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

Knowledge, Attitudes, and Practices about Electronic Personal Health Records: A Cross-Sectional Study in a Region of Northern Italy

The Electronic Personal Health Record (EPHR) provides an innovative service for citizens and professionals to manage health data, promoting patient-centred care. It enhances communication between patients and physicians and improves accessibility to documents for remote medical information management. The study aims to assess the prevalence of awareness and acceptance of the EPHR in northern Italy and define determinants and barriers to its implementation. In 2022, a region-wide cross-sectional study was carried out through a paper-based and online survey shared among adult citizens. Univariable and multivariable regression models analysed the association between the outcome variables (knowledge and attitudes toward the EPHR) and selected independent variables. Overall, 1634 people were surveyed, and two-thirds were aware of the EPHR. Among those unaware of the EPHR, a high prevalence of specific socio-demographic groups, such as foreign-born individuals and those with lower educational levels, was highlighted. Multivariable regression models showed a positive association between being aware of the EPHR and educational level, health literacy, and perceived poor health status, whereas age was negatively associated. A higher knowledge of the EPHR was associated with a higher attitude towards the EPHR. The current analysis confirms a lack of awareness regarding the existence of the EPHR, especially among certain disadvantaged demographic groups. This should serve as a driving force for a powerful campaign tailored to specific categories of citizens for enhancing knowledge and usage of the EPHR. Involving professionals in promoting this tool is crucial for helping patients and managing health data.

Estimating Cognitive Load in a Mobile Personal Health Record Application: A Cognitive Task Analysis Approach

OBJECTIVES

Mobile health applications that are designed without considering usability criteria can lead to cognitive overload, resulting in the rejection of these apps. To avoid this problem, the user interface of mobile health applications should be evaluated for cognitive load. This evaluation can contribute to the improvement of the user interface and help prevent cognitive overload for the user.

METHODS

In this study, we evaluated a mobile personal health records application using the cognitive task analysis method, specifically the goals, operators, methods, and selection rules (GOMS) approach, along with the related updated GOMS model and gesture-level model techniques. The GOMS method allowed us to determine the steps of the tasks and categorize them as physical or cognitive tasks. We then estimated the completion times of these tasks using the updated GOMS model and gesture-level model.

RESULTS

All 10 identified tasks were split into 398 steps consisting of mental and physical operators. The time to complete all the tasks was 5.70 minutes and 5.45 minutes according to the updated GOMS model and gesture-level model, respectively. Mental operators covered 73% of the total fulfillment time of the tasks according to the updated GOMS model and 76% according to the gesture-level model. The inter-rater reliability analysis yielded an average of 0.80, indicating good reliability for the evaluation method.

CONCLUSIONS

The majority of the task execution times comprised mental operators, suggesting that the cognitive load on users is high. To enhance the application's implementation, the number of mental operators should be reduced.

Personal Health Record (PHR) Experience and Recommendations for a Transformation in Saudi Arabia

A Personal Health Record (PHR) is a patient-managed platform for health data. Most hospitals provide a PHR as an extension of the Electronic Medical Record (EMR). However, there are unresolved issues around the adoption rate, functionalities, barriers and, more importantly, the impact of the PHR on patients' health. A cross-sectional, survey-based descriptive study was conducted in which patients from four main tertiary hospitals in Saudi Arabia were targeted from September 2022 to February 2023. The survey was tested and validated to address the objectives of the study. The survey covered components related to intention to use the PHR, required functions, obstacles and expected outcomes. This study involved 396 participants from the top four hospitals. It was discovered that the majority of them had intentions to use the PHR (93%) and believed it to be useful (94%) and easy to use (94%). It was widely agreed that accessing medical records (77%), scheduling appointments (88%), renewing medication (90%), tracking patient data (70%) and receiving personalized education (78%) were essential aspects of the PHR. Furthermore, the survey revealed that 54% of respondents saw a positive effect on their health status. A significant number of participants, around 54%, expressed concerns about the privacy of their PHR, and 46% reported concerns about the accuracy of their information. The study found that demographic factors and the type of hospital did not have a statistically significant association with the intention to use the PHR. Our findings showed that there were no significant barriers to adopting the PHR. Additionally, we found that less than half of the participants believed that their current PHR helped them to improve their health. This highlights the need for healthcare organizations to focus on improving the PHR's functionality and overall purpose. Instead of simply providing basic features, the PHR should allow patients to manage their health information comprehensively, including compiling information from hospitals and patient-generated data. Having a PHR is crucial in improving an individual's overall health. As technology advances, more data are being generated that should be included in the PHR to ensure an accurate and comprehensive view of the patient's health. Expanding the scope of the PHR to include capabilities beyond merely hospital data is important. Achieving this requires an open and honest discussion about the role of the PHR, potential obstacles and how to coordinate efforts among different stakeholders.

Identifying Nonpatient Authors of Patient Portal Secure Messages in Oncology: A Proof-of-Concept Demonstration of Natural Language Processing Methods

PURPOSE

Patient portal secure messages are not always authored by the patient account holder. Understanding who authored the message is particularly important in an oncology setting where symptom reporting is crucial to patient treatment. Natural language processing has the potential to detect messages not authored by the patient automatically.

