The Confounding Influence of Older Age in Statistical Models of Telehealth Utilization

Older age is a potentially confounding variable in models of telehealth utilization. We compared unified and stratified logistic regression models using data from the 2021 National Health Interview Survey. A total of 27,626 patients were identified, of whom 38.9% had utilized telehealth. Unified and stratified modeling showed a number of important differences in their quantitative estimates, especially for gender, Hispanic ethnicity, heart disease, COPD, food allergies, high cholesterol, weak or failing kidneys, liver conditions, difficulty with self-care, the use of mobility equipment, health problems that limit the ability to work, problems paying bills, and filling a recent prescription. Telehealth utilization odds ratios differ meaningfully between younger and older patients in stratified modeling. Traditional statistical adjustments in logistic regression may not sufficiently account for the confounding influence of older age in models of telehealth utilization. Stratified modeling by age may be more effective in obtaining clinical inferences

Performance Measures Based on How Adults With Cancer Feel and Function: Stakeholder Recommendations and Feasibility Testing in Six Cancer Centers

PURPOSE Patient-reported outcome measures (PROMs) that assess how patients feel and function have potential for evaluating quality of care. Stakeholder recommendations for PRO-based performance measures (PMs) were elicited, and feasibility testing was conducted at six cancer centers. METHODS Interviews were conducted with 124 stakeholders to determine priority symptoms and risk adjustment variables for PRO-PMs and perceived acceptability. Stakeholders included patients and advocates, caregivers, clinicians, administrators, and thought leaders. Feasibility testing was conducted in six cancer centers. Patients completed PROMs at home 5-15 days into a chemotherapy cycle. Feasibility was operationalized as $75$ 75% patient acceptability. RESULTS Stakeholder priority PRO-PMs for systemic therapy were GI symptoms (diarrhea, constipation, nausea, vomiting), depression/anxiety, pain, insomnia, fatigue, dyspnea, physical function, and neuropathy. Recommended risk adjusters included demographics, insurance type, cancer type, comorbidities, emetic risk, and difficulty paying bills. In feasibility testing, 653 patients enrolled (approximately 110 per site), and 607 (93%) completed PROMs, which indicated high feasibility for home collection. The majority of patients (470 of 607; 77%) completed PROMs without a reminder call, and 137 (23%) of 607 completed them after a reminder call. Most patients (72%) completed PROMs through web, 17% paper, or 2% interactive voice response (automated call that verbally asked patient questions). For acceptability, . 95% of patients found PROM items to be easy to understand and complete. CONCLUSION Clinicians, patients, and other stakeholders agree that PMs that are based on how patients feel and function would be an important addition to quality measurement. This study also shows that PRO-PMs can be feasibly captured at home during systemic therapy and are acceptable to patients. PRO-PMs may add value to the portfolio of PMs as oncology transitions from fee-for-service payment models to performance-based care that emphasizes outcome measures

Factors of quality of care and their association with smartphone based PHR adoption in South Korean hospitals

Background Healthcare organizations have begun to adopt personal health records (PHR) systems to engage patients, but little is known about factors associated with the adoption of PHR systems at an organizational level. The objective of this study is to investigate factors associated with healthcare organizations’ adoption of PHR systems in South Korea. Methods The units of analysis were hospitals with more than 100 beds. Study data of 313 hospitals were collected from May 1 to June 30, 2020. The PHR adoption status for each hospital was collected from PHR vendors and online searches. Adoption was then confirmed by downloading the hospital’s PHR app and the PHR app was examined to ascertain its available functions. One major outcome variable was PHR adoption status at hospital level. Data were analysed by logistic regressions using SAS 9.4 version. Results Out of 313 hospitals, 103 (32.9%) hospitals adopted PHR systems. The nurse-patient ratio was significantly associated with PHR adoption (OR 0.758; 0.624 to 0.920, p = 0.005). The number of health information management staff was associated with PHR adoption (OR 1.622; 1.228 to 2.141, p = 0.001). The number of CTs was positively associated with PHR adoption (OR 5.346; 1.962 to 14.568, p = 0.001). Among the hospital characteristics, the number of beds was significantly related with PHR adoption in the model of standard of nursing care (OR 1.003; 1.001 to 1.005, p < 0.001), HIM staff (OR 1.004; 1.002 to 1.006, p < 0.001), and technological infrastructure (OR 1.050; 1.003 to 1.006, p < 0.001). Conclusions One-third of study hospitals had adopted PHR systems. Standard of nursing care as well as information technology infrastructure in terms of human resources for health information management and advanced technologies were significantly associated with adoption of PHR systems. A favourable environment for adopting new technologies in general may be associated with the adoption and use of PHR systems.This study was supported for two years by a Pusan National University Research Grant

What do primary care staff think about patients accessing electronic health records? A focus group study

Background Patients have expressed a growing interest in having easy access to their personal health information, and internationally there has been increasing policy focus on patient and care records being more accessible. Limited research from the UK has qualitatively explored this topic from the primary care staff perspective. This study aimed to understand what primary care staff think about patients accessing electronic health records, highlighting errors in electronic health records, and providing feedback via online patient portals. Methods A focus group study involving 19 clinical and non-clinical primary care staff. Primary care practices were purposively sampled based on practice size and the percentage of patients using online services. Data were analysed inductively using reflexive thematic analysis. Results Three themes were generated: (1) Information – what, why and when? (2) Changing behaviours and protecting relationships, and (3) Secure access and safeguarding. The emotional considerations and consequences for staff and patients featured prominently in the data as an overarching theme. Conclusions Primary care staff described being invested and supportive of patients accessing their electronic health records, and acknowledged the numerous potential benefits for safety. Uncertainty around the parameters of access, the information available and what this might look like in the future, processes for patients highlighting errors in records, relational issues, security and safeguarding and equitable access, were key areas warranting examination in future research

