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

Background and Aims

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

Methods

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

Results

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

Conclusion

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

Continuing the quality improvement of an electronic personal health record and interactive website for people with diabetes in Scotland (My Diabetes My Way)

AIMS

eHealth applications have the potential to enable patients to take more control over managing their own health, helping to delay and prevent complications. My Diabetes My Way (MDMW) is an electronic personal health record/educational platform available to people with diabetes in Scotland. This study aims to assess user experience with respect to demographic subgroups, examine effectiveness of previous improvements made to the platform and inform its ongoing development.

METHODS

All active MDMW users (22,665) were invited to take part in a questionnaire combining Likert scale and free-response items relating to system utility. Likert responses were used to generate a 'utility score'. This was used in regression analyses to determine predictors of system utility scoring. Free-response answers were analysed thematically and themes were generated.

RESULTS

A total of 4713 (21%) MDMW users responded to the questionnaire. Most agreed that MDMW helps them to track changes over time, prepare for face-to-face consultations, remember information discussed in consultations and reduced the need to contact their general practitioner. Free-response answers showed that users valued earlier enhancements made to the site (e.g. linking Fitbit data), and highlighted areas needing further improvement. Evidence of the 'digital divide' was seen in respondent demographics, and some users mentioned 'lack of digital skills' as a barrier to engaging with the platform.

CONCLUSIONS

User experience of MDMW was positive. Users agreed with statements that MDMW facilitates diabetes self management. Several areas of potential improvement were identified, including linking more wearable device data, and assisting/directing users to gain the digital skills required to engage fully with MDMW.

Patterns in the Use of Heart Failure Telemonitoring: Post Hoc Analysis of the e-Vita Heart Failure Trial

BACKGROUND

Research on the use of home telemonitoring data and adherence to it can provide new insights into telemonitoring for the daily management of patients with heart failure (HF).

OBJECTIVE

We described the use of a telemonitoring platform-including remote patient monitoring of blood pressure, pulse, and weight-and the use of the electronic personal health record. Patient characteristics were assessed in both adherent and nonadherent patients to weight transmissions.

METHODS

We used the data of the e-Vita HF study, a 3-arm parallel randomized trial performed in stable patients with HF managed in outpatient clinics in the Netherlands. In this study, data were analyzed from the participants in the intervention arm (ie, e-Vita HF platform). Adherence to weight transmissions was defined as transmitting weight ≥3 times per week for at least 42 weeks during a year.

RESULTS

Data from 150 patients (mean age 67, SD 11 years; n=37, 25% female; n=123, 82% self-assessed New York Heart Association class I-II) were analyzed. One-year adherence to weight transmissions was 74% (n=111). Patients adherent to weight transmissions were less often hospitalized for HF in the 6 months before enrollment in the study compared to those who were nonadherent (n=9, 8% vs n=9, 23%; P=.02). The percentage of patients visiting the personal health record dropped steadily over time (n=140, 93% vs n=59, 39% at one year). With univariable analyses, there was no significant correlation between patient characteristics and adherence to weight transmissions.

CONCLUSIONS

Adherence to remote patient monitoring was high among stable patients with HF and best for weighing; however, adherence decreased over time. Clinical and demographic variables seem not related to adherence to transmitting weight.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01755988; https://clinicaltrials.gov/ct2/show/NCT01755988.

Electronic health records in Brazil: Prospects and technological challenges

Electronic Health Records (EHR) are critical tools for advancing digital health worldwide. In Brazil, EHR development must follow specific standards, laws, and guidelines that contribute to implementing beneficial resources for population health monitoring. This paper presents an audit of the main approaches used for EHR development in Brazil, thus highlighting prospects, challenges, and existing gaps in the field. We applied a systematic review protocol to search for articles published from 2011 to 2021 in seven databases (Science Direct, Web of Science, PubMed, Springer, IEEE Xplore, ACM Digital Library, and SciELO). Subsequently, we analyzed 14 articles that met the inclusion and quality criteria and answered our research questions. According to this analysis, 78.58% (11) of the articles state that interoperability between systems is essential for improving patient care. Moreover, many resources are being designed and deployed to achieve this communication between EHRs and other healthcare systems in the Brazilian landscape. Besides interoperability, the articles report other considerable elements: (i) the need for increased security with the deployment of permission resources for viewing patient data, (ii) the absence of accurate data for testing EHRs, and (iii) the relevance of defining a methodology for EHR development. Our review provides an overview of EHR development in Brazil and discusses current gaps, innovative approaches, and technological solutions that could potentially address the related challenges. Lastly, our study also addresses primary elements that could contribute to relevant components of EHR development in the context of Brazil's public health system. Systematic review registration: PROSPERO, identifier CRD42021233219, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021233219.

