the usability study, there were 15 participants. The usability study participants expressed satisfaction with the app and provided comments and suggestions for further development.

Conclusions

This new mobile PHR app provides options for users to manage a wide range of personal health data conveniently in one place. The app fills the information gap between clinical visits. The study results indicated that this new mobile PHR app meets the need of users and that users welcome this app.

The Use of an Electronic Health Record Patient Portal to Access Diagnostic Test Results by Emergency Patients at an Academic Medical Center: Retrospective Study

BACKGROUND

Electronic health record (EHR) patient portals provide a means by which patients can access their health information, including diagnostic test results. Little is known about portal usage by emergency department (ED) patients.

OBJECTIVE

The study aimed to assess patient portal utilization by ED patients at an academic medical center using account activation rates along with the rates of access of diagnostic test results (laboratory results and radiology reports), analyzing the impact of age, gender, and self-reported patient race.

METHODS

This institutional review board-approved retrospective study was performed at a 60,000-visits-per-year university-based ED. We utilized EHR data reporting tools to examine EHR portal activation and utilization for all patients who had at least one ED encounter with one or more diagnostic tests performed between October 1, 2016, and October 1, 2017. The total dataset for laboratory testing included 208,635 laboratory tests on 25,361 unique patients, of which 9482 (37.39%) had active portal accounts. The total dataset for radiologic imaging included 23,504 radiology studies on 14,455 unique patients, of which 5439 (37.63%) had an active portal account.

RESULTS

Overall, 8.90% (18,573/208,635) of laboratory tests and 8.97% (2019/22,504) of radiology reports ordered in the ED were viewed in the patient portal. The highest rates of viewing of laboratory and radiology results were seen for those who were female, were aged 0 to 11 years (parent or guardian viewing by proxy) and 18 to 60 years, and self-reported their race as Caucasian or Asian. The lowest rates were for those who were teenagers, aged older than 81 years, African American/black, and Hispanic/Latino. Infectious disease, urinalysis, and pregnancy testing constituted the highest number of laboratory tests viewed. Magnetic resonance imaging reports were viewed at higher rates than computed tomography or x-ray studies (P<.001). Approximately half of all the diagnostic test results accessed by patients were reviewed within 72 hours of availability in the patient portal (laboratory results: 9904/18,573, 53.32% and radiology reports: 971/2019, 48.1%). On the other extreme, 19.9% (3701/18,573) of laboratory results and 31.6% (639/2019) of radiology reports were viewed more than 2 weeks after availability in the portal.

CONCLUSIONS

The data highlight the relatively low use of a patient portal by ED patients and existing disparities between patient groups. There can be wide lag time (months) between result/report availability and access by patients. Opportunities for improvement exist for both activation and more robust utilization of patient portals by ED patients.

"Call a Teenager… That's What I Do!" - Grandchildren Help Older Adults Use New Technologies: Qualitative Study

Background

Although family technical support seems intuitive, there is very little research exploring this topic.

Objective

The objective of this study was to conduct a subanalysis of data collected from a large-scale qualitative project regarding older adults’ experiences in using health information technology. Specifically, the subanalysis explored older adults’ experiences with technology support from family members to inform strategies for promoting older adults’ engagement with new health technologies. Although the primary analysis of the original study was theoretically driven, this paper reports results from an inductive, open-coding analysis.

Methods

This is a subanalysis of a major code identified unexpectedly from a qualitative study investigating older adults’ use experience of a widespread health technology, the patient portal. A total of 24 older patients (≥65 years) with multiple chronic conditions (Charlson Comorbidity Index >2) participated in focus groups conducted at the patients’ primary clinic. While conducting the primary theoretically driven analysis, coders utilized an open-coding approach to ensure important ideas not reflected in the theoretical code book were captured. Open coding resulted in 1 code: family support. This subanalysis further categorized family support by who provided tech support, how tech support was offered, and the opinions of older participants about receiving family tech support.

Results

The participants were not specifically asked about family support, yet themes around family assistance and encouragement for technology emerged from every focus group. Participants repeatedly mentioned that they called their grandchildren and adult children if they needed help with technology. Participants also reported that family members experienced difficulty when teaching technology use. Family members struggled to explain simple technology tasks and were frustrated by the slow teaching process.

Conclusions

The results suggest that older adults ask their family members, particularly grandchildren, to support them in the use of new technologies. However, family may experience difficulties in providing this support. Older adults will be increasingly expected to use health technologies, and family members may help with tech support. Providers and health systems should consider potential family support and engagement strategies to foster adoption and use among older patients.

The Patient Experience and Safety

Patient harm continues to be a leading cause of morbidity and mortality in the United States. Among high-risk industries, the health care system has a significantly lower safety profile than that of others. There are many driving forces behind this, including significant resistance within the medical community in the late 1960s to consumer demand of patient-centered and family-centered care. In subsequent decades the voice of the customer has taken center stage. The mounting research linking patient experience and engagement to patient safety and positive clinical outcomes is indisputable.

