Adult patient access to electronic health records

Electronic health record and primary care physician self-reported quality of care: a multilevel study in China

BACKGROUND

Health information technology is one of the building blocks of a high-performing health system. However, the evidence regarding the influence of an electronic health record (EHR) on the quality of care remains mixed, especially in low- and middle-income countries.

OBJECTIVE

This study examines the association between greater EHR functionality and primary care physician self-reported quality of care.

METHODS

A total of 224 primary care physicians from 38 community health centres (CHCs) in four large Chinese cities participated in a cross-sectional survey to assess CHC care quality. Each CHC director scored their CHC's EHR functionality on the availability of ten typical features covering health information, data, results management, patient access, and clinical decision support. Data analysis utilised hierarchical linear modelling.

RESULTS

The availability of five EHR features was positively associated with physician self-reported clinical quality: share records online with providers outside the practice (β = 0.276, p = 0.04), access records online by the patient (β = 0.325, p = 0.04), alert provider of potential prescription problems (β = 0.353, p = 0.04), send the patient reminders for care (β = 0.419, p = 0.003), and list patients by diagnosis or health risk (β = 0.282, p = 0.04). However, no association was found between specific features availability or total features score and physician self-reported preventive quality.

CONCLUSIONS

This study provides evidence that the availability of EHR systems, and specific features of these systems, was positively associated with physician self-reported quality of care in these 38 CHCs. Future longitudinal studies focused on standardised quality metrics, and designed to control known confounding variables, will further inform quality improvement efforts in primary care.

CHIME-GP trial of online education for prescribing, pathology and imaging ordering in general practice - how did it bring about behaviour change?

BACKGROUND

There is a need for scalable clinician education in rational medication prescribing and rational ordering of pathology and imaging to help improve patient safety and enable more efficient utilisation of healthcare resources. Our wider study evaluated the effectiveness of a multifaceted education intervention for general practitioners (GPs) in rational prescribing and ordering of pathology and imaging tests, in the context of Australia's online patient-controlled health record system, My Health Record (MHR), and found evidence for measurable behaviour change in pathology ordering among participants who completed the educational activities. This current study explored the mechanisms of behaviour change brought about by the intervention, with a view to informing the development of similar interventions in the future.

METHODS

This mixed methods investigation used self-reported questionnaires at baseline and post-education on MHR use and rational prescribing and test ordering. These were analysed using multi-level ordinal logistic regression models. Semi-structured interviews pre- and post-intervention were also conducted and were analysed thematically using the COM-B framework.

RESULTS

Of the 106 GPs recruited into the study, 60 completed baseline and 37 completed post-education questionnaires. Nineteen participants were interviewed at baseline and completion. Analysis of questionnaires demonstrated a significant increase in confidence using MHR and in self-reported frequency of MHR use, post-education compared with baseline. There were also similar improvements in confidence across the cohort pre-post education in deprescribing, frequency of review of pathology ordering regimens and evidence-based imaging. The qualitative findings showed an increase in GPs' perceived capability with, and the use of MHR, at post-education compared with baseline. Participants saw the education as an opportunity for learning, for reinforcing what they already knew, and for motivating change of behaviour in increasing their utilisation of MHR, and ordering fewer unnecessary tests and prescriptions.

CONCLUSIONS

Our education intervention appeared to provide its effects through providing opportunity, increasing capability and enhancing motivation to increase MHR knowledge and usage, as well as rational prescribing and test ordering behaviour. There were overlapping effects of skills acquisition and confidence across intervention arms, which may have contributed to wider changes in behaviour than the specific topic area addressed in the education.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12620000010998) (09/01/2020).

The unfulfilled promises of electronic health records

We provide a brief update on the current evidence on electronic health records' benefits, risks, and potential harms through a rapid narrative review. Many of the promised benefits of electronic health records have not yet been realised. Electronic health records are often not user-friendly. To enhance their potential, electronic health record platforms should be continuously evaluated and enhanced by carefully considering feedback from all stakeholders.

Blood test result communication in primary care: mixed-methods systematic review protocol

BACKGROUND

After testing, ensuring test results are communicated and actioned is important for patient safety, with failure or delay in diagnosis the most common cause of malpractice claims in primary care worldwide. Identifying interventions to improve test communication from the decision to test through to sharing of results has important implications for patient safety, GP workload, and patient engagement.

AIM

To assess the factors around communication of blood test results between primary care providers (for example GPs, nurses, reception staff) and their patients and carers.

DESIGN & SETTING

A mixed methods systematic review including primary studies involving communication of blood test results in primary care.

METHOD

The review will use a segregated convergent synthesis method. Qualitative information will be synthesised using a meta-aggregative approach, and quantitative data will be meta-analysed or synthesised if pooling of studies is appropriate and data are available. If not, data will be presented in tabular and descriptive summary form.

CONCLUSION

This review has the potential to provide conclusions about blood test result communication interventions and factors important to stakeholders, including barriers and facilitators to improved communication.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Paving the Way for Electronic Patient-Centered Measurement in Team-Based Primary Care: Integrated Knowledge Translation Approach

Background

Patient-centered measurement (PCM) aims to improve the overall quality of care through the collection and sharing of patient values, outcomes, and perspectives. However, the use of PCM in care team decisions remains limited. Integrated knowledge translation (IKT) offers a collaborative, adaptive approach to explore best practices for incorporating PCM into primary care practices by involving knowledge users, including patients and providers, in the exploratory process.

Objective

This study aims to test the feasibility of using patient-generated data in team-based care; describe the use of these data for team-based mental health care; and summarize patient and provider care experiences with PCM.

Methods

We conducted a multi-method exploratory study in a rural team-based primary care clinic using IKT to co-design, implement, and evaluate the use of PCM in team-based mental health care. Care pathways, workflows, and quality improvement activities were adjusted iteratively to improve integration efforts. Patient and provider experiences were evaluated using individual interviews relating to the use of PCM and patient portals in practice. All meeting notes, interview summaries, and emails were analyzed to create a narrative evaluation.

Results

During co-design, a care workflow was developed to incorporate electronically collected patient-generated data from the patient portal into the electronic medical record, and customized educational tools and resources were added. During implementation, care pathways and patient workflows for PCM were developed. Patients found portal use easy, educational, and validating, but data entries were not used during care visits. Providers saw the portal as extra work, and the lack of portal and electronic medical record integration was a major barrier. The IKT approach was invaluable for addressing workflow changes and understanding the ongoing barriers to PCM use and quality improvement.

Conclusions

Although the culture toward using PCM is changing, the use of PCM during care has not been successful. Patients felt validated and supported through portal use and could be empowered to bring these data to their visits. Training, modeling, and adaptable PCM methods are required before PCM can be integrated into routine care.

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.

Sharing Clinical Notes and Electronic Health Records With People Affected by Mental Health Conditions: Scoping Review

BACKGROUND

Electronic health records (EHRs) are increasingly implemented internationally, whereas digital sharing of EHRs with service users (SUs) is a relatively new practice. Studies of patient-accessible EHRs (PAEHRs)-often referred to as open notes-have revealed promising results within general medicine settings. However, studies carried out in mental health care (MHC) settings highlight several ethical and practical challenges that require further exploration.

OBJECTIVE

This scoping review aims to map available evidence on PAEHRs in MHC. We seek to relate findings with research from other health contexts, to compare different stakeholders' perspectives, expectations, actual experiences with PAEHRs, and identify potential research gaps.

METHODS

A systematic scoping review was performed using 6 electronic databases. Studies that focused on the digital sharing of clinical notes or EHRs with people affected by mental health conditions up to September 2021 were included. The Mixed Methods Appraisal Tool was used to assess the quality of the studies. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Extension for Scoping Reviews guided narrative synthesis and reporting of findings.

RESULTS

Of the 1034 papers screened, 31 were included in this review. The studies used mostly qualitative methods or surveys and were predominantly published after 2018 in the United States. PAEHRs were examined in outpatient (n=29) and inpatient settings (n=11), and a third of all research was conducted in Veterans Affairs Mental Health. Narrative synthesis allowed the integration of findings according to the different stakeholders. First, SUs reported mainly positive experiences with PAEHRs, such as increased trust in their clinician, health literacy, and empowerment. Negative experiences were related to inaccurate notes, disrespectful language use, or uncovering of undiscussed diagnoses. Second, for health care professionals, concerns outweigh the benefits of sharing EHRs, including an increased clinical burden owing to more documentation efforts and possible harm triggered by reading the notes. Third, care partners gained a better understanding of their family members' mental problems and were able to better support them when they had access to their EHR. Finally, policy stakeholders and experts addressed ethical challenges and recommended the development of guidelines and trainings to better prepare both clinicians and SUs on how to write and read notes.

CONCLUSIONS

PAEHRs in MHC may strengthen user involvement, patients' autonomy, and shift medical treatment to a coproduced process. Acceptance issues among health care professionals align with the findings from general health settings. However, the corpus of evidence on digital sharing of EHRs with people affected by mental health conditions is limited. Above all, further research is needed to examine the clinical effectiveness, efficiency, and implementation of this sociotechnical intervention.

Oncology Patients' Experiences With Novel Electronic Patient Portals to Support Care and Treatment: Qualitative Study With Early Users and Nonusers of Portals in Alberta, Canada

Background

With the current proliferation of clinical information technologies internationally, patient portals are increasingly being adopted in health care. Research, conducted mostly in the United States, shows that oncology patients have a keen interest in portals to gain access to and track comprehensive personal health information. In Canada, patient portals are relatively new and research into their use and effects is currently emerging. There is a need to understand oncology patients’ experiences of using eHealth tools and to ground these experiences in local sociopolitical contexts of technology implementation, while seeking to devise strategies to enhance portal benefits.

Objective

The purpose of this study was to explore the experiences of oncology patients and their family caregivers when using electronic patient portals to support their health care needs. We focused on how Alberta’s unique, 2-portal context shapes experiences of early portal adopters and nonadopters, in anticipation of a province-wide rollout of a clinical information system in oncology facilities.

Methods

This qualitative descriptive study employed individual semistructured interviews and demographic surveys with 11 participants. Interviews were audio-recorded and transcribed verbatim. Data were analyzed thematically. The study was approved by the University of Alberta Human Research Ethics Board.

Results

Participants currently living with nonactive cancer discussed an online patient portal as one among many tools (including the internet, phone, videoconferencing, print-out reports) available to make sense of their diagnosis and treatment, maintain connections with health care providers, and engage with information. In the Fall of 2020, most participants had access to 1 of 2 of Alberta’s patient portals and identified ways in which this portal was supportive (or not) of their ongoing health care needs. Four major themes, reflecting the participants’ broader concerns within which the portal use was occurring, were generated from the data: (1) experiencing doubt and the desire for transparency; (2) seeking to become an informed and active member of the health care team; (3) encountering complexity; and (4) emphasizing the importance of the patient–provider relationship.

Conclusions

Although people diagnosed with cancer and their family caregivers considered an online patient portal as beneficial, they identified several areas that limit how portals support their oncology care. Providers of health care portals are invited to recognize these limitations and work toward addressing them.

Improvement and Evaluation of the TOPCOP Taxonomy of Patient Portals: Taxonomy-Evaluation-Delphi Approach (TED)

Background

Patient portals have been introduced in many countries over the last 10 years, but many health information managers still feel they have too little knowledge of patient portals. A taxonomy can help them to better compare and select portals. This has led us to develop the TOPCOP taxonomy for classifying and comparing patient portals. However, the taxonomy has not been evaluated by users.

Objective

This study aimed to evaluate the taxonomy’s usefulness to support health information managers in comparing, classifying, defining a requirement profile for, and selecting patient portals and to improve the taxonomy where needed.

Methods

We used a modified Delphi approach. We sampled a heterogeneous panel of 13 health information managers from 3 countries using the criterion sampling strategy. We conducted 4 anonymous survey rounds with qualitative and quantitative questions. In round 1, the panelists assessed the appropriateness of each dimension, and we collected new ideas to improve the dimensions. In rounds 2 and 3, the panelists iteratively evaluated the taxonomy that was revised based on round 1. In round 4, the panelists assessed the need for a taxonomy and the appropriateness of patient engagement as a distinguishing concept. Then, they compared 2 real portals with the final taxonomy and evaluated its usefulness for comparing portals, creating an initial requirement profile, and selecting patient portals. To determine group consensus, we applied the RAND/UCLA Appropriateness Method.

Results

The final taxonomy consists of 25 dimensions with 65 characteristics. Five new dimensions were added to the original taxonomy, with 8 characteristics added to already existing dimensions. Group consensus was achieved on the need for such a taxonomy to compare portals, on patient engagement as an appropriate distinguishing concept, and on the comprehensibility of the taxonomy’s form. Further, consensus was achieved on the taxonomy’s usefulness for classifying and comparing portals, assisting users in better understanding portals, creating a requirement profile, and selecting portals. This allowed us to test the usefulness of the final taxonomy with the intended users.

Conclusions

The TOPCOP taxonomy aims to support health information managers in comparing and selecting patient portals. By providing a standardized terminology to describe various aspects of patient portals independent of clinical setting or country, the taxonomy will also be useful for advancing research and evaluation of patient portals.

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

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

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

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

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

The State of Evidence in Patient Portals: Umbrella Review

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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