Meaningful Use of an Electronic Personal Health Record (ePHR) among Pediatric Cancer Survivors

Background and Objectivs: Survivors of pediatric and adolescent cancer are at an increased risk of chronic and debilitating health conditions and require life-long specialized care. Stand-alone electronic personal health records (ePHRs) may aid their self-management. This analysis characterizes young adult survivors and parents who meaningfully use an ePHR, Cancer SurvivorLink^TM, designed for survivors of pediatric and adolescent cancer.

METHODS

This was a retrospective observational study of patients seen at a pediatric survivor clinic for annual survivor care. Young adult survivors and/or parent proxies for survivors <18 years old who completed ePHR registration prior to their appointment or within 90 days were classified as registrants. Registrants who uploaded or downloaded a document and/or shared their record were classified as meaningful users.

RESULTS

Overall, 23.7% (148/624) of survivors/parents registered and 38% of registrants used SurvivorLink meaningfully. Young adult registrants who transferred to adult care during the study period were more likely to be meaningful users (aOR: 2.6 (95% CI: 1.1, 6.1)) and used the ePHR twice as frequently as those who continued to receive care in our institution's pediatric survivor clinic. Among survivors who continued to receive care at our institution, being a registrant was associated with having an annual follow-up visit (aOR: 2.6 (95% CI: 1.2, 5.8)).

CONCLUSIONS

While ePHRs may not be utilized by all survivors, SurvivorLink is a resource for a subset and may serve as an important bridge for patients who transfer their care. Using SurvivorLink was also associated with receiving recommended annual survivor care.

MyDiabetesMyWay: An Evolving National Data Driven Diabetes Self-Management Platform

MyDiabetesMyWay (MDMW) is an award-wining national electronic personal health record and self-management platform for diabetes patients in Scotland. This platform links multiple national institutional and patient-recorded data sources to provide a unique resource for patient care and self-management. This review considers the current evidence for online interventions in diabetes and discusses these in the context of current and ongoing developments for MDMW. Evaluation of MDMW through patient reported outcomes demonstrates a positive impact on self-management. User feedback has highlighted barriers to uptake and has guided platform evolution from an education resource website to an electronic personal health record now encompassing remote monitoring, communication tools and personalized education links. Challenges in delivering digital interventions for long-term conditions include integration of data between institutional and personal recorded sources to perform big data analytics and facilitating technology use in those with disabilities, low digital literacy, low socioeconomic status and in minority groups. The potential for technology supported health improvement is great, but awareness and adoption by health workers and patients remains a significant barrier.

Telemedicine for Gestational Diabetes Mellitus (TeleGDM): A Mixed-Method Study Protocol of Effects of a Web-Based GDM Support System on Health Service Utilization, Maternal and Fetal Outcomes, Costs, and User Experience

Background

Women with insulin-treated gestational diabetes mellitus (GDM) require close monitoring and support to manage their diabetes. Recent changes to the diagnostic criteria have implications for service provision stemming from increased prevalence, suggesting an increased burden on health services in the future. Telemedicine may augment usual care and mitigate service burdens without compromising clinical outcomes but evidence in GDM is limited.

Objective

The Telemedicine for Gestational Diabetes Mellitus (TeleGDM) trial aims to explore the use of telemedicine in supporting care and management of women with GDM treated with insulin.

Methods

The TeleGDM is a mixed-methods study comprising an exploratory randomized controlled trial (RCT) and a qualitative evaluation using semistructured interviews. It involves women with insulin-treated GDM who are up to 35 weeks gestation. Participating patients (n=100) are recruited face-to-face in outpatient GDM clinics at an outer metropolitan tertiary hospital with a culturally diverse catchment and a regional tertiary hospital. The second group of participants (n=8) comprises Credentialed Diabetes Educator Registered Nurses involved in routine care of the women with GDM at the participating clinics. The RCT involves use of a Web-based patient-controlled personal health record for GDM data sharing between patients and clinicians compared to usual care. Outcomes include service utilization, maternal and fetal outcomes (eg, glycemic control, 2nd and 3rd trimester fetal size, type of delivery, baby birth weight), diabetes self-efficacy, satisfaction, and costs. Semistructured interviews will be used to examine user experiences and acceptability of telemedicine.

