Helping clinicians and patients navigate electronic patient portals: ethical and legal principles

Guiding Principles for Adolescent Web-Based Portal Access Policies: Interviews With Informatics Administrators

BACKGROUND

Web-based patient portals are tools that could support adolescents in managing their health and developing autonomy. However, informatics administrators must navigate competing interests when developing portal access policies for adolescents and their parents.

OBJECTIVE

We aimed to assess the perspectives of informatics administrators on guiding principles for the development of web-based health care portal access policies in adolescent health care.

METHODS

We interviewed informatics administrators from US hospitals with ≥50 dedicated pediatric beds. We performed a thematic analysis of guiding principles for developing and implementing adolescent portal access policies.

RESULTS

We interviewed 65 informatics leaders who represented 63 pediatric hospitals, 58 health care systems, 29 states, and 14,379 pediatric hospital beds. Participants described 9 guiding principles related to three overarching themes: (1) balancing confidentiality and other care needs, (2) balancing simplicity and granularity, and (3) collaborating and advocating. Participants described the central importance of prioritizing the health and safety of the adolescent while also complying with state and federal laws. However, there were differing beliefs about how to prioritize health and safety and what role parents should play in supporting the adolescent's health care. Participants also identified areas where clinicians and institutions can advocate for adolescents, especially with electronic health record vendors and legislators.

CONCLUSIONS

Informatics administrators provided guiding principles for adolescent portal access policies that aimed to balance the competing needs of adolescent confidentiality and the usefulness of the portal. Portal access policies must prioritize the adolescent's health and safety while complying with state and federal laws. However, institutions must determine how to best enact these principles. Institutions and clinicians should strive for consensus on principles to strengthen advocacy efforts with institutional leadership, electronic health record vendors, and lawmakers.

Pre-implementation perceptions of clinicians regarding a patient portal in inpatient addictions settings: A qualitative descriptive study

BACKGROUND

Patient portals have been implemented in many organizations to support patient engagement and empowerment. However, their use in inpatient mental health and addiction settings is relatively new and has not been extensively studied. To address this gap, this study explored clinician perspectives of implementing a patient portal in inpatient addiction settings.

METHODS

The study followed qualitative descriptive methodology and used the Consolidated Framework for Implementation Research (CFIR) to guide the research. Interviews were conducted with clinicians working in an inpatient addictions service at a large mental health and addictions teaching hospital in Toronto, Canada. Data analysis was performed using directed content analysis and the CFIR domains.

RESULTS

Twelve clinicians participated in semi-structured interviews. Participants included prescribers (such as physicians and nurse practitioners), registered nurses, allied health clinicians, and leadership. Participants had positive attitudes toward the patient portal, believing it would benefit patients and support consistency in healthcare. However, they also expressed reservations about its relevance and value during short inpatient admissions. Clinicians perceived the patient portal as compatible with existing workflows, enhancing patient empowerment and facilitating access to medical documentation. Concerns were raised about potential negative impacts on therapeutic rapport, particularly if patients disagreed with or were upset by the contents of their notes. Adaptations to the portal, such as improving documentation templates and providing detailed medication information, were suggested. Participants also highlighted advantages of the portal, including secure communication and access to laboratory results.

CONCLUSIONS

Clinicians generally had positive attitudes toward implementing a patient portal. However, concerns about maintaining therapeutic rapport and the relevance of information to patients were identified, and adaptations were suggested to improve the utility of a portal in the context of short inpatient stays. The findings provide insights into clinician perspectives and can inform the implementation of patient portals in inpatient addiction settings.

The Impact of an Electronic Portal on Patient Encounters in Primary Care: Interrupted Time-Series Analysis

BACKGROUND

Electronic patient portals are online applications that allow patients access to their own health information, a form of asynchronous virtual care. The long-term impact of portals on the use of traditional primary care services is unclear, but it is an important question at this juncture, when portals are being incorporated into many primary care practices.

OBJECTIVE

We sought to investigate how an electronic patient portal affected the use of traditional, synchronous primary care services over a much longer time period than any existing studies and to assess the impact of portal messaging on clinicians' workload.