METHODS

Patient portal secure messages from the Memorial Sloan Kettering Cancer Center were retrieved and manually annotated as a predicted unregistered proxy (ie, not written by the patient) or a presumed patient. After randomly splitting the annotated messages into training and test sets in a 70:30 ratio, a bag-of-words approach was used to extract features and then a Least Absolute Shrinkage and Selection Operator (LASSO) model was trained and used for classification.

RESULTS

Portal secure messages (n = 2,000) were randomly selected from unique patient accounts and manually annotated. We excluded 335 messages from the data set as the annotators could not determine if they were written by a patient or proxy. Using the remaining 1,665 messages, a LASSO model was developed that achieved an area under the curve of 0.932 and an area under the precision recall curve of 0.748. The sensitivity and specificity related to classifying true-positive cases (predicted unregistered proxy-authored messages) and true negatives (presumed patient-authored messages) were 0.681 and 0.960, respectively.

CONCLUSION

Our work demonstrates the feasibility of using unstructured, heterogenous patient portal secure messages to determine portal secure message authorship. Identifying patient authorship in real time can improve patient portal account security and can be used to improve the quality of the information extracted from the patient portal, such as patient-reported outcomes.

Chinese Americans' Use of Patient Portal Systems: Scoping Review

BACKGROUND

Electronic patient portals are increasingly used in health care systems as communication and information-sharing tools and show promise in addressing health care access, quality, and outcomes. However, limited research exists on portal use patterns and practices among diverse patient populations, resulting in the lack of culturally and contextually tailored portal systems for these patients.

OBJECTIVE

This study aimed to summarize existing evidence on the access and use patterns, barriers, and facilitators of patient portals among Chinese Americans, who represent a growing patient population in the United States with unique health care and health technology needs.

METHODS

The authors conducted a literature search using the PRISMA Protocol for Scoping Reviews (Preferred Reporting Items for Systematic Reviews and Meta-Analyses-ScR) for extracting articles published in major databases (MEDLINE, Embase, and PsycINFO) on patient portals and Chinese Americans. Authors independently reviewed the papers during initial screening and full-text review. The studies were analyzed and coded for the study method type, sample population, and main outcomes of interest.

RESULTS

In total, 17 articles were selected for inclusion in the review. The included articles were heterogenous and varied in their study aims, methodologies, sample populations, and outcomes. Major findings identified from the articles include variable patterns of portal access and use among Chinese Americans compared to other racial or ethnic groups, with limited evidence on the specific barriers and facilitators for this group; a preference for cross-sectional quantitative tools such as patient surveys and electronic health record-based data over qualitative or other methodologies; and a pattern of aggregating Chinese American-related data into a larger Asian or Asian American designation.

CONCLUSIONS

There is limited research evaluating the use patterns, experiences, and needs of Chinese Americans who access and use patient portal systems. Existing research is heterogeneous, largely cross-sectional, and does not disaggregate Chinese Americans from larger Asian demographics. Future research should be devoted to the specific portal use patterns, preferences, and needs of Chinese Americans to help ensure contextually appropriate and acceptable design and implementation of these digital health tools.

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.

Predicting Patients' Intention to Use a Personal Health Record Using an Adapted Unified Theory of Acceptance and Use of Technology Model: Secondary Data Analysis

Background

With the rise in the use of information and communication technologies in health care, patients have been encouraged to use eHealth tools such as personal health records (PHRs) for better health and well-being services. PHRs support patient-centered care and patient engagement. To support the achievement of the Kingdom of Saudi Arabia’s Vision 2030 ambitions, the National Transformation program provides a framework to use PHRs in meeting the 3-fold aim for health care—increased access, reduced cost, and improved quality of care—and to provide patient- and person-centered care. However, there has been limited research on PHR uptake within the country.

Objective

Using the Unified Theory of Acceptance and Use of Technology (UTAUT) as the theoretical framework, this study aims at identifying predictors of patient intention to utilize the Ministry of National Guard-Health Affairs PHR (MNGHA Care) app.

Methods

Using secondary data from a cross-sectional survey, data measuring the intention to use the MNGHA Care app, along with its predictors, were collected from among adults (n=324) visiting Ministry of National Guard-Health Affairs facilities in Riyadh, Jeddah, Dammam, Madinah, Al Ahsa, and Qassim. The relationship of predictors (main theory constructs) and moderators (age, gender, and experience with health apps) with the dependent variable (intention to use MNGHA Care) was tested using hierarchical multiple regression.

Results

Of the eligible population, a total of 261 adult patients were included in the analysis. They had a mean age of 35.07 (SD 9.61) years, 50.6 % were male (n=132), 45.2% had university-level education (n=118), and 53.3% had at least 1 chronic medical condition (n=139). The model explained 48.9% of the variance in behavioral intention to use the PHR (P=.38). Performance expectancy, effort expectancy, and positive attitude were significantly associated with behavioral intention to use the PHR (P<.05). Prior experience with health apps moderated the relationship between social influence and behavioral intention to use the PHR (P=.04).

Conclusions

This study contributes to the existing literature on PHR adoption broadly as well as in the context of the Kingdom of Saudi Arabia. Understanding which factors are associated with patient adoption of PHRs can guide future development and support the country’s aim of transforming the health care system. Similar to previous studies on PHR adoption, performance expectancy, effort expectancy, and positive attitude are important factors, and practical consideration should be given to support these areas.