Results

The trial recruitment is currently underway. Results are expected by the end of 2016 and will be reported in a follow-up paper.

Conclusions

Innovative use of technology in supporting usual care delivery in women with GDM may facilitate timely access to GDM monitoring data and mitigate care burdens without compromising maternal and fetal outcomes. The intervention may potentially reduce health service utilization.

Trial Registration

Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12614000934640; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366740 (Archived by WebCite® at http://www.webcitation.org/6jRiqzjSv).

Methodological Aspects of Focus Groups in Health Research: Results of Qualitative Interviews With Focus Group Moderators

Although focus groups are commonly used in health research to explore the perspectives of patients or health care professionals, few studies consider methodological aspects in this specific context. For this reason, we interviewed nine researchers who had conducted focus groups in the context of a project devoted to the development of an electronic personal health record. We performed qualitative content analysis on the interview data relating to recruitment, communication between the focus group participants, and appraisal of the focus group method. The interview data revealed aspects of the focus group method that are particularly relevant for health research and that should be considered in that context. They include, for example, the preferability of face-to-face recruitment, the necessity to allow participants in patient groups sufficient time to introduce themselves, and the use of methods such as participant-generated cards and prioritization.

A case study of stakeholder perceptions of patient held records: the Patients Know Best (PKB) solution

INTRODUCTION

Patients Know Best (PKB) provides a patient portal with integrated, patient-controlled digital care records. Patient-controlled personal health records facilitate coordinated management of chronic disease through improved communications among, and about, patients across professional and organisational boundaries. An NHS foundation trust hospital has used PKB to support self-management in patients with inflammatory bowel disease; this paper presents a case study of usage.

METHODS

The stakeholder empowered adoption model provided a framework for consulting variously placed stakeholders. Qualitative interviews with clinical stakeholders and a patient survey.

RESULTS

Clinicians reported PKB to have enabled a new way of managing stable patients, this facilitated clinical and cost effective use of specialist nurses; improved two-way communications, and more optimal use of outpatient appointments and consultant time. The portal also facilitated a single, rationalised pathway for stable patients, enabling access to information and pro-active support. For patients, the system was a source of support when unwell and facilitated improved communication with specialists. Three main barriers to adoption were identified; these related to concerns over security, risk averse attitudes of users and problems with data integration.

CONCLUSIONS

Patient-controlled personal health records offer significant potential in supporting self-management. Digital connection to healthcare can help patients to understand their condition better and access appropriate, timely clinical advice.

Patient Portals and Patient Engagement: A State of the Science Review

Background

Patient portals (ie, electronic personal health records tethered to institutional electronic health records) are recognized as a promising mechanism to support greater patient engagement, yet questions remain about how health care leaders, policy makers, and designers can encourage adoption of patient portals and what factors might contribute to sustained utilization.

Objective

The purposes of this state of the science review are to (1) present the definition, background, and how current literature addresses the encouragement and support of patient engagement through the patient portal, and (2) provide a summary of future directions for patient portal research and development to meaningfully impact patient engagement.

Methods

We reviewed literature from 2006 through 2014 in PubMed, Ovid Medline, and PsycInfo using the search terms “patient portal” OR “personal health record” OR “electronic personal health record”. Final inclusion criterion dictated that studies report on the patient experience and/or ways that patients may be supported to make competent health care decisions and act on those decisions using patient portal functionality.

Results

We found 120 studies that met the inclusion criteria. Based on the research questions, explicit and implicit aims of the studies, and related measures addressed, the studies were grouped into five major topics (patient adoption, provider endorsement, health literacy, usability, and utility). We discuss the findings and conclusions of studies that address the five topical areas.

Conclusions

Current research has demonstrated that patients’ interest and ability to use patient portals is strongly influenced by personal factors such age, ethnicity, education level, health literacy, health status, and role as a caregiver. Health care delivery factors, mainly provider endorsement and patient portal usability also contribute to patient’s ability to engage through and with the patient portal. Future directions of research should focus on identifying specific populations and contextual considerations that would benefit most from a greater degree of patient engagement through a patient portal. Ultimately, adoption by patients and endorsement by providers will come when existing patient portal features align with patients’ and providers’ information needs and functionality.