Characterization and Representation of Patient Use of Virtual Health Technology in Primary Care

Purpose. Advances in virtual care technology have made healthcare more convenient and accessible. The goal of this study was to elucidate current patient portal behaviors by examining the pattern of time and service type use of patients, via data provided by access logs within electronic health records, to increase communication and care coordination through online healthcare portals. Methods. We conducted a retrospective study of patients in an academic healthcare center over a 5-year period using access log records in electronic health records (EHR). Dimensionality reduction analysis was applied to group portal functionalities into more interpretable and meaningful feature domains, followed by negative binomial regression analysis to evaluate how patient and practice characteristics affected the use of each feature domain. Results. Patient portal usage was categorized into four feature domains: messaging, health information management, billing/insurance, and resource/education. Individuals having more chronic conditions, lab tests or prescriptions generally had greater patient portal usage. However, patients who were male, elderly, in minority groups, or living in rural areas persistently had lower portal usage. Individuals on public insurance were also less likely than those on commercial insurance to use patient portals, though Medicare patients showed greater portal usage on health information management features and uninsured patients had greater usage on viewing resource/education features. Having Internet access only affected the use of messaging features, but not other feature. Conclusions. Efforts in enrolling patients in online portals does not guarantee patients using the portals to manage their health. While promoting the use of virtual health tools as part of patient-center care delivery model, primary care clinicians need to be aware of technological, socioeconomic, and cultural challenges faced by their patients

Factors that affect the use of electronic personal health records among patients: A systematic review

Background: Electronic personal health records (ePHRs) are web-based tools that enable patients to access parts of their medical records and other services. In spite of the potential benefits of using ePHRs, their adoption rates remain very low. The lack of use of ePHRs among patients leads to implementation failures of these systems. Many studies have been conducted to examine the factors that influence patients’ use of ePHRs, and they need to be synthesised in a meaningful way.ObjectiveThe current study aimed to systematically review the evidence regarding factors that influence patients’ use of ePHRs. Methods: The search included: 42 bibliographic databases (e.g. Medline, Embase, CINHAL, and PsycINFO), hand searching, checking reference lists of the included studies and relevant reviews, contacting experts, and searching two general web engines. Study selection, data extraction, and study quality assessment were carried out by two reviewers independently. The quality of studies was appraised using the Mixed Methods Appraisal Tool. The extracted data were synthesised narratively according to the outcome: intention to use, subjective measures of use, and objective measures of use. The identified factors were categorised into groups based on Or and Karsh’s conceptual framework. Results: Of 5225 citations retrieved, 97 studies were relevant to this review. These studies examined more than 150 different factors: 59 related to intention to use, 52 regarding subjectively-measured use, and 105 related to objectively-measured use. The current review was able to draw definitive conclusions regarding the effect of only 18 factors. Of these, only three factors have been investigated in connection with every outcome, which are: perceived usefulness, privacy and security concerns, and internet access. Conclusion: Of the numerous factors examined by the included studies, this review concluded the effect of 18 factors: 13 personal factors (e.g. gender, ethnicity, and income), four human-technology factors (e.g. perceived usefulness and ease of use), and one organisational factor (facilitating conditions). These factors should be taken into account by stakeholders for the successful implementation of these systems. For example, patients should be assured that the system is secure and no one can access their records without their permission in order to decrease their concerns about the privacy and security. Further, advertising campaigns should be carried out to increase patients’ awareness of the system. More studies are needed to conclude the effect of other factors. In addition, researchers should conduct more theory-based longitudinal studies for assessing factors affecting initial use and continuing use of ePHRs among patients

PATIENT PORTAL USE AND ITS ASSOCIATION WITH CLINICAL OUTCOMES IN PATIENTS WITH TYPE 2 DIABETES

Background: The rapid growth of type 2 diabetes mellitus (T2DM) in the United States presents significant challenges. Patient portals are promising tools that address the increasing number of individuals with T2DM and engage these people in the process of managing their chronic condition. Objectives: The purposes of this study were: 1) to describe the portal usage pattern by individuals with T2DM over the two-year study period; 2) to identify whether sociodemographic, socioeconomic, and clinical characteristics differ between portal users and non-users; and 3) to longitudinally examine the effect of portal use on glycemic control in patients with T2DM. Methods: This two-year retrospective, observational cohort study utilized data from the ambulatory electronic health records (EHR) of the University of Pittsburgh Medical Center (UPMC) Physician Services and its ancillary patient portal. The study included adults seen in an outpatient setting of UPMC between January 2015 and December 2016. We applied descriptive statistics to describe sample characteristics and portal usage patterns. Logistic regression was used to examine factors associated with portal use. A propensity score matching (PSM) technique was conducted to equate the portal user and non-user groups, and mixed modeling was performed to examine the effect of portal use on hemoglobin A1c (HbA1c) over time. Results: Nearly one-third of