Interventions to increase patient portal use in vulnerable populations: a systematic review

BACKGROUND

More than 100 studies document disparities in patient portal use among vulnerable populations. Developing and testing strategies to reduce disparities in use is essential to ensure portals benefit all populations.

OBJECTIVE

To systematically review the impact of interventions designed to: (1) increase portal use or predictors of use in vulnerable patient populations, or (2) reduce disparities in use.

MATERIALS AND METHODS

A librarian searched Ovid MEDLINE, EMBASE, CINAHL, and Cochrane Reviews for studies published before September 1, 2018. Two reviewers independently selected English-language research articles that evaluated any interventions designed to impact an eligible outcome. One reviewer extracted data and categorized interventions, then another assessed accuracy. Two reviewers independently assessed risk of bias.

RESULTS

Out of 18 included studies, 15 (83%) assessed an intervention's impact on portal use, 7 (39%) on predictors of use, and 1 (6%) on disparities in use. Most interventions studied focused on the individual (13 out of 26, 50%), as opposed to facilitating conditions, such as the tool, task, environment, or organization (SEIPS model). Twelve studies (67%) reported a statistically significant increase in portal use or predictors of use, or reduced disparities. Five studies (28%) had high or unclear risk of bias.

CONCLUSION

Individually focused interventions have the most evidence for increasing portal use in vulnerable populations. Interventions affecting other system elements (tool, task, environment, organization) have not been sufficiently studied to draw conclusions. Given the well-established evidence for disparities in use and the limited research on effective interventions, research should move beyond identifying disparities to systematically addressing them at multiple levels.

Designing an IT Ecosystem for Pregnancy Care Management Based on Pervasive Technologies

Pregnancy care is a topic of interest for both academia and practitioners. Novel pervasive technologies and applications, such as mobile technologies, wearables and IoT, open a wide corpus of possibilities for fostering pregnancy care management, and reducing risks and problems, improving communication among stakeholders and society development. This article introduces a model of a pregnancy care IT ecosystem based on the integration of various services in a semantically enriched e-health ecosystem. As proof of concept, both the web and mobile applications that aim to help pregnant women and gynaecologists were designed and employed in a real environment. An evaluation of the developed ecosystem was performed on a sample of 500 pregnant women and 100 doctors. After pilot usage, a survey was used to collect the data from participants, and assess the acceptance of the developed system. Results show that quality, usability and usefulness are on a high level, and that both pregnant women and doctors are ready for more extensive use of the system. In addition, research findings imply that employing pervasive technologies could bring significant benefits to all the parties in pregnancy care systems.

I am ready to see you now, Doctor! A mixed-method study of the Let's Discuss Health website implementation in Primary Care

Background

Let's Discuss Health (LDH) is a website that encourages patients to prepare their health‐care encounters by providing communication training, review of topics and questions that are important to them.

Objective

To describe LDH implementation during primary care (PC) visits for chronic illnesses.

Methods

Design: Descriptive mixed‐method study. Setting: 6 PC clinics. Participants: 156 patients and 51 health‐care providers (HCP). Intervention: LDH website implementation. Outcome Measures: Perceived quality and usefulness of LDH; perceived quality of HCP‐patient communication; patient activation; LDH integration in routine PC practices and barriers to its use.

Results

Patients reported a positive perception of the website in that it helped them to adopt an active role in the encounters; recall their visit agenda and reduce encounter‐related stress; feel more confident to ask questions, feel more motivated to prepare their future medical visits and improve their chronic illness management. However, a certain disconnect emerged between HCP and patient perceptions as to the value of LDH in promoting a sense of partnership and collaboration. The main barriers to the use of LDH are HCP lack of interest, limited access to technology, lack of time and language barriers.

Conclusion

Our findings indicate that it is advantageous for patients to prepare their medical encounters. However, the study needs to be replicated in other medical environments using larger and more diverse samples.

Patient and Public Contribution

Patient partners were involved in the conduct of this study.

Beyond Known Barriers-Assessing Physician Perspectives and Attitudes Toward Introducing Open Health Records in Germany: Qualitative Study

Background

Giving patients access to their medical records (ie, open health records) can support doctor-patient communication and patient-centered care and can improve quality of care, patients’ health literacy, self-care, and treatment adherence. In Germany, patients are entitled by law to have access to their medical records. However, in practice doing so remains an exception in Germany. So far, research has been focused on organizational implementation barriers. Little is known about physicians’ attitudes and perspectives toward opening records in German primary care.

Objective

This qualitative study aims to provide a better understanding of physicians’ attitudes toward opening records in primary care in Germany. To expand the knowledge base that future implementation programs could draw from, this study focuses on professional self-conception as an influencing factor regarding the approval for open health records. Perspectives of practicing primary care physicians and advanced medical students were explored.

Methods

Data were collected through semistructured guide-based interviews with general practitioners (GPs) and advanced medical students. Participants were asked to share their perspectives on open health records in German general practices, as well as perceived implications, their expectations for future medical records, and the conditions for a potential implementation. Data were pseudonymized, audiotaped, and transcribed verbatim. Themes and subthemes were identified through thematic analysis.