Improving medication management after a hospitalization with pharmacist home visits and electronic personal health records: an observational study

Background

Substantial opportunity exists to improve medication management in the period following a hospital discharge. The objective of this study was to assess and improve medication management during care transitions through pharmacist home visits and the use of an electronic personal health record (ePHR) system.

Methods

Recently discharged patients aged 50 years or older and having a chronic medical condition were offered the opportunity to meet with a pharmacist in the home setting to review medication instructions and receive a demonstration of an ePHR system. Patients agreeable to using the ePHR system were offered pharmacist support with setting up the ePHR system, having emphasis on documenting and reviewing medication regimens. Medication-related problems identified by the pharmacist during the visit were categorized according to ePHR use and by other characteristics.

Results

Thirty recently discharged patients with chronic disease were visited by a pharmacist over a 6-month period. The percentage of medication-related problems identified by the pharmacist was greater among those patients who agreed to use the ePHR system, as compared with patients whose visit did not include use of the ePHR (75% versus 40%, respectively; P=0.06). Differing types of medication-related problems were identified, including therapy duplications, lack of use of clinically important therapies, and patient nonadherence.

Conclusion

For some patients, the home setting can be a suitable venue for medication review and education after discharge from hospital. Assisting patients with setting up the ePHR system may enhance pharmacists’ ability to identify and resolve medication-related problems that may lead to rehospitalization.

Tables or bar graphs? Presenting test results in electronic medical records

BACKGROUND

Electronic personal health records offer a promising way to communicate medical test results to patients. We compared the usability of tables and horizontal bar graphs for presenting medical test results electronically.

METHODS

We conducted experiments with a convenience sample of 106 community-dwelling adults. In the first experiment, participants viewed either table or bar graph formats (between subjects) that presented medical test results with normal and abnormal findings. In a second experiment, participants viewed table and bar graph formats (within subjects) that presented test results with normal, borderline, and abnormal findings.

RESULTS

Participants required less viewing time when using bar graphs rather than tables. This overall difference was due to superior performance of bar graphs in vignettes with many test results. Bar graphs and tables performed equally well with regard to recall accuracy and understanding. In terms of ease of use, participants did not prefer bar graphs to tables when they viewed only one format. When participants viewed both formats, those with experience with bar graphs preferred bar graphs, and those with experience with tables found bar graphs equally easy to use. Preference for bar graphs was strongest when viewing tests with borderline results.

CONCLUSIONS

Compared to horizontal bar graphs, tables required more time and experience to achieve the same results, suggesting that tables can be a more burdensome format to use. The current practice of presenting medical test results in a tabular format merits reconsideration.

The association between personal health record use and diabetes quality measures

BACKGROUND

Electronic personal health records (PHRs) have the potential to empower patients in self-management of chronic diseases, which should lead to improved outcomes.

OBJECTIVE

To measure the association between use of an advanced electronic medical record-linked PHR and diabetes quality measures in adults with diabetes mellitus (DM).

DESIGN

Retrospective audit of PHR use and multivariable regression analyses.

PATIENTS

10,746 adults 18-75-years of age with DM seen at least twice at the office of their primary care physician at the Cleveland Clinic from July 2008 through June 2009.

MAIN MEASURES

PHR use was measured as number of use days. Diabetes quality measures were: hemoglobin A1c (HbA1c), LDL cholesterol, blood pressure, body mass index (BMI), HbA1c testing, ACEi/ARB use and/or microalbumin testing, pneumococcal vaccination, foot and dilated eye examination, and smoking status.

KEY RESULTS

Compared to non-users, PHR users were younger, had higher incomes and educational attainment, were more likely to identify as Caucasian, and had better unadjusted and adjusted diabetes quality measure profiles. Adjusted odds ratio of HbA1c testing was 2.06 (p < 0.01) and most recent HbA1c was 0.29% lower (p < 0.01). Among PHR users, increasing number of login days was generally not associated with more favorable diabetes quality measure profiles.

CONCLUSIONS

PHR use, but not intensity of use, was associated with improved diabetes quality measure profiles. It is likely that better diabetes profiles among PHR users is due to higher level of engagement with their health among those registered for the PHR rather than PHR use itself. PHR use was infrequent. To maximize value, next-generation PHRs must be designed to engage patients in everyday diabetes self-management.