METHODS

We conducted a propensity-score-matched, open-cohort, interrupted time-series evaluation of a primary care portal from its implementation in 2010. We extracted information from the electronic medical record regarding age, sex, education, income, family health team enrollment, diagnoses at index date, and number of medications prescribed in the previous year. We also extracted the annual number of encounters for up to 8 years before and after the index date and provider time spent on secure messaging through the portal.

RESULTS

A total of 7247 eligible portal patients and 7647 eligible potential controls were identified, with 3696 patients matched one to one. We found that portal registration was associated with an increase in the number of certain traditional encounters over the time period surrounding portal registration. Following the index year, there was a significant jump in annual number of visits to physicians in the portal arm (0.42 more visits/year vs control, P<.001) but not for visits to nurse practitioners and physician assistants. The annual number of calls to the practice triage nurses also showed a greater increase in the portal arm compared to the control arm after the index year (an additional 0.10 calls, P=.006). The average provider time spent on portal-related work was 5.7 minutes per patient per year.

CONCLUSIONS

We found that portal registration was associated with a subsequent increase in the number of some traditional encounters and an increase in clerical workload for providers. Portals have enormous potential to truly engage patients as partners in their own health care, but their impact on use of traditional health care services and clerical burden must also be considered when they are incorporated into primary care.

Implementation Strategies to Improve Engagement With a Multi-Institutional Patient Portal: Multimethod Study

Background

Comprehensive multi-institutional patient portals that provide patients with web-based access to their data from across the health system have been shown to improve the provision of patient-centered and integrated care. However, several factors hinder the implementation of these portals. Although barriers and facilitators to patient portal adoption are well documented, there is a dearth of evidence examining how to effectively implement multi-institutional patient portals that transcend traditional boundaries and disparate systems.

Objective

This study aims to explore how the implementation approach of a multi-institutional patient portal impacted the adoption and use of the technology and to identify the lessons learned to guide the implementation of similar patient portal models.

Methods

This multimethod study included an analysis of quantitative and qualitative data collected during an evaluation of the multi-institutional MyChart patient portal that was deployed in Southwestern Ontario, Canada. Descriptive statistics were performed to understand the use patterns during the first 15 months of implementation (between August 2018 and October 2019). In addition, 42 qualitative semistructured interviews were conducted with 18 administrative stakeholders, 16 patients, 7 health care providers, and 1 informal caregiver to understand how the implementation approach influenced user experiences and to identify strategies for improvement. Qualitative data were analyzed using an inductive thematic analysis approach.

Results

Between August 2018 and October 2019, 15,271 registration emails were sent, with 67.01% (10,233/15,271) registered for an account across 38 health care sites. The median number of patients registered per site was 19, with considerable variation (range 1-2114). Of the total number of sites, 55% (21/38) had ≤30 registered patients, whereas only 2 sites had over 1000 registered patients. Interview participants perceived that the patient experience of the portal would have been improved by enhancing the data comprehensiveness of the technology. They also attributed the lack of enrollment to the absence of a broad rollout and marketing strategy across sites. Participants emphasized that provider engagement, change management support, and senior leadership endorsement were central to fostering uptake. Finally, many stated that regional alignment and policy support should have been sought to streamline implementation efforts across participating sites.

Conclusions

Without proper management and planning, multi-institutional portals can suffer from minimal adoption. Data comprehensiveness is the foundational component of these portals and requires aligned policies and a key base of technology infrastructure across all participating sites. It is important to look beyond the category of the technology (ie, patient portal) and consider its functionality (eg, data aggregation, appointment scheduling, messaging) to ensure that it aligns with the underlying strategic priorities of the deployment. It is also critical to establish a clear vision and ensure buy-ins from organizational leadership and health care providers to support a cultural shift that will enable a meaningful and widespread engagement.

