Barriers and Facilitators of Online Patient Portals to Personal Health Records Among Persons Living With HIV: Formative Research

Patient Perspectives on Portal-Based Anxiety and Depression Screening in HIV Care: A Qualitative Study Using the Consolidated Framework for Implementation Research

Electronic patient portals represent a promising means of integrating mental health assessments into HIV care where anxiety and depression are highly prevalent. Patient attitudes toward portal-based mental health screening within HIV clinics have not been well described. The aim of this formative qualitative study is to characterize the patient-perceived facilitators and barriers to portal-based anxiety and depression screening within HIV care in order to inform implementation strategies for mental health screening. Twelve adult HIV clinic patients participated in semi-structured interviews that were audio recorded and transcribed. The transcripts were coded using constructs from the Consolidated Framework for Implementation Research and analyzed thematically to identify the barriers to and facilitators of portal-based anxiety and depression screening. Facilitators included an absence of alternative screening methods, an approachable design, perceived adaptability, high compatibility with HIV care, the potential for linkage to treatment, an increased self-awareness of mental health conditions, the ability to bundle screening with clinic visits, and communicating an action plan for results. The barriers included difficulty navigating the patient portal system, a lack of technical support, stigmatization from the healthcare system, care team response times, and the novelty of using patient portals for communication. The patients in the HIV clinic viewed the use of a portal-based anxiety and depression screening tool as highly compatible with routine HIV care. Technical difficulties, follow-up concerns, and a fear of stigmatization were commonly perceived as barriers to portal use. The results of this study can be used to inform implementation strategies when designing or incorporating portal-based mental health screening into other HIV care settings.

Population-Level Portal-Based Anxiety and Depression Screening Perspectives in HIV Care Clinicians: Qualitative Study Using the Consolidated Framework for Implementation Research

BACKGROUND

Depression and anxiety are common among people with HIV and are associated with inadequate viral suppression, disease progression, and increased mortality. However, depression and anxiety are underdiagnosed and undertreated in people with HIV owing to inadequate visit time and personnel availability. Conducting population-level depression and anxiety screening via the patient portal is a promising intervention that has not been studied in HIV care settings.

OBJECTIVE

We aimed to explore facilitators of and barriers to implementing population-level portal-based depression and anxiety screening for people with HIV.

METHODS

We conducted semistructured hour-long qualitative interviews based on the Consolidated Framework for Implementation Research with clinicians at an HIV clinic.

RESULTS

A total of 10 clinicians participated in interviews. In total, 10 facilitators and 7 barriers were identified across 5 Consolidated Framework for Implementation Research domains. Facilitators included advantages of systematic screening outside clinic visits; the expectation that assessment frequency could be tailored to patient needs; evidence from the literature and previous experience in other settings; respect for patient privacy; empowering patients and facilitating communication about mental health; compatibility with clinic culture, workflows, and systems; staff beliefs about the importance of mental health screening and benefits for HIV care; engaging all clinic staff and leveraging their strengths; and clear planning and communication with staff. Barriers included difficulty in ensuring prompt response to suicidal ideation; patient access, experience, and comfort using the portal; limited availability of mental health services; variations in how providers use the electronic health record and communicate with patients; limited capacity to address mental health concerns during HIV visits; staff knowledge and self-efficacy regarding the management of mental health conditions; and the impersonal approach to a sensitive topic.

CONCLUSIONS

We proposed 13 strategies for implementing population-level portal-based screening for people with HIV. Before implementation, clinics can conduct local assessments of clinicians and clinic staff; engage clinicians and clinic staff with various roles and expertise to support the implementation; highlight advantages, relevance, and evidence for population-level portal-based mental health screening; make screening frequency adaptable based on patient history and symptoms; use user-centered design methods to refine results that are displayed and communicated in the electronic health record; make screening tools available for patients to use on demand in the portal; and create protocols for positive depression and anxiety screeners, including those indicating imminent risk. During implementation, clinics should communicate with clinicians and clinic staff and provide training on protocols; provide technical support and demonstrations for patients on how to use the portal; use multiple screening methods for broad reach; use patient-centered communication in portal messages; provide clinical decision support tools, training, and mentorship to help clinicians manage mental health concerns; and implement integrated behavioral health and increase mental health referral partnerships.

Electronic Patient Portal Use Among People Living With HIV

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A qualitative study of factors influencing ePHR adoption by caregivers and care providers of Alzheimer's patients: An extension of the unified theory of acceptance and use of technology model

Background and Aims

As the nowadays provision of many healthcare services relies on technology, a better understanding of the factors contributing to the acceptance and use of technology in health care is essential. For Alzheimer's patients, an electronic personal health record (ePHR) is one such technology. Stakeholders should understand the factors affecting the adoption of this technology for its smooth implementation, adoption, and sustainable use. So far, these factors have not fully been understood for Alzheimer's disease (AD)-specific ePHR. Therefore, the present study aimed to understand these factors in ePHR adoption based on the perceptions and views of care providers and caregivers involved in AD care.

Methods

This qualitative study was conducted from February 2020 to August 2021 in Kerman, Iran. Seven neurologists and 13 caregivers involved in AD care were interviewed using semi-structured and in-depth interviews. All interviews were conducted through phone contacts amid Covid-19 imposed restrictions, recorded, and transcribed verbatim. The transcripts were coded using thematic analysis based on the unified theory of acceptance and use of technology (UTAUT) model. ATLAS.ti8 was used for data analysis.

Results

The factors affecting ePHR adoption in our study comprised subthemes under the five main themes of performance expectancy, effort expectancy, social influence, facilitating conditions of the UTAUT model, and the participants' sociodemographic factors. From the 37 facilitating factors and 13 barriers identified for ePHR adoption, in general, the participants had positive attitudes toward the ease of use of this system. The stated obstacles were dependent on the participants' sociodemographic factors (such as age and level of education) and social influence (including concern about confidentiality and privacy). In general, the participants considered ePHRs efficient and useful in increasing neurologists' information about their patients and managing their symptoms in order to provide better and timely treatment.

Conclusion

The present study gives a comprehensive insight into the acceptance of ePHR for AD in a developing setting. The results of this study can be utilized for similar healthcare settings with regard to technical, legal, or cultural characteristics. To develop a useful and user-friendly system, ePHR developers should involve users in the design process to take into account the functions and features that match their skills, requirements, and preferences.

People with long-term conditions sharing personal health data via digital health technologies: A scoping review to inform design

The use of digital technology amongst people living with a range of long-term health conditions to support self-management has increased dramatically. More recently, digital health technologies to share and exchange personal health data with others have been investigated. Sharing personal health data with others is not without its risks: sharing data creates threats to the privacy and security of personal data and plays a role in trust, adoption and continued use of digital health technology. Our work aims to inform the design of these digital health technologies by investigating the reported intentions of sharing health data with others, the associated user experiences when using these digital health technologies and the trust, identity, privacy and security (TIPS) considerations for designing digital health technologies that support the trusted sharing of personal health data to support the self-management of long-term health conditions. To address these aims, we conducted a scoping review, analysing over 12,000 papers in the area of digital health technologies. We conducted a reflexive thematic analysis of 17 papers that described digital health technologies that support sharing of personal health data, and extracted design implications that could enhance the future development of trusted, private and secure digital health technologies.