Characteristics of Future Models of Integrated Outpatient Care

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

Screening and Management of Depression in Patients With Cardiovascular Disease: JACC State-of-the-Art Review

Depression is a common problem in patients with cardiovascular disease (CVD) and is associated with increased mortality, excess disability, greater health care expenditures, and reduced quality of life. Depression is present in 1 of 5 patients with coronary artery disease, peripheral artery disease, and heart failure. Depression complicates the optimal management of CVD by worsening cardiovascular risk factors and decreasing adherence to healthy lifestyles and evidence-based medical therapies. As such, standardized screening pathways for depression in patients with CVD offer the potential for early identification and optimal management of depression to improve health outcomes. Unfortunately, the burden of depression in patients with CVD is under-recognized; as a result, screening and management strategies targeting depression have been poorly implemented in patients with CVD. In this review, the authors discuss a practical approach for the screening and management of depression in patients with CVD.

Using the Technology Acceptance Model to Explore User Experience, Intent to Use, and Use Behavior of a Patient Portal Among Older Adults With Multiple Chronic Conditions: Descriptive Qualitative Study

BACKGROUND

Patient portals offer modern digital tools for older adults with multiple chronic conditions (MCC) to engage in their health management. However, there are barriers to portal adoption among older adults. Understanding portal user interface and user experience (UI and UX) preferences of older adults with MCC may improve the accessibility, acceptability, and adoption of patient portals.

OBJECTIVE

The aim of this study was to use the Technology Acceptance Model (TAM) as a framework for qualitatively describing the UI and UX, intent to use, and use behaviors among older patients with MCC.

METHODS

We carried out a qualitative descriptive study of Kaiser Permanente Colorado's established patient portal, My Health Manager. Older patients (N=24; mean 78.41 (SD 5.4) years) with MCC participated in focus groups. Stratified random sampling was used to maximize age and experience with the portal among participants. The semistructured focus groups used a combination of discussion and think-aloud strategies. A total of 2 coders led the theoretically driven analysis based on the TAM to determine themes related to use behavior, portal usefulness and ease of use, and intent to use.

RESULTS

Portal users commonly used email, pharmacy, and lab results sections of the portal. Although, generally, the portal was seen to be easy to use, simple, and quick, challenges related to log-ins, UI design (color and font), and specific features were identified. Such challenges inhibited participants' intent to use the portal entirely or specific features. Participants indicated that the portal improved patient-provider communication, saved time and money, and provided relevant health information. Participants intended to use features that were beneficial to their health management and easy to use.

CONCLUSIONS

Older adults are interested in using patient portals and are already taking advantage of the features available to them. We have the opportunity to better engage older adults in portal use but need to pay close attention to key considerations promoting usefulness and ease of use.

Assessment of Personal Health Care Management and Chronic Disease Prevalence: Comparative Analysis of Demographic, Socioeconomic, and Health-Related Variables

Background

The use of personal health care management (PHM) is increasing rapidly within the United States because of implementation of health technology across the health care continuum and increased regulatory requirements for health care providers and organizations promoting the use of PHM, particularly the use of text messaging (short message service), Web-based scheduling, and Web-based requests for prescription renewals. Limited research has been conducted comparing PHM use across groups based on chronic conditions.

Objective

This study aimed to describe the overall utilization of PHM and compare individual characteristics associated with PHM in groups with no reported chronic conditions, with 1 chronic condition, and with 2 or more such conditions.

Methods

Datasets drawn from the National Health Interview Survey were analyzed using multiple logistic regression to determine the level of PHM use in relation to demographic, socioeconomic, or health-related factors. Data from 47,814 individuals were analyzed using logistic regression.

Results

Approximately 12.19% (5737/47,814) of respondents reported using PHM, but higher rates of use were reported by individuals with higher levels of education and income. The overall rate of PHM remained stable between 2009 and 2014, despite increased focus on the promotion of patient engagement initiatives. Demographic factors predictive of PHM use included people who were younger, non-Hispanic, and who lived in the western region of the United States. There were also differences in PHM use based on socioeconomic factors. Respondents with college-level education were over 2.5 times more likely to use PHM than respondents without college-level education. Health-related factors were also predictive of PHM use. Individuals with health insurance and a usual place for health care were more likely to use PHM than individuals with no health insurance and no usual place for health care. Individuals reporting a single chronic condition or multiple chronic conditions reported slightly higher levels of PHM use than individuals reporting no chronic conditions. Individuals with no chronic conditions who did not experience barriers to accessing health care were more likely to use PHM than individuals with 1 or more chronic conditions.

Conclusions

The findings of this study illustrated the disparities in PHM use based on the number of chronic conditions and that multiple factors influence the use of PHM, including economics and education. These findings provide evidence of the challenge associated with engaging patients using electronic health information as the health care industry continues to evolve.