Results

Barriers and potential advantages were reported by 7 GPs and 7 medical students (N=14). The following barriers were identified: (1) data security, (2) increased workload, (3) costs, (4) the patients’ limited capabilities, and (5) the physicians’ concerns. The following advantages were reported: (1) patient education and empowerment, (2) positive impact on the practice, and (3) improved quality of care. GPs’ professional self-conception influenced their approval for open records: GPs considered their aspiration for professional autonomy and freedom from external control to be threatened and their knowledge-based support of patients to be obstructed by open records. Medical students emphasized the chance to achieve shared decision making through open records and expected the implementation to be realistic in the near future. GPs were more hesitant and voiced a strong resistance toward sharing notes on perceptions that go beyond clinical data. Reliable technical conditions, the participants’ consent, and a joint development of the implementation project to meet the GPs’ interests were requested.

Conclusions

Open health record concepts can be seen as a chance to increase transparency in health care. For a potential future implementation in Germany, thorough consideration regarding the compatibility of GPs’ professional values would be warranted. However, the medical students’ positive attitude provides an optimistic perspective. Further research and a broad support from decision makers would be crucial to establish open records in Germany.

Making the Case for a P2P Personal Health Record

Improved health care services can benefit from a more seamless exchange of medical information between patients and health care providers. This exchange is especially important considering the increasing trends in mobility, comorbidity and outbreaks. However, current Electronic Health Records (EHR) tend to be institution-centric, often leaving the medical information of the patient fragmented and more importantly inaccessible to the patient for sharing with other health providers in a timely manner. Nearly a decade ago, several client–server models for personal health records (PHR) were proposed. The aim of these previous PHRs was to address data fragmentation issues. However, these models were not widely adopted by patients. This paper discusses the need for a new PHR model that can enhance the patient experience by making medical services more accessible. The aims of the proposed model are to (1) help patients maintain a complete lifelong health record, (2) facilitate timely communication and data sharing with health care providers from multiple institutions and (3) promote integration with advanced third-party services (e.g., risk prediction for chronic diseases) that require access to the patient’s health data. The proposed model is based on a Peer-to-Peer (P2P) network as opposed to the client–server architecture of the previous PHR models. This architecture consists of a central index server that manages the network and acts as a mediator, a peer client for patients and providers that allows them to manage health records and connect to the network, and a service client that enables third-party providers to offer services to the patients. This distributed architecture is essential since it promotes ownership of the health record by the patient instead of the health care institution. Moreover, it allows the patient to subscribe to an extended range of personalized e-health services.

Adoption of a Personal Health Record in the Digital Age: Cross-Sectional Study

BACKGROUND

As health care organizations strive to improve health care access, quality, and costs, they have implemented patient-facing eHealth technologies such as personal health records to better engage patients in the management of their health. In the Kingdom of Saudi Arabia, eHealth is also growing in accordance with Vision 2030 and its National Transformation Program framework, creating a roadmap for increased quality and efficiency of the health care system and supporting the goal of patient-centered care.

OBJECTIVE

The aim of this study was to investigate the adoption of the personal health record of the Ministry of National Guard Health Affairs (MNGHA Care).

METHODS

A cross-sectional survey was conducted in adults visiting outpatient clinics in hospitals at the Ministry of National Guard Health Affairs hospitals in Riyadh, Jeddah, Dammam, Madinah, and Al Ahsa, and primary health care clinics in Riyadh and Qassim. The main outcome measure was self-reported use of MNGHA Care.

RESULTS

In the sample of 546 adult patients, 383 (70.1%) reported being users of MNGHA Care. MNGHA Care users were more likely to be younger (P<.001), high school or university educated (P<.001), employed (P<.001), have a chronic condition (P=.046), use the internet to search for health-related information (P<.001), and use health apps on their mobile phones (P<.001).

CONCLUSIONS

The results of this study show that there is substantial interest for the use of MNGHA Care personal health record with 70% of participants self-reporting use. To confirm these findings, objective data from the portal usage logs are needed. Maximizing the potential of MNGHA Care supports patient engagement and is aligned with the national eHealth initiative to encourage the use of technology for high-quality, accessible patient-centered care. Future research should include health care provider perspectives, incorporate objective data, employ a mixed-methods approach, and use a theoretical framework.

Sociodemographic Differences and Factors Affecting Patient Portal Utilization

BACKGROUND

The primary function of the patient portal is to give patients greater access to their personal health information. Granting patients electronic access allows them to make well-informed health care decisions.

OBJECTIVE

This study aimed to identify sociodemographic differences in patient portal use and examine factors affecting patient portal utilization following the final stage of the Meaningful Use program which aimed to promote the use of certified electronic health record (EHR) technology.

RESEARCH DESIGN

Survey data from Health Information National Trends Survey (HINTS) 5, cycles 1, 2, and 3 were analyzed. The sample included 8291 completed surveys. Multivariable logistic regression on a selected response for each surveyed question was used to assess the racial and ethnic difference after controlling for age, sex, income, and education.

SUBJECTS

Subjects included English and Spanish speaking adults in the USA.

MEASURES

Measures included assessment of patient portal use, patient portal access, understanding health information, usefulness of health records, and privacy and security.

RESULTS

After adjusting for age, sex, income, and education, there was a significant association between race/ethnicity and patient portal non-users responding, "no need to use online medical record" as the reason for not using the patient portal (P = 0.005). Among the portal users, there were significant associations between race/ethnicity and health care provider maintaining an EHR (P = 0.006), being offered access to their portal (P < 0.001), understanding health information in the portal (P = 0.004), finding the portal useful for health monitoring (P < 0.001), reporting concern about unauthorized access (P = 0.017), and keeping information from health care providers (P = 0.012).

CONCLUSIONS

Race/ethnicity affects perceptions on the need for the patient portal, being offered access to a portal, and the reasons to access information online. Understanding the factors affecting patient portal use can inform future strategies aimed at increasing adoption.

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.

The Use of Mobile Personal Health Records for Hemoglobin A1c Regulation in Patients With Diabetes: Retrospective Observational Study

BACKGROUND

The effectiveness of personal health records (PHRs) in diabetes management has already been verified in several clinical trials; however, evidence of their effectiveness in real-world scenarios is also necessary. To provide solid real-world evidence, an analysis that is more accurate than the analyses solely based on patient-generated health data should be conducted.

OBJECTIVE

This study aimed to conduct a more accurate analysis of the effectiveness of using PHRs within electronic medical records (EMRs). The results of this study will provide precise real-world evidence of PHRs as a feasible diabetes management tool.

METHODS

We collected log data of the sugar function in the My Chart in My Hand version 2.0 (MCMH 2.0) app from Asan Medical Center (AMC), Seoul, Republic of Korea, between December 2015 and April 2018. The EMR data of MCMH 2.0 users from AMC were collected and integrated with the PHR data. We classified users according to whether they were continuous app users. We analyzed and compared their characteristics, patterns of hemoglobin A_1c (HbA_1c) levels, and the proportion of successful HbA_1c control. The following confounders were adjusted for HbA_1c pattern analysis and HbA_1c regulation proportion comparison: age, sex, first HbA_1c measurement, diabetes complications severity index score, sugar function data generation weeks, HbA_1c measurement weeks before MCMH 2.0 start, and generated sugar function data count.

RESULTS

The total number of MCMH 2.0 users was 64,932, with 7453 users having appropriate PHRs and diabetes criteria. The number of continuous and noncontinuous users was 133 and 7320, respectively. Compared with noncontinuous users, continuous users were younger (P<.001) and had a higher male proportion (P<.001). Furthermore, continuous users had more frequent HbA_1c measurements (P=.007), shorter HbA_1c measurement days (P=.04), and a shorter period between the first HbA_1c measurement and MCMH 2.0 start (P<.001). Diabetes severity-related factors were not statistically significantly different between the two groups. Continuous users had a higher decrease in HbA_1c (P=.02) and a higher proportion of regulation of HbA_1c levels to the target level (P=.01). After adjusting the confounders, continuous users had more decline in HbA_1c levels than noncontinuous users (P=.047). Of the users who had a first HbA_1c measurement higher than 6.5% (111 continuous users and 5716 noncontinuous users), continuous users had better regulation of HbA_1c levels with regard to the target level, 6.5%, which was statistically significant (P=.04).

CONCLUSIONS

By integrating and analyzing patient- and clinically generated data, we demonstrated that the continuous use of PHRs improved diabetes management outcomes. In addition, the HbA_1c reduction pattern was prominent in the PHR continuous user group. Although the continued use of PHRs has proven to be effective in managing diabetes, further evaluation of its effectiveness for various diseases and a study on PHR adherence are also required.

Towards an Adoption Framework for Patient Access to Electronic Health Records: Systematic Literature Mapping Study

Background

Patient access to electronic health records (EHRs) is associated with increased patient engagement and health care quality outcomes. However, the adoption of patient portals and personal health records (PHRs) that facilitate this access is impeded by barriers. The Clinical Adoption Framework (CAF) has been developed to analyze EHR adoption, but this framework does not consider the patient as an end-user.

Objective

We aim to extend the scope of the CAF to patient access to EHRs, develop guidance documentation for the application of the CAF, and assess the interrater reliability.

Methods

We systematically reviewed existing systematic reviews on patients' access to EHRs and PHRs. Results of each review were mapped to one of the 43 CAF categories. Categories were iteratively adapted when needed. We measured the interrater reliability with Cohen’s unweighted kappa and statistics regarding the agreement among reviewers on mapping quotes of the reviews to different CAF categories.

Results

We further defined the framework’s inclusion and exclusion criteria for 33 of the 43 CAF categories and achieved a moderate agreement among the raters, which varied between categories.

Conclusions

In the reviews, categories about people, organization, system quality, system use, and the net benefits of system use were addressed more often than those about international and regional information and communication technology infrastructures, standards, politics, incentive programs, and social trends. Categories that were addressed less might have been underdefined in this study. The guidance documentation we developed can be applied to systematic literature reviews and implementation studies, patient and informal caregiver access to EHRs, and the adoption of PHRs.

Consumer preference to utilise a mobile health app: A stated preference experiment

BACKGROUND

One prominent barrier faced by healthcare consumers when accessing health services is a common requirement to complete repetitive, inefficient paper-based documentation at multiple registration sites. Digital innovation has a potential role to reduce the burden in this area, through the collection and sharing of data between healthcare providers. While there is growing evidence for digital innovations to potentially improve the effectiveness and efficiency of health systems, there is less information on the willingness of healthcare consumers to embrace and utilise technology to provide data.

AIM

The study aims to improve understanding of consumers' preference for utilising a digital health administration mobile app.

METHODS

The online study used a stated preference experiment design to explore aspects of consumers' preference for a mobile health administration app and its impact on the likelihood of using the app. The survey was answered by a representative sample (by age and gender) of Australian adults, and sociodemographic factors were also recorded for analysis. Each participant answered eight choice sets in which a hypothetical app (defined by a set of dimensions and levels) was presented and the respondent was asked if they would be willing to provide data using that app. Analysis was conducted using bivariate logistic regression.

RESULTS

For the average respondent, the two most important dimensions were the time it took to register on the app and the electronic governance arrangements around their personal information. Willingness to use any app was found to differ based on respondent characteristics: people with higher education, and women, were relatively more willing to utilise the mobile health app.

CONCLUSION

This study investigated consumers' willingness to utilise a digital health administration mobile app. The identification of key characteristics of more acceptable apps provide valuable insight and recommendations for developers of similar digital health administration technologies. This would increase the likelihood of achieving successful acceptance and utilisation by consumers. The results from this study provide evidence-based recommendations for future research and policy development, planning and implementation of digital health administration mobile applications in Australia.

Digitalizing Health Services by Implementing a Personal Electronic Health Record in Germany: Qualitative Analysis of Fundamental Prerequisites From the Perspective of Selected Experts

Background

The implementation of a personal electronic health record (PHR) is a central objective of digitalization policies in the German health care system. Corresponding legislation was passed with the 2015 Act for Secure Digital Communication and Applications in the Health Sector (eHealth Act). However, compared with other European countries, Germany still lags behind concerning the implementation of a PHR.

Objective

In order to explore potential barriers and facilitators for the adoption of a PHR in routine health care in Germany, this paper aims to identify policies, structures, and practices of the German health care system that influence the uptake and use of a PHR.

Methods

A total of 33 semistructured interviews were conducted with a purposive sample of experts: 23 interviews with different health care professionals and 10 interviews with key actors of the German health care system who were telematics, eHealth, and information technology experts (eHealth experts). The interviews were transcribed verbatim and subjected to a content analysis.

Results

From the expert perspective, a PHR was basically considered desirable and unavoidable. At the same time, a number of challenges for implementation in Germany have been outlined. Three crucial themes emerged: (1) documentation standards: prevailing processes of the analog bureaucratic paper world, (2) interoperability: the plurality of actors and electronic systems, and (3) political structure: the lack of clear political regulations and political incentive structures.

Conclusions

With regard to the implementation of a PHR, an important precondition of a successful digitalization will be the precedent reform of the system to be digitized. Whether the recently passed Act for Faster Appointments and Better Care will be a step in the right direction remains to be seen.

Experiences of adult patients with chronic non-communicable disease using electronic personal health records for self-management: a qualitative systematic review protocol

OBJECTIVE

The objective of the systematic review is to explore adult patients' experiences using electronic personal health records (e-PHRs) for chronic non-communicable disease self-management.

INTRODUCTION

Self-management is a key component of chronic disease management. One of the strategies to support self-management in patients with chronic disease is the use of e-PHRs. Electronic personal health records offer patients the opportunity to actively engage with their own health information, promote continuity of care and collaboration through disease tracking, and provide patients and providers with an ongoing connection. To adopt e-PHRs and maximize any benefits for chronic disease management, they should align with patients' values and preferences.

INCLUSION CRITERIA

The review will include qualitative studies that explore the experiences of adult patients (aged 18 years and over) with a chronic non-communicable disease who have used e-PHR for the self-management of their condition. This review will consider studies conducted in any setting or country.

METHODS

The systematic review will be conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence, with meta-aggregation as the method of synthesis. Published studies will be searched in CINAHL, PubMed, PsycINFO, Embase and Scopus. Gray literature will also be considered. Critical appraisal and data extraction will be conducted using the appropriate JBI tools. Extracted data will be aggregated and analyzed to produce a set of synthesized findings that can be used to develop evidence-informed recommendations for the use of e-PHRs in chronic disease self-management.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019133301.

Digital Inclusion & Health Communication: A Rapid Review of Literature

Information and communication technologies can be a valuable tool for enhancing health communication. However, not everyone is utilising the wide suite of digital opportunities. This disparity has the potential to exacerbate existing social and health inequalities, particularly among vulnerable groups such as those who are in poor health and the elderly. This review aimed to systematically identify the common barriers to, and facilitators of, digital inclusion. A comprehensive database search yielded 969 citations. Following screening, seven systematic reviews and three non-systematic reviews were identified. Collectively, the reviews found that physical access continues to be a barrier to digital inclusion. However, provision of access alone is insufficient, as digital ability and attitude were also potential barriers. Social support, direct user experience and collaborative learning/design were identified as key strategies to improve inclusion. These review findings provide guidance for health communication practitioners in designing and implementing effective programmes in the digital environment.

What are the important design features of personal health records to improve medication adherence for patients with long-term conditions? A systematic literature review

OBJECTIVES

This systematic literature review aims to identify important design features of the electronic personal health record (PHR) that may improve medication adherence in the adult population with long-term conditions.

DATA SOURCES

PubMed (including MEDLINE), CINAHL, Science Direct (including EMBASE), BioMed Central, ACM digital, Emerald Insight, Google Scholar and Research Gate.

METHODS

Studies that were published between 1 January 2002 and 31 May 2018 in English were included if the participants were adults, with at least one long-term condition, were able to self-administer their medication and were treated in primary care settings. The quality of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system and the risk of bias was appraised using the Cochrane risk of bias tool.

RESULTS

From a total of 27 studies that matched the inclusion criteria, 12 were excluded due to low quality of evidence, 10 were rated moderate and 5 were rated high quality. All the included studies had low sample size and limited follow-up duration. Thirteen of the included studies found that the use of a PHR has increased medication adherence. The identified design features are reminders, education, personalisation and tailoring, feedback and alerts, gamification, medication management, medical appointment management, diary and self-monitoring, health condition management, set goals, patient's blog and tethered. It was impossible to draw conclusions as to which feature is important to what group of patients and why. The most frequently identified conditions were HIV and diabetes. This review did not identify any papers with negative results. It was not possible to numerically aggregate the PHR effect due to high heterogeneity of the medication adherence measurement, study type, participants and PHRs used.

CONCLUSION

Although we found recurrent evidence that PHRs can improve medication adherence, there is little evidence to date to indicate which design features facilitate this process.

PROSPERO REGISTRATION NUMBER

CRD42017060542.

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.

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.

Determinants and outcomes of patient access to medical records: Systematic review of systematic reviews

BACKGROUND

Patient access to electronic health records (EHRs) is associated with several determinants and outcomes, which are interrelated. However, individual studies and the reviews summarizing them have only addressed particular aspects, such as policy, usability or health outcomes of adoption. Therefore, no comprehensive overview exists. Additionally, reviews used different theoretical frameworks, which makes results difficult to compare.

OBJECTIVE

We aimed to systematically review recent systematic reviews on determinants and outcomes of patient access to EHRs to create a comprehensive overview and inform policy-makers and EHR implementers about the available literature, and to identify knowledge gaps in the literature reviews.

METHODS

We searched MEDLINE, EMBASE and PsycINFO for systematic reviews on patient portals, personal health records, and patient access to records that addressed determinants and outcomes of adoption. We synthesized the results from these reviews into the Clinical Adoption Framework (CAF), by mapping quotes from the reviews to categories and dimensions of the CAF, starting with the most recent ones until saturation of the CAF had been reached. The risk of bias in the reviews was assessed using the AMSTAR2 checklist.

RESULTS

We included nineteen reviews from 8871 records that were retrieved until February 19^th, 2018. The reviews had a median of 4 (IQR: 4-4) critical flaws according to the AMSTAR2 checklist. The reviews contained a total of 1054 quotes that were mapped to the CAF. All reviews reported on the dimension 'People' that can affect adoption (e.g. personal characteristics such as age) and the dimension 'HIS use' (health information system use). Most reviews reported the dimensions 'Organisation', 'Implementation', HIS 'System quality', and outcomes of HIS use. However, gaps in knowledge might exist on macro-level determinants and outcomes, such as healthcare standards, funding, and incentives, because few reviews addressed these aspects.

CONCLUSIONS

No review covered all aspects of the CAF and there was a large variety in aspects that were addressed, but all dimensions of the CAF were addressed by at least two reviews. Although reviews had critical flaws according to the AMSTAR2 checklist, almost half of the reviews did use methods to assess bias in primary studies. Implementers can use the synthesized results from this study as a reference for implementation and development when taking quality restrictions into account. Researchers should address the risk of bias in primary studies in future reviews and use a framework such as CAF to make results more comparable and reusable.

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.

Sociodemographic Factors Influencing the Use of eHealth in People with Chronic Diseases

Alongside the growing number of older persons, the prevalence of chronic diseases is increasing, leading to higher pressure on health care services. eHealth is considered a solution for better and more efficient health care. However, not every patient is able to use eHealth, for several reasons. This study aims to provide an overview of: (1) sociodemographic factors that influence the use of eHealth; and (2) suggest directions for interventions that will improve the use of eHealth in patients with chronic disease. A structured literature review of PubMed, ScienceDirect, Association for Computing Machinery Digital Library (ACMDL), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) was conducted using four sets of keywords: "chronic disease", "eHealth", "factors", and "suggested interventions". Qualitative, quantitative, and mixed-method studies were included. Four researchers each assessed quality and extracted data. Twenty-two out of 1639 articles were included. Higher age and lower income, lower education, living alone, and living in rural areas were found to be associated with lower eHealth use. Ethnicity revealed mixed outcomes. Suggested solutions were personalized support, social support, use of different types of Internet devices to deliver eHealth, and involvement of patients in the development of eHealth interventions. It is concluded that eHealth is least used by persons who need it most. Tailored delivery of eHealth is recommended.

Technology Access, Technical Assistance, and Disparities in Inpatient Portal Use

BACKGROUND

Disadvantaged populations, including minorities and the elderly, use patient portals less often than relatively more advantaged populations. Limited access to and experience with technology contribute to these disparities. Free access to devices, the Internet, and technical assistance may eliminate disparities in portal use.

OBJECTIVE

To examine predictors of frequent versus infrequent portal use among hospitalized patients who received free access to an iPad, the Internet, and technical assistance.

MATERIALS AND METHODS

This subgroup analysis includes 146 intervention-arm participants from a pragmatic randomized controlled trial of an inpatient portal. The participants received free access to an iPad and inpatient portal while hospitalized on medical and surgical cardiac units, together with hands-on help using them. We used logistic regression to identify characteristics predictive of frequent use.

RESULTS

More technology experience (adjusted odds ratio [OR] = 5.39, p = 0.049), less severe illness (adjusted OR = 2.07, p = 0.077), and private insurance (adjusted OR = 2.25, p = 0.043) predicted frequent use, with a predictive performance (area under the curve) of 65.6%. No significant differences in age, gender, race, ethnicity, level of education, employment status, or patient activation existed between the frequent and infrequent users in bivariate analyses. Significantly more frequent users noticed medical errors during their hospital stay.

DISCUSSION AND CONCLUSION

Portal use was not associated with several sociodemographic characteristics previously found to limit use in the inpatient setting. However, limited technology experience and high illness severity were still barriers to frequent use. Future work should explore additional strategies, such as enrolling health care proxies and improving usability, to reduce potential disparities in portal use.

BAQALC: Blockchain Applied Lossless Efficient Transmission of DNA Sequencing Data for Next Generation Medical Informatics

Due to the development of high-throughput DNA sequencing technology, genome-sequencing costs have been significantly reduced, which has led to a number of revolutionary advances in the genetics industry. However, the problem is that compared to the decrease in time and cost needed for DNA sequencing, the management of such large volumes of data is still an issue. Therefore, this research proposes Blockchain Applied FASTQ and FASTA Lossless Compression (BAQALC), a lossless compression algorithm that allows for the efficient transmission and storage of the immense amounts of DNA sequence data that are being generated by Next Generation Sequencing (NGS). Also, security and reliability issues exist in public sequence databases. For methods, compression ratio comparisons were determined for genetic biomarkers corresponding to the five diseases with the highest mortality rates according to the World Health Organization. The results showed an average compression ratio of approximately 12 for all the genetic datasets used. BAQALC performed especially well for lung cancer genetic markers, with a compression ratio of 17.02. BAQALC performed not only comparatively higher than widely used compression algorithms, but also higher than algorithms described in previously published research. The proposed solution is envisioned to contribute to providing an efficient and secure transmission and storage platform for next-generation medical informatics based on smart devices for both researchers and healthcare users.

Utilizing a Prototype Patient-Controlled Electronic Health Record in Germany: Qualitative Analysis of User-Reported Perceptions and Perspectives

Background

Personal electronic health records (PHR) are considered instrumental in improving health care quality and efficiency, enhancing communication between all parties involved and strengthening the patient’s role. Technical architectures, data privacy, and applicability issues have been discussed for many years. Nevertheless, nationwide implementation of a PHR is still pending in Germany despite legal regulations provided by the eHealth Act passed in 2015. Within the information technology for patient-oriented care project funded by the Federal Ministry of Education and Research (2012-2017), a Web-based personal electronic health record prototype (PEPA) was developed enabling patient-controlled information exchange across different care settings. Gastrointestinal cancer patients and general practitioners utilized PEPA during a 3-month trial period. Both patients and physicians authorized by them could view PEPA content online and upload or download files.

Objective

This paper aims to outline findings of the posttrial qualitative study carried out to evaluate user-reported experiences, perceptions, and perspectives, focusing on their interpretation of PEPA beyond technical usability and views on a future nationwide implementation.

Methods

Data were collected through semistructured guide-based interviews with 11 patients and 3 physicians (N=14). Participants were asked to share experiences, views of perceived implications, and perspectives towards nationwide implementation. Further data were generated through free-text fields in a subsequent study-specific patient questionnaire and researcher’s notes. Data were pseudonymized, audiotaped, and transcribed verbatim. Content analysis was performed through the Framework Analysis approach. All qualitative data were systemized by using MAXQDA Analytics PRO 12 (Rel.12.3.1). Additionally, participant characteristics were analyzed descriptively using IBM SPSS Statistics Version 24.

Results

Users interpreted PEPA as a central medium containing digital chronological health-related documentation that simplifies information sharing across care settings. While patients consider the implementation of PEPA in Germany in the near future, physicians are more hesitant. Both groups believe in PEPA’s concept, but share awareness of concerns about data privacy and older or impaired people’s abilities to manage online records. Patients perceive benefits for involvement in treatment processes and continuity of care but worry about financing and the implementation of functionally reduced versions. Physicians consider integration into primary systems critical for interoperability but anticipate technical challenges, as well as resistance from older patients and colleagues. They omit clear positioning regarding PEPA’s potential incremental value for health care organizations or the provider-patient relationship.

Conclusions

Digitalization in German health care will continue to bring change, both organizational and in the physician-patient relationship. Patients endorse and expect a nationwide PEPA implementation, anticipating various benefits. Decision makers and providers need to contribute to closing modernization gaps by committing to new concepts and by invigorating transformed roles.