Desires for Individual- and Interpersonal-Level Patient Portal Use for HIV Prevention Among Urban Sexual Minority Men: Cross-sectional Study

BACKGROUND

Gay, bisexual, and other sexual minority men have expressed the acceptability of patient portals as tools for supporting HIV prevention behaviors, including facilitating disclosure of HIV and other sexually transmitted infection (STI/HIV) laboratory test results to sex partners. However, these studies, in which Black or African American sexual minority men were undersampled, failed to determine the relationship of reported history of discussing HIV results with sex partners and anticipated willingness to disclose web-based STI/HIV test results using a patient portal.

OBJECTIVE

Among a sample of predominantly Black sexual minority men, this study aimed to (1) determine preferences for patient portal use for HIV prevention and (2) test the associations between reported history of discussing HIV results and anticipated willingness to disclose web-based STI/HIV test results with most recent main and nonmain partners using patient portals.

METHODS

Data come from audio-computer self-assisted interview survey data collected during the 3-month visit of a longitudinal cohort study. Univariate analysis assessed patient portal preferences by measuring the valuation rankings of several portal features. Multiple Poisson regression models with robust error variance determined the associations between history of discussing HIV results and willingness to disclose those results using web-based portals by partner type, and to examine criterion validity of the enhancing dyadic communication (EDC) scale to anticipated willingness.

RESULTS

Of the 245 participants, 71% (n=174) were Black and 22% (n=53) were White. Most participants indicated a willingness to share web-based STI/HIV test results with their most recent main partner. Slightly fewer, nonetheless a majority, indicated a willingness to share web-based test results with their most recent nonmain partner. All but 2 patient portal features were valued as high or moderately high priority by >80% of participants. Specifically, tools to help manage HIV (n=183, 75%) and information about pre- and postexposure prophylaxis (both 71%, n=173 and n=175, respectively) were the top-valuated features to include in patient portals for HIV prevention. Discussing HIV test results was significantly associated with increased prevalence of willingness to disclose web-based test results with main (adjusted prevalence ratio [aPR] 1.46, 95% CI 1.21-1.75) and nonmain partners (aPR 1.54, 95% CI 1.23-1.93).

CONCLUSIONS

Our findings indicate what features Black sexual minority men envision may be included in the patient portal's design to optimize HIV prevention, further supporting the criterion validity of the EDC scale. Efforts should be made to support Black sexual minority men's willingness to disclose STI/HIV testing history and status with partners overall as it is associated significantly with a willingness to disclose testing results digitally via patient portals. Future studies should consider discussion behaviors regarding past HIV test results with partners when tailoring interventions that leverage patient portals in disclosure events.

Factors Associated with Non-use of and Dissatisfaction with the National Patient Portal in Finland in the Era of COVID-19: A Population-based Cross-sectional Survey Study (Preprint)

Background

In the abnormal circumstances caused by the COVID-19 pandemic, patient portals have supported patient empowerment and engagement by providing patients with access to their health care documents and medical information. However, the potential benefits of patient portals cannot be utilized unless the patients accept and use the services. Disparities in the use of patient portals may exacerbate the already existing inequalities in health care access and health outcomes, possibly increasing the digital inequality in societies.

Objective

The aim of this study is to examine the factors associated with nonuse of and dissatisfaction with the Finnish nationwide patient portal My Kanta Pages among the users of health care services during the COVID-19 outbreak. Several factors related to sociodemographic characteristics, health, and the use of health care services; experiences of guidance concerning electronic services; and digital skills and attitudes were evaluated.

Methods

A national population survey was sent using stratified sampling to 13,200 Finnish residents who had reached the age of 20 years. Data were collected from September 2020 to February 2021 during the COVID-19 pandemic. Respondents who had used health care services and the internet for transactions or for searching for information in the past 12 months were included in the analyses. Bivariate logistic regression analyses were used to examine the adjusted associations of respondent characteristics with the nonuse of My Kanta Pages and dissatisfaction with the service. The inverse probability weighting (IPW) method was applied in all statistical analyses to correct for bias.

Results

In total, 3919 (64.9%) of 6034 respondents were included in the study. Most respondents (3330/3919, 85.0%) used My Kanta Pages, and 2841 (85.3%) of them were satisfied. Nonusers (589/3919, 15%) were a minority among all respondents, and only 489 (14.7%) of the 3330 users were dissatisfied with the service. Especially patients without a long-term illness (odds ratio [OR] 2.14, 95% CI 1.48-3.10), those who were not referred to electronic health care services by a professional (OR 2.51, 95% CI 1.70-3.71), and those in need of guidance using online social and health care services (OR 2.26, 95% CI 1.41-3.65) were more likely nonusers of the patient portal. Perceptions of poor health (OR 2.10, 95% CI 1.51-2.93) and security concerns (OR 1.87, 95% CI 1.33-2.62) were associated with dissatisfaction with the service.

Conclusions

Patients without long-term illnesses, those not referred to electronic health care services, and those in need of guidance on the use of online social and health care services seemed to be more likely nonusers of the Finnish nationwide patient portal. Moreover, poor health and security concerns appeared to be associated with dissatisfaction with the service. Interventions to promote referral to electronic health care services by professionals are needed. Attention should be targeted to information security of the service and promotion of the public’s confidence in the protection of their confidential data.

Patient empowerment through a user-centered design of an electronic personal health record: a qualitative study of user requirements in chronic kidney disease

Background

To improve chronic disease outcomes, self-management is an effective strategy. An electronic personal health record (ePHR) is a promising tool with the potential to support chronic patient’s education, counseling, and self-management. Fitting ePHRs within the daily practices of chronic care providers and chronic patients requires user-centered design approaches. We aimed to understand users’ needs and requirements in chronic kidney disease (CKD) care to consider in the design of an ePHR to facilitate its implementation, adoption, and use.

Methods

A qualitative study was conducted in a major Iranian nephrology center including inpatient and outpatient settings in 2019. We conducted 28 semi-structured interviews with CKD patients, nurses, and adult nephrologists. To confirm or modify the requirements extracted from the interviews, a focus group was also held. Data were analyzed to extract especially those requirements that can facilitate implementation, adoption, and sustained use based on the PHR adoption model and the unified theory of acceptance and use of technology.

Results

Participants requested an ePHR that provides access to up to date patient information, facilitates patient-provider communication, and increases awareness about patient individualized conditions. Participants expected a system that is able to cater to low patient e-health literacy and high provider workload. They requested the ePHR to include purposeful documentation of medical history, diagnostic and therapeutic procedures, tailored educational content, and scheduled care reminders. Messaging function, tailored educational content to individual patients’ conditions, and controlled access to information were highly valued in order to facilitate its implementation, adoption, and use.

Conclusions

We focused on the ePHR’s content and functionalities in the face of facilitators and/or barriers envisioned for its adoption in nephrology care. Designers and implementers should value CKD patients’ needs and requirements for self-management such as providing personalized education and counseling (on the basis of their condition and risk factors), health literacy, and disease progression levels. The socio-technical aspects of care also need further attention to facilitate ePHR’s adoption.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01689-2.

Factors Affecting the Extent of Patients' Electronic Medical Record Use: An Empirical Study Focusing on System and Patient Characteristics

Background

Patients’ access to and use of electronic medical records (EMRs) places greater information in their hands, which helps them better comanage their health, leading to better clinical outcomes. Despite numerous benefits that promote health and well-being, patients’ acceptance and use of EMRs remains low. We study the impact of predictors that affect the use of EMR by patients to understand better the underlying causal factors for the lower use of EMR.

Objective

This study aims to examine the critical system (eg, performance expectancy and effort expectancy) and patient characteristics (eg, health condition, issue involvement, preventive health behaviors, and caregiving status) that influence the extent of patients’ EMR use.

Methods

We used secondary data collected by Health Information National Trends Survey 5 cycle 3 and performed survey data analysis using structural equation modeling technique to test our hypotheses. Structural equation modeling is a technique commonly used to measure and analyze the relationships of observed and latent variables. We also addressed common method bias to understand if there was any systematic effect on the observed correlation between the measures for the predictor and predicted variables.

Results

The statistically significant drivers of the extent of EMR use were performance expectancy (β=.253; P<.001), perceived behavior control (β=.236; P<.001), health knowledge (β=–.071; P=.007), caregiving status (β=.059; P=.013), issue involvement (β=.356; P<.001), chronic conditions (β=.071; P=.016), and preventive health behavior (β=.076; P=.005). The model accounted for 32.9% of the variance in the extent of EMR use.

Conclusions

The study found that health characteristics, such as chronic conditions and patient disposition (eg, preventive health behavior and issue involvement), directly affect the extent of EMR use. The study also revealed that issue involvement mediates the impact of preventive health behaviors and the presence of chronic conditions on the extent of patients’ EMR use.

Socio-technical drivers and barriers in the consumer adoption of personal health records: An empirical investigation

BACKGROUND

Increasingly popular in the healthcare domain, electronic personal health records (PHRs) have the potential to foster engagement towards improving health outcomes, achieve efficiencies in care, and reducing costs. Despite touted benefits, the uptake of PHRs is lackluster, with low adoption rates.

OBJECTIVE

This paper reports findings from an empirical investigation on socio-technical factors affecting the adoption of PHRs.

METHODS

A research model comprising personal and technological determinants of PHR adoption is developed and validated in this study. Demographic, technographic and psychographic data pertaining to the use of PHRs was collected through an online questionnaire for past, current, and potential users. Partial least squares (PLS) based structural equation modeling (SEM) was used to estimate a structural model of cognitive and affective factors impacting intentions to use PHRs.

RESULTS

Analysis reveal that in addition to the expected positive impact of a PHR system's usefulness and usability, system integration also positively effects consumer intention to adopt. Results also suggest that higher levels of perceived usability and integration do not translate into higher levels of perceived usefulness. The study also highlights the importance of subjective norm, technology awareness, and technology anxiety as direct antecedents of intention to adopt PHRs. Differential effects of adoption factors are also discussed.

CONCLUSIONS

Our study hopes to contribute to an understanding of consumer adoption of PHRs, and to help improve the design and delivery of consumer-centric healthcare technologies. After implications for research, we provide suggestions and guidelines for PHR technology developers and constituents in the healthcare delivery chain.

CLINICALTRIAL

Lived experiences of people living with HIV: a descriptive qualitative analysis of their perceptions of themselves, their social spheres, healthcare professionals and the challenges they face daily

BACKGROUND

Human immunodeficiency virus (HIV) infection rates have been gradually increasing in Istanbul, Turkey. Many people living with HIV (PLWH) here encounter difficulties, for example, in adapting to the chronic disease and obtaining continuous access to healthcare services. In this study, we aimed to explore the challenges PLWH face in their daily lives and understand their perceptions of themselves, healthcare professionals and services, and their social spheres via their expressed lived experiences in the healthcare setting.

METHOD

Individual semi-structured in-depth interviews were conducted face-to-face with 20 PLWH in Istanbul. All the interviews were voice-recorded and transcribed verbatim except one, upon participant request, for which the interviewer took notes. These logs and the interviewer's notes were analyzed thematically using the inductive content analysis method.

RESULTS

The themes concerned experiences in three distinct contexts: 1) Interactions with healthcare providers; 2) Participants' responses to their HIV diagnosis; and 3) Interactions with their social networks. Firstly, the results highlighted that the participants perceived that healthcare professionals did not inform them about the diagnosis properly, failed to protect patients' confidentiality and exhibited discriminative behaviors towards them. Secondly, after the diagnosis the participants had difficulty in coping with their unsettled emotional state. While many ceased sexual activities and isolated themselves, some sought support. Lastly, living with HIV affected their relationships with their families and friends either positively or negatively. Moreover, they had to face the difficulties concerning spouse/partner notification issues about which many needed professional support.

CONCLUSION

Healthcare professionals' discriminative or inappropriate attitudes and customs in healthcare institutions are perceived to impair PLWH's utilization of healthcare services. Structural factors such as social pressure, societal ignorance about HIV, limited access to HIV prevention, and regulatory barriers might contribute to these challenges. The results suggest that it is necessary to raise healthcare professionals' and society's awareness about HIV and develop national policies to establish a well-functioning referral system and appropriate spouse/partner notification services.

Using the Patient Portal Sexual Health Instrument in Surveys and Patient Questionnaires Among Sexual Minority Men in the United States: Cross-sectional Psychometric Validation Study

Background

Patient portal modules, including electronic personal health records, health education, and prescription refill ordering, may be leveraged to address the sexually transmitted infection (STI) burden, including HIV, among gay, bisexual, and other sexual minority men (SMM). Theoretical frameworks in the implementation sciences highlight examining constructs of innovation attributes and performance expectations as key determinants of behavioral intentions and the use of new web-based health technologies. However, behavioral intentions to use patient portals for HIV and other STI prevention and care among SMM is understudied.

Objective

The aim of this study is to develop a brief instrument for measuring attitudes focused on using patient portals for STI prevention and care among a nationwide sample of SMM.

Methods

A total of 12 items of the American Men’s Internet Survey-Patient Portal Sexual Health Instrument (AMIS-PPSHI) were adapted from a previous study. Psychometric analyses of the AMIS-PPSHI items were conducted among a randomized subset of 2018 AMIS participants reporting web-based access to their health records (N=1375). Parallel analysis and inspection of eigenvalues in a principal component analysis (PCA) informed factor retention in exploratory factor analysis (EFA). After EFA, Cronbach α was used to examine the internal consistency of the scale and its subscales. Confirmatory factor analysis (CFA) was used to assess the goodness of fit of the final factor structure. We calculated the total AMIS-PPSHI scale scores for comparisons within group categories, including age, STI diagnosis history, recency of testing, serious mental illness, and anticipated health care stigma.

Results

The AMIS-PPSHI scale resulting from EFA consisted of 12 items and had good internal consistency (α=.84). The EFA suggested 3 subscales: sexual health engagement and awareness (α=.87), enhancing dyadic communication (α=.87), and managing sexual health care (α=.79). CFA demonstrated good fit in the 3-factor PPSHI structure: root mean square error of approximation=0.061, comparative fit index=0.964, Tucker-Lewis index=0.953, and standardized root mean square residual=0.041. The most notable differences were lower scores on the enhanced dyadic communication subscale among people living with HIV.

Conclusions

PPSHI is a brief instrument with strong psychometric properties that may be adapted for use in large surveys and patient questionnaires in other settings. Scores demonstrate that patient portals are favorable web-based solutions to deliver health services focused on STI prevention and care among SMM in the United States. More attention is needed to address the privacy implications of interpersonal use of patient portals outside of traditional health settings among persons with HIV.

"They know what they are getting into:" Researchers confront the benefits and challenges of online recruitment for HIV research

Online research has become a critical recruitment modality for understanding and reducing health disparities among hidden populations most at risk for HIV infection. There is a lack of consensus and guidelines for the responsible conduct of online recruitment for HIV risk populations. Using semi-structured phone interviews, this study drew on the experiences of principal investigators (PIs) engaged in online HIV research to illuminate scientific and ethical benefits and challenges of social media recruitment. Using Thematic Analysis five major themes emerged: sampling advantages and disadvantages; challenges of data integrity; control of privacy protections; researcher competence and responsibility; and resources.

Patient Portal Implementation and Uptake: Qualitative Comparative Case Study

BACKGROUND

Giving patients access to their health information is a provincial and national goal, and it is critical to the delivery of patient-centered care. With this shift, patient portals have become more prevalent. In Alberta, the Alberta Health Services piloted a portal (MyChart). There was a need to identify factors that promoted the use of this portal. Furthermore, it was imperative to understand why there was variability in uptake within the various clinics that participated in the pilot.

OBJECTIVE

This study aims to identify potential factors that could improve the uptake of MyChart from the perspectives of both users and nonusers at pilot sites. We focused on factors that promoted the use of MyChart along with related benefits and barriers to its use, with the intention that this information could be incorporated into the plan for its province-wide implementation.

METHODS

A qualitative comparative case study was conducted to determine the feasibility, acceptability, and initial perceptions of users and to identify ways to increase uptake. Semistructured interviews were conducted with 56 participants (27 patients, 21 providers, 4 nonmedical staff, and 4 clinic managers) from 5 clinics. Patients were asked about the impact of MyChart on their health and health care. Providers were asked about the impact on the patient-provider relationship and workflow. Managers were asked about barriers to implementation. The interviews were recorded, transcribed verbatim, and entered into NVivo. A thematic analysis was used to analyze the data.

RESULTS

Results from a comparison of factors related to uptake of MyChart in 5 clinics (2 clinics with high uptake, 1 with moderate uptake, 1 with low uptake, and 1 with no uptake) are reported. Some theoretical constructs in our study, such as intention to use, perceived value, similarity (novelty) of the technology, and patient health needs, were similar to findings published by other research teams. We also identified some new factors associated with uptake, including satisfaction or dissatisfaction with the current status quo, performance expectancy, facilitating conditions, behavioral intentions, and use behavior. All these factors had an impact on the level of uptake in each setting and created different opportunities for end users.

CONCLUSIONS

There is limited research on factors that influence the uptake of patient portals. We identified some factors that were consistent with those reported by others but also several new factors that were associated with the update of MyChart, a new patient portal, in the clinics we studied. On the basis of our results, we posit that a shared understanding of the technology among patients, clinicians, and managers, along with dissatisfaction with nonportal-based communications, is foundational and must be addressed for patient portals to support improvements in care.

Barriers to patient, provider, and caregiver adoption and use of electronic personal health records in chronic care: a systematic review

Background

Electronic personal health records (ePHRs) are defined as electronic applications through which individuals can access, manage, and share health information in a private, secure, and confidential environment. Existing evidence shows their benefits in improving outcomes, especially for chronic disease patients. However, their use has not been as widespread as expected partly due to barriers faced in their adoption and use. We aimed to identify the types of barriers to a patient, provider, and caregiver adoption/use of ePHRs and to analyze their extent in chronic disease care.

Methods

A systematic search in Medline, PubMed, Science Direct, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Central Register of Controlled Trials, and the Institute of Electrical and Electronics Engineers (IEEE) database was performed to find original studies assessing barriers to ePHR adoption/use in chronic care until the end of 2018. Two researchers independently screened and extracted data. We used the PHR adoption model and the Unified Theory of Acceptance and Use of Technology to analyze the results. The Mixed Methods Appraisal Tool (MMAT) version 2018 was used to assess the quality of evidence in the included studies.

Results

Sixty publications met our inclusion criteria. Issues found hindering ePHR adoption/use in chronic disease care were associated with demographic factors (e.g., patient age and gender) along with key variables related to health status, computer literacy, preferences for direct communication, and patient’s strategy for coping with a chronic condition; as well as factors related to medical practice/environment (e.g., providers’ lack of interest or resistance to adopting ePHRs due to workload, lack of reimbursement, and lack of user training); technological (e.g., concerns over privacy and security, interoperability with electronic health record systems, and lack of customized features for chronic conditions); and chronic disease characteristics (e.g., multiplicities of co-morbid conditions, settings, and providers involved in chronic care).

Conclusions

ePHRs can be meaningfully used in chronic disease care if they are implemented as a component of comprehensive care models specifically developed for this care. Our results provide insight into hurdles and barriers mitigating ePHR adoption/use in chronic disease care. A deeper understating of the interplay between these barriers will provide opportunities that can lead to an enhanced ePHR adoption/use.

E-health. Patterns of use and perceived benefits and barriers among people living with HIV (PLHIV) and their physicians - Part 3: Telemedicine and collection of computerized personal information

OBJECTIVES

To evaluate the patterns of use and perceived benefits and barriers among people living with HIV and their physicians concerning telemedicine and the collection of computerized personal information.

METHODS

Multicenter online observational survey from October 15 to 19, 2018.

RESULTS

Study participation was accepted by 229 physicians and 838/1,377 PLHIV followed in 46 centers, of which 325 (39%) responded online. We found that while 226/302 (75%) PLHIV accept online prescription renewals and 197/302 (65%) accept online medical certificates, 182/302 (60%) PLHIV-who were more often in material/social deprivation (OR=1.70±0.45; P=0.045), less often born in Île-de-France (OR=0.43±0.15; P=0.018), with lower CD4 T-cell counts (OR=0.999±0.0004; P=0.038), and less often on psychiatric treatment (OR=0.50±0.18; P=0.047)-were receptive to teleconsultations. However, 137/225 (61%) physicians would be uncomfortable teleconsulting due to inadequate data security without it reducing the number of consultations or offering economic benefit. Asked about collection of computerized personal information, 197/296 (67%) PLHIV and 139/223 (62%) physicians agreed it improved quality of care, but 144 (49%) PLHIV and 94/222 (42%) physicians thought it was not sufficiently framed by the law. eHealth was seen as improving coordination between health professionals by 240/296 (81%) PLHIV and seen as a good thing by 181/225 (81%) physicians.

CONCLUSION

More than half of PLHIV were ready for telemedicine. PLHIV and physicians endorsed the advantage of e-health in terms of better coordination across health professionals but mistrust the data collection factor, which warrants either clarification or stronger legal protections.

ImPlementation REsearCh to DEvelop Interventions for People Living with HIV (the PRECluDE consortium): Combatting chronic disease comorbidities in HIV populations through implementation research

Antiretroviral therapy (ART) prevented premature mortality and improved the quality of life among people living with the human immunodeficiency virus (PLWH), such that now more than half of PLWH in the United States are 50 years of age and older. Increased longevity among PLWH has resulted in a significant rise in chronic, comorbid diseases. However, the implementation of guideline-based interventions for preventing, treating, and managing such age-related, chronic conditions among the HIV population is lacking. The PRECluDE consortium supported by the Center for Translation Research and Implementation Science at the National Heart, Lung, and Blood Institute catalyzes implementation research on proven-effective interventions for co-occurring heart, lung, blood, and sleep diseases and conditions among PLWH. These collaborative research studies use novel implementation frameworks with HIV, mental health, cardiovascular, and pulmonary care to advance comprehensive HIV and chronic disease healthcare in a variety of settings and among diverse populations.

Barriers and Facilitators to the Implementation of eHealth Services: Systematic Literature Analysis

Background

The field of eHealth has a history of more than 20 years. During that time, many different eHealth services were developed. However, factors influencing the adoption of such services were seldom the main focus of analyses. For this reason, organizations adopting and implementing eHealth services seem not to be fully aware of the barriers and facilitators influencing the integration of eHealth services into routine care.

Objective

The objective of this work is to provide (1) a comprehensive list of relevant barriers to be considered and (2) a list of facilitators or success factors to help in planning and implementing successful eHealth services.

Methods

For this study, a twofold approach was applied. First, we gathered experts’ current opinions on facilitators and barriers in implementing eHealth services via expert discussions at two health informatics conferences held in Europe. Second, we conducted a systematic literature analysis concerning the barriers and facilitators for the implementation of eHealth services. Finally, we merged the results of the expert discussions with those of the systematic literature analysis.

Results

Both expert discussions (23 and 10 experts, respectively) identified 15 barriers and 31 facilitators, whereas 76 barriers and 268 facilitators were found in 38 of the initial 56 articles published from 12 different countries. For the analyzed publications, the count of distinct barriers reported ranged from 0 to 40 (mean 10.24, SD 8.87, median 8). Likewise, between 0 and 48 facilitators were mentioned in the literature (mean 9.18, SD 9.33, median 6). The combination of both sources resulted in 77 barriers and 292 facilitators for the adoption and implementation of eHealth services.

Conclusions

This work contributes a comprehensive list of barriers and facilitators for the implementation and adoption of eHealth services. Addressing barriers early, and leveraging facilitators during the implementation, can help create eHealth services that better meet the needs of users and provide higher benefits for patients and caregivers.

"Get Ready and Empowered About Treatment" (GREAT) Study: a Pragmatic Randomized Controlled Trial of Activation in Persons Living with HIV

BACKGROUND

Little is known about strategies to improve patient activation, particularly among persons living with HIV (PLWH).

OBJECTIVE

To assess the impact of a group intervention and individual coaching on patient activation for PLWH.

DESIGN

Pragmatic randomized controlled trial.

SITES

Eight practices in New York and two in New Jersey serving PLWH.

PARTICIPANTS

Three hundred sixty PLWH who received care at participating practices and had at least limited English proficiency and basic literacy.

INTERVENTION

Six 90-min group training sessions covering use of an ePersonal Health Record loaded onto a handheld mobile device and a single 20-30 min individual pre-visit coaching session.

MAIN MEASURES

The primary outcome was change in Patient Activation Measure (PAM). Secondary outcomes were changes in eHealth literacy (eHEALS), Decision Self-efficacy (DSES), Perceived Involvement in Care Scale (PICS), health (SF-12), receipt of HIV-related care, and change in HIV viral load (VL).

KEY RESULTS

The intervention group showed significantly greater improvement than the control group in the primary outcome, the PAM (difference 2.82: 95% confidence interval [CI] 0.32-5.32). Effects were largest among participants with lowest quartile PAM at baseline (p < 0.05). The intervention doubled the odds of improving one level on the PAM (odds ratio 1.96; 95% CI 1.16-3.31). The intervention group also had significantly greater improvement in eHEALS (difference 2.67: 95% CI 1.38-3.9) and PICS (1.27: 95% CI 0.41-2.13) than the control group. Intervention effects were similar by race/ethnicity and low education with the exception of eHealth literacy where effects were stronger for minority participants. No statistically significant effects were observed for decision self-efficacy, health status, adherence, receipt of HIV relevant care, or HIV viral load.

CONCLUSIONS

The patient activation intervention modestly improved several domains related to patient empowerment; effects on patient activation were largest among those with the lowest levels of baseline patient activation.

TRIAL REGISTRATION

This study is registered at Clinical Trials.Gov (NCT02165735).

Is research on patient portals attuned to health equity? A scoping review

OBJECTIVE

Our scoping review examined how research on patient portals addresses health equity. Questions guiding our review were: 1) What health equity concepts are addressed in patient portal research-both explicitly and implicitly? 2) What are the gaps? 3) Is the potential for ehealth-related health inequities explicitly acknowledged in studies on patient portals? 4) What novel approaches and interventions to reduce health inequities are tested in patient portal research?

MATERIALS AND METHODS

We searched 4 databases. Search terms included "patient portal" in combination with a comprehensive list of health equity terms relevant in ehealth context. Authors independently reviewed the papers during initial screening and full-text review. We applied the eHealth Equity Framework to develop search terms and analyze the included studies.

RESULTS

Based on eHealth Equity Framework categories, the main findings generated from 65 reviewed papers were governance structures, ehealth policies, and cultural and societal values may further inequities; social position of providers and patients introduces differential preferences in portal use; equitable portal implementation can be supported through diverse user-centered design; and intermediary strategies are typically recommended to encourage portal use across populations.

DISCUSSION

The predominant focus on barriers in portal use may be inadvertently placing individual responsibility in addressing these barriers on patients already experiencing the greatest health disparities. This approach may mask the impact of the socio-technical-economic-political context on outcomes for different populations.

CONCLUSION

To support equitable health outcomes related to patient portals we need to look beyond intermediary initiatives and develop equitable strategies across policy, practice, research, and implementation.

Factors Affecting Patients' Use of Electronic Personal Health Records in England: Cross-Sectional Study

Background

Electronic personal health records (ePHRs) are secure Web-based tools that enable individuals to access, manage, and share their medical records. England recently introduced a nationwide ePHR called Patient Online. As with ePHRs in other countries, adoption rates of Patient Online remain low. Understanding factors affecting patients’ ePHR use is important to increase adoption rates and improve the implementation success of ePHRs.

Objective

This study aimed to examine factors associated with patients’ use of ePHRs in England.

Methods

The unified theory of acceptance and use of technology was adapted to the use of ePHRs. To empirically examine the adapted model, a cross-sectional survey of a convenience sample was carried out in 4 general practices in West Yorkshire, England. Factors associated with the use of ePHRs were explored using structural equation modeling.

Results

Of 800 eligible patients invited to take part in the survey, 624 (78.0%) returned a valid questionnaire. Behavioral intention (BI) was significantly influenced by performance expectancy (PE; beta=.57, P<.001), effort expectancy (EE; beta=.16, P<.001), and perceived privacy and security (PPS; beta=.24, P<.001). The path from social influence to BI was not significant (beta=.03, P=.18). Facilitating conditions (FC) and BI significantly influenced use behavior (UB; beta=.25, P<.001 and beta=.53, P<.001, respectively). PE significantly mediated the effect of EE and PPS on BI (beta=.19, P<.001 and beta=.28, P=.001, respectively). Age significantly moderated 3 paths: PE→BI, EE→BI, and FC→UB. Sex significantly moderated only the relationship between PE and BI. A total of 2 paths were significantly moderated by education and internet access: EE→BI and FC→UB. Income moderated the relationship between FC and UB. The adapted model accounted for 51% of the variance in PE, 76% of the variance in BI, and 48% of the variance in UB.

Conclusions

This study identified the main factors that affect patients’ use of ePHRs in England, which should be taken into account for the successful implementation of these systems. For example, developers of ePHRs should involve patients in the process of designing the system to consider functions and features that fit patients’ preferences and skills to ensure systems are useful and easy to use. The proposed model accounted for 48% of the variance in UB, indicating the existence of other, as yet unidentified, factors that influence the adoption of ePHRs. Future studies should confirm the effect of the factors included in this model and identify additional factors.

Development of Comprehensive Personal Health Records Integrating Patient-Generated Health Data Directly From Samsung S-Health and Apple Health Apps: Retrospective Cross-Sectional Observational Study

BACKGROUND

Patient-generated health data (PGHD), especially lifelog data, are important for managing chronic diseases. Additionally, personal health records (PHRs) have been considered an effective tool to engage patients more actively in the management of their chronic diseases. However, no PHRs currently integrate PGHD directly from Samsung S-Health and Apple Health apps.

OBJECTIVE

The purposes of this study were (1) to demonstrate the development of an electronic medical record (EMR)-tethered PHR system (Health4U) that integrates lifelog data from Samsung S-Health and Apple Health apps and (2) to explore the factors associated with the use rate of the functions.

METHODS

To upgrade conventional EMR-tethered PHRs, a task-force team (TFT) defined the functions necessary for users. After implementing a new system, we enrolled adults aged 19 years and older with prior experience of accessing Health4U in the 7-month period after November 2017, when the service was upgraded.

RESULTS

Of the 17,624 users, 215 (1.22%) integrated daily steps data, 175 (0.99%) integrated weight data, 51 (0.29%) integrated blood sugar data, and 90 (0.51%) integrated blood pressure data. Overall, 61.95% (10,919/17,624) had one or more chronic diseases. For integration of daily steps data, 48.3% (104/215) of patients used the Apple Health app, 43.3% (93/215) used the S-Health app, and 8.4% (18/215) entered data manually. To retrieve medical documentation, 324 (1.84%) users downloaded PDF files and 31 (0.18%) users integrated their medical records into the Samsung S-Health app via the Consolidated-Clinical Document Architecture download function. We found a consistent increase in the odds ratios for PDF downloads among patients with a higher number of chronic diseases. The age groups of ≥60 years and ≥80 years tended to use the download function less frequently than the others.

CONCLUSIONS

This is the first study to examine the factors related to integration of lifelog data from Samsung S-Health and Apple Health apps into EMR-tethered PHRs and factors related to the retrieval of medical documents from PHRs. Our findings on the lifelog data integration can be used to design PHRs as a platform to integrate lifelog data in the future.

Capturing a Patient-Reported Measure of Physical Function Through an Online Electronic Health Record Patient Portal in an Ambulatory Clinic: Implementation Study

Background

Despite significant interest in the collection of patient-reported outcomes to make care more patient-centered, few studies have evaluated implementation efforts to collect patient-reported outcomes from diverse patient populations

Objective

We assessed the collection of patient-reported outcomes from rheumatoid arthritis patients in an academic rheumatology clinic, using a paper and an online form through the electronic health record patient portal.

Methods

We identified patients seen between 2012-2016 with ≥2 face-to-face encounters with a rheumatology provider and International Classification of Diseases codes for RA, ≥30 days apart. In 2013, our clinic implemented a paper version of the Patient Reported Outcome Measurement Information System (PROMIS) physical function form that was administered to patients upon their check-in at the clinic. In 2015, an online version of the form became available by way of the electronic health record patient portal to patients with active portal accounts. We compared the proportion of visits with documented PROMIS scores across age, race and ethnicity, and language and examined trends over time using a control chart.

Results

We included 1078 patients with rheumatoid arthritis with 7049 in-person encounters at the rheumatology clinic over 4 years, with an average of 168 visits per month. Of the included patients, 80.4% of patients (867/1078) were female and the mean age was 58 (SD 16) years. The overall PROMIS physical function score documentation increased from 60.4% (1081/1791) of visits in 2013 to 74.4% (905/1217) of visits in 2016. Online score documentation increased from 10.0% (148/1473) in 2015 to 19.3% (235/1217) in 2016. African American patients were least likely to have a PROMIS physical function score recorded (55/88, 62.5% compared to 792/990, 80.0% for other racial or ethnic groups; P<.001). Compared with white patients, both African American and Hispanic patients were less likely to have active online electronic health record portal accounts (44/88, 50% and 90/157, 57.3% respectively, compared to 437/521, 83.9% of white patients; P<.001) and, once activated, less likely to use the online survey (6/44, 13.6% and 16/90, 17.8% respectively, compared to 135/437, 30.9% of white patients; P=.02). There was no significant difference in the proportion of any PROMIS physical function forms recorded between non-English vs English preferred patients. No significant differences were found across age or gender.

Conclusions

PROMIS physical function form completion improved overall from 2012-2016 but lagged among racial and ethnic minorities and non-English preferred patients. Future studies should address issues of portal access, enrollment, satisfaction, and persistence and focus on developing PRO implementation strategies that accommodate the needs and preferences of diverse populations.

Barriers, Facilitators, and Solutions to Optimal Patient Portal and Personal Health Record Use: A Systematic Review of the Literature

Patient portal and personal health record adoption and usage rates have been suboptimal. A systematic review of the literature was performed to capture all published studies that specifically addressed barriers, facilitators, and solutions to optimal patient portal and personal health record enrollment and use. Consistent themes emerged from the review. Patient attitudes were critical as either barrier or facilitator. Institutional buy-in, information technology support, and aggressive tailored marketing were important facilitators. Interface redesign was a popular solution. Quantitative studies identified many barriers to optimal patient portal and personal health record enrollment and use, and qualitative and mixed methods research revealed thoughtful explanations for why they existed. Our study demonstrated the value of qualitative and mixed research methodologies in understanding the adoption of consumer health technologies. Results from the systematic review should be used to guide the design and implementation of future patient portals and personal health records, and ultimately, close the digital divide.

Activation and Utilization of an Electronic Health Record Patient Portal at an Academic Medical Center-Impact of Patient Demographics and Geographic Location

The advent of the online electronic health record patient portal has provided an efficient and practical means for patients to become more involved in their health care. In this report, we analyze how demographic variables such as age, gender, race, and geographic location affect patient portal activation and usage at the University of Iowa Hospitals and Clinics, the sole academic medical center in the state of Iowa, a predominantly rural state. Our primary end points were activation of the patient portal (MyChart, Epic, Inc) and access of outpatient laboratory and radiology results, among the most commonly accessed and popular features of the patient portal. We thus analyzed data from 536 378 patients to determine rates of patient portal activation and data from 219 671 patient encounters to determine the frequency at which patients access their online diagnostic test results. Higher rates of patient portal activation and usage were associated with female gender, Caucasians/non-underrepresented minorities, geographic location in closer proximity to the medical center (Iowa City and neighboring cities/suburbs), and nonelderly adults. For underrepresented minority and rural patients, opportunities for improvement exist for both activation and more robust use of online patient portal accounts. Overall, these data highlight existing disparities with online patient portal usage and provide a base on which further studies and interventions can help to improve utilization of these systems.

Personal health records in the Netherlands: potential user preferences quantified by a discrete choice experiment

Objective

To identify groups of potential users based on their preferences for characteristics of personal health records (PHRs) and to estimate potential PHR uptake.

Methods

We performed a discrete choice experiment, which consisted of 12 choice scenarios, each comprising 2 hypothetical PHR alternatives and an opt-out. The alternatives differed based on 5 characteristics. The survey was administered to Internet panel members of the Dutch Federation of Patients and Consumer Organizations. We used latent class models to analyze the data.

Results

A total of 1,443 potential PHR users completed the discrete choice experiment. We identified 3 latent classes: "refusers" (class probability 43%), "eager adopters" (37%), and "reluctant adopters" (20%). The predicted uptake for the reluctant adopters ranged from 4% in the case of a PHR with the worst attribute levels to 68% in the best case. Those with 1 or more chronic diseases were significantly more likely to belong to the eager adopter class. The data storage provider was the most decisive aspect for the eager and reluctant adopters, while cost was most decisive for the refusers. Across all classes, health care providers and independent organizations were the most preferred data storage providers.

Conclusion

We identified 3 groups, of which 1 group (more than one-third of potential PHR users) indicated great interest in a PHR irrespective of PHR characteristics. Policymakers who aim to expand the use of PHRs will be most successful when health care providers and health facilities or independent organizations store PHR data while refraining from including market parties.

Barriers to the use of personal health records by patients: a structured review

Introduction

An increasing focus on personal electronic health records (PHRs) offers healthcare benefits for patients, particularly those in undeserved and marginalised populations, who are at risk of receiving less effective healthcare, and may have worse health outcomes. However, PHRs are likely to favour text, technical and health literate users, and be less suitable for disadvantaged patients. These concerns have prompted this review of the literature, which seeks evidence about barriers to the adoption and continued use of PHRs, the nature of the evidence for those barriers, and the stage of PHR implementation where particular barriers apply.

Methods

Searches in PubMed, Embase, CINAHL and ProQuest databases were used to retrieve articles published in English after 2003 in a refereed journal, or presented in a refereed conference or scientific meeting. After screening to remove items which were out of scope, the phase of the PHR implementation, the type of investigation, and PHR barriers were categorised using thematic coding.

Results

The search retrieved 395 items; screening identified 34 in-scope publications, which provided evidence of 21 identified barriers to patient adoption and continued use of PHRs, categorised here as Individual, Demographic, Capability, Health-related, PHR or Attitudinal factors. Barriers were identified in most phases of PHR implementation, and in most types of study. A secondary outcome identified that eleven of the publications may have introduced a bias by excluding participants who were less affluent, less capable, or marginalised.

Conclusions

PHR barriers can interfere with the decision to start using a PHR, with the adoption process, and with continued use, and the impact of particular barriers may vary at different phases of PHR adoption. The complex interrelationships which exist between many of the barriers is suggested in some publications, and emerges more clearly from this review. Many PHR barriers appear to be related to low socioeconomic status. A better understanding is needed of how the effect of barriers is manifested, how that effect can be countered, and how planning and implementation of PHR initiatives can make allowance for patient level barriers to PHR adoption and use, with appropriate actions to mitigate the effect of those barriers for more disadvantaged patients.

Perceived challenges for adopting the Personal Health Record (PHR) at Ministry of National Guard Health Affairs (MNGHA)- Riyadh

BACKGROUND

The Personal Health Record (PHR) is an electronic record that allows patients to maintain, manage and access their health information in one secure location. However, despite these potential capabilities, the adoption rate of the PHR has been slow due to various challenges.

OBJECTIVES

This study, being the first of its kind in Saudi Arabia, investigates the perceived barriers and /or challenges for PHR adoption in the Ministry of National Guard Health Affairs (MNGHA). The study explored perceived barriers and /or challenges from two different perspectives; a technical perspective and a social perspective.

METHODS

The study was conducted using a mixed methods approach. A cross-sectional study design using a questionnaire was used to measure patients' perceptions of the PHR and a qualitative approach through focus groups was used to capture comments and opinions from technical personnel for perceived technical barriers to PHR adoption.

RESULT

Results from 424 patients revealed a positive perception for PHR adoption with almost all of the participants (96.7%) indicating interest in using the PHR and the majority (73.3%) expressing no confidentiality concerns for the online accessibility of their health information. Patients with higher levels of education indicated higher interest in using the PHR and expressed more concern with confidentiality than patients with lower levels of education. However, the majority of patients (78.3%) expressed their lack of awareness of existing patient e-services on the MNGHA website. The themes that emerged from the focus groups reinforced lack of awareness of e-services as a potential barrier for PHR adoption as well as the role of policy in the regulation and business process for PHR adoption.

CONCLUSION

This study has highlighted the perceived challenges and barriers for adoption of the PHR in MNGHA-Riyadh. In order to ensure an efficient PHR with a strong adoption rate, effective steps need to be undertaken by building PHR awareness as well as setting clear guidelines and regulations from policy makers.

Adoption of Electronic Personal Health Records in Canada: Perceptions of Stakeholders

BACKGROUND

Healthcare stakeholders have a great interest in the adoption and use of electronic personal health records (ePHRs) because of the potential benefits associated with them. Little is known, however, about the level of adoption of ePHRs in Canada and there is limited evidence concerning their benefits and implications for the healthcare system. This study aimed to describe the current situation of ePHRs in Canada and explore stakeholder perceptions regarding barriers and facilitators to their adoption.

METHODS

Using a qualitative descriptive study design, we conducted semi-structured phone interviews between October 2013 and February 2014 with 35 individuals from seven Canadian provinces. The participants represented six stakeholder groups (patients, ePHR administrators, healthcare professionals, organizations interested in health technology development, government agencies, and researchers). A detailed summary of each interview was created and thematic analysis was conducted.

RESULTS

We observed that there was no consensual definition of ePHR in Canada. Factors that could influence ePHR adoption were related to knowledge (confusion with other electronic medical records [EMRs] and lack of awareness), system design (usability and relevance), user capacities and attitudes (patient health literacy, education and interest, support for professionals), environmental factors (government commitment, targeted populations) and legal and ethical issues (information control and custody, confidentiality, privacy and security).

CONCLUSION

ePHRs are slowly entering the Canadian healthcare landscape but provinces do not seem well-prepared for the implementation of this type of record. Guidance is needed on critical issues regarding ePHRs, such as ePHR definition, data ownership, access to information and interoperability with other electronic health records (EHRs). Better guidance on these issues would provide a greater awareness of ePHRs and inform stakeholders including clinicians, decision-makers, patients and the public. In turn, it may facilitate their adoption in the country.

Determinants of Consumer eHealth Information Seeking Behavior

Patients are increasingly using the Internet and other technologies to engage in their own healthcare, but little research has focused on the determinants of consumer eHealth behaviors related to Internet use. This study uses data from 115,089 respondents to four years of the National Health Interview Series to identify the associations between one consumer eHealth behavior (information seeking) and demographics, health measures, and Personal Health Information Management (PHIM) (messaging, scheduling, refills, and chat). Individuals who use PHIM are 7.5 times more likely to search the internet for health related information. Just as health has social determinants, the results of this study indicate there are potential social determinants of consumer eHealth behaviors including personal demographics, health status, and healthcare access.

Antiretroviral Therapy Adherence and Use of an Electronic Shared Medical Record Among People Living with HIV

Electronic shared medical records (SMR) are emerging healthcare technologies that allow patients to engage in their healthcare by communicating with providers, refilling prescriptions, scheduling appointments, and viewing portions of medical records. We conducted a pre-post cohort study of HIV-positive adults who used and did not use SMR in two integrated healthcare systems. We compared the difference in antiretroviral refill adherence between SMR users and age- and sex-frequency matched non-users from the 12-month period prior to SMR useto the 12-month period starting 6 months after initiation of SMR use. High adherence was maintained among SMR users (change = -0.11 %) but declined among non-users (change = -2.05 %; p = 0.003). Among SMR users, there was a steady improvement in adherence as monthly frequency of SMR use increased (p = 0.009). SMR use, particularly more frequent use, is associated with maintaining high adherence and non-use is associated with declines in adherence over time among patients with access to these online services.

The usability of electronic personal health record systems for an underserved adult population

OBJECTIVE

The goals of this study were to identify the demands associated with using electronic personal health records (PHRs) and to evaluate the ability of adults of lower socioeconomic status and low health literacy to use PHRs to perform health management activities.

BACKGROUND

PHRs are proliferating in clinical practices and health care organizations. These systems offer the potential of increasing the active involvement of patients in health self-management. However, little is known about the actual usability of these tools for health consumers.

METHOD

We used task analysis and health literacy load analysis to identify the cognitive and literacy demands inherent in the use of PHRs and evaluated the usability of three currently available PHR systems with a sample of 54 adults. Participants used the systems to perform tasks related to medication management, interpretation of lab/test results, and health maintenance. Data were also gathered on the participants' perception of the potential value of using a PHR.

RESULTS

The results indicated that a majority of the participants had difficulty completing the tasks and needed assistance. There was some variability according to task and PHR system. However, most participants perceived the use of PHRs as valuable.

CONCLUSIONS

Although considered a valuable tool by consumers, the use of PHR systems may be challenging for many people. Strategies are needed to enhance the usability of these systems, especially for people with low literacy, low health literacy, or limited technology skills.

APPLICATION

The data from this study have implications for the design of PHRs.

Barriers to patient portal access among veterans receiving home-based primary care: a qualitative study

BACKGROUND

Electronic, or web-based, patient portals can improve patient satisfaction, engagement and health outcomes and are becoming more prevalent with the advent of meaningful use incentives. However, adoption rates are low, particularly among vulnerable patient populations, such as those patients who are home-bound with multiple comorbidities. Little is known about how these patients view patient portals or their barriers to using them.

OBJECTIVE

To identify barriers to and facilitators of using My HealtheVet (MHV), the United States Department of Veterans Affairs (VA) patient portal, among Veterans using home-based primary care services.

DESIGN

Qualitative study using in-depth semi-structured interviews. We conducted a content analysis informed by grounded theory.

PARTICIPANTS

Fourteen Veterans receiving home-based primary care, surrogates of two of these Veterans, and three home-based primary care (HBPC) staff members.

KEY RESULTS

We identified five themes related to the use of MHV: limited knowledge; satisfaction with current HBPC care; limited computer and Internet access; desire to learn more about MHV and its potential use; and value of surrogates acting as intermediaries between Veterans and MHV.

CONCLUSIONS

Despite their limited knowledge of MHV and computer access, home-bound Veterans are interested in accessing MHV and using it as an additional point of care. Surrogates are also potential users of MHV on behalf of these Veterans and may have different barriers to and benefits from use.

Online access to doctors' notes: patient concerns about privacy

Background

Offering patients online access to medical records, including doctors’ visit notes, holds considerable potential to improve care. However, patients may worry about loss of privacy when accessing personal health information through Internet-based patient portals. The OpenNotes study provided patients at three US health care institutions with online access to their primary care doctors’ notes and then collected survey data about their experiences, including their concerns about privacy before and after participation in the intervention.

Objective

To identify patients’ attitudes toward privacy when given electronic access to their medical records, including visit notes.

Methods

The design used a nested cohort study of patients surveyed at baseline and after a 1-year period during which they were invited to read their visit notes through secure patient portals. Participants consisted of 3874 primary care patients from Beth Israel Deaconess Medical Center (Boston, MA), Geisinger Health System (Danville, PA), and Harborview Medical Center (Seattle, WA) who completed surveys before and after the OpenNotes intervention. The measures were patient-reported levels of concern regarding privacy associated with online access to visit notes.

Results

32.91% of patients (1275/3874 respondents) reported concerns about privacy at baseline versus 36.63% (1419/3874 respondents) post-intervention. Baseline concerns were associated with non-white race/ethnicity and lower confidence in communicating with doctors, but were not associated with choosing to read notes or desire for continued online access post-intervention (nearly all patients with notes available chose to read them and wanted continued access). While the level of concern among most participants did not change during the intervention, 15.54% (602/3874 respondents, excluding participants who responded “don’t know”) reported more concern post-intervention, and 12.73% (493/3874 respondents, excluding participants who responded “don’t know”) reported less concern.

Conclusions

When considering online access to visit notes, approximately one-third of patients had concerns about privacy at baseline and post-intervention. These perceptions did not deter participants from accessing their notes, suggesting that the benefits of online access to medical records may outweigh patients’ perceived risks to privacy.

Consumers' perceptions of patient-accessible electronic medical records

Background

Electronic health information (eHealth) tools for patients, including patient-accessible electronic medical records (patient portals), are proliferating in health care delivery systems nationally. However, there has been very limited study of the perceived utility and functionality of portals, as well as limited assessment of these systems by vulnerable (low education level, racial/ethnic minority) consumers.

Objective

The objective of the study was to identify vulnerable consumers’ response to patient portals, their perceived utility and value, as well as their reactions to specific portal functions.

Methods

This qualitative study used 4 focus groups with 28 low education level, English-speaking consumers in June and July 2010, in New York City.

Results

Participants included 10 males and 18 females, ranging in age from 21-63 years; 19 non-Hispanic black, 7 Hispanic, 1 non-Hispanic White and 1 Other. None of the participants had higher than a high school level education, and 13 had less than a high school education. All participants had experience with computers and 26 used the Internet. Major themes were enhanced consumer engagement/patient empowerment, extending the doctor’s visit/enhancing communication with health care providers, literacy and health literacy factors, improved prevention and health maintenance, and privacy and security concerns. Consumers were also asked to comment on a number of key portal features. Consumers were most positive about features that increased convenience, such as making appointments and refilling prescriptions. Consumers raised concerns about a number of potential barriers to usage, such as complex language, complex visual layouts, and poor usability features.

Conclusions

Most consumers were enthusiastic about patient portals and perceived that they had great utility and value. Study findings suggest that for patient portals to be effective for all consumers, portals must be designed to be easy to read, visually engaging, and have user-friendly navigation.