Patients, clinicians and open notes: information blocking as a case of epistemic injustice

In many countries, including patients are legally entitled to request copies of their clinical notes. However, this process remains time-consuming and burdensome, and it remains unclear how much of the medical record must be made available. Online access to notes offers a way to overcome these challenges and in around 10 countries worldwide, via secure web-based portals, many patients are now able to read at least some of the narrative reports written by clinicians ('open notes'). However, even in countries that have implemented the practice many clinicians have resisted the idea remaining doubtful of the value of opening notes, and anticipating patients will be confused or anxious by what they read. Against this scepticism, a growing body of qualitative and quantitative research reveals that patients derive multiple benefits from reading their notes. We address the contrasting perceptions of this practice innovation, and claim that the divergent views of patients and clinicians can be explained as a case of epistemic injustice. Using a range of evidence, we argue that patients are vulnerable to (oftentimes, non-intentional) epistemic injustice. Nonetheless, we conclude that the marginalisation of patients' access to their health information exemplifies a form of epistemic exclusion, one with practical and ethical consequences including for patient safety.

Patient Access to Mental Health Notes: Motivating Evidence-Informed Ethical Guidelines

ABSTRACT

In the last decade, many health organizations have embarked on a revolution in clinical communication. Using electronic devices, patients can now gain rapid access to their online clinical records. Legally, patients in many countries already have the right to obtain copies of their health records; however, the practice known as "open notes" is different. Via secure online health portals, patients are now able to access their test results, lists of medications, and the very words that clinicians write about them. Open notes are growing with most patients in the Nordic countries already offered access to their full electronic record. From April 2021, a new federal ruling in the United States mandates-with few exemptions-that providers offer patients access to their online notes (Office of the National Coordinator for Health Information Technology, Department of Health and Human Services, Available at: https://www.govinfo.gov/content/pkg/FR-2019-03-04/pdf/2019-02224.pdf#page=99). Against these policy changes, only limited attention has been paid to the ethical question about whether patients with mental health conditions should access their notes, as mentioned in the articles by Strudwick, Yeung, and Gratzer (Front Psychiatry 10:917, 2019) and Blease, O'Neill, Walker, Hägglund, and Torous (Lancet Psychiatry 7:924-925, 2020). In this article, our goal is to motivate further inquiry into opening mental health notes to patients, particularly among persons with serious mental illness and those accessing psychological treatments. Using biomedical ethical principles to frame our discussion, we identify key empirical questions that must be pursued to inform ethical practice guidelines.

"Clearly they are in the circle of care, but . . .": A qualitative study exploring perceptions of personal health information sharing with community pharmacists in an integrated care model

Background

Ontario's Health Links approach to care is an integrated care model designed to optimize care for patients with complex needs. Currently, community pharmacists have no formalized role. This study aimed to explore stakeholders' perceptions about privacy and its impact on community pharmacists' involvement with integrated care models.

Methods

A qualitative study using semistructured telephone-based interviews was conducted. Participants worked in Ontario as pharmacists, providers in Health Links or team-based models or decision-makers in Health Links or health regions. Thematic analysis followed the Qualitative Analysis Guide of Leuven.

Results

Twenty-two participants were interviewed, and all but one commented on privacy or information sharing in integrating community pharmacists with integrated care models. The 4 themes identified were as follows: 1) what does the circle of care look like? 2) value of sharing information, 3) uncertainty of what information to share and 4) perceptions on how to share information.

Interpretation

The concerns surrounding privacy of personal health information and who is included in the circle of care represented an important barrier for integration. Enablers to mitigate privacy concerns included relationship building between community pharmacists, patients and other health care professionals and mutual access to information-sharing platforms such as electronic health records.

Conclusion

Providers' and decision-makers' perceptions about community pharmacists and privacy affect information sharing and are incongruent with Ontario's Personal Health Information Protection Act. Education is needed for health care professionals on legislation, especially as health systems move towards integrated care models to improve care. Can Pharm J (Ott) 2020;153:xx-xx.

Sharing clinical notes, and placebo and nocebo effects: Can documentation affect patient health?

This paper connects findings from the field of placebo studies with research into patients' interactions with their clinician's visit notes, housed in their electronic health records. We propose specific hypotheses about how features of clinicians' written notes might trigger mechanisms of placebo and nocebo effects to elicit positive or adverse health effects among patients. Bridging placebo studies with (a) survey data assaying patient and clinician experiences with portals and (b) randomized controlled trials provides preliminary support for our hypotheses. We conclude with actionable proposals for testing our understanding of the health effects of access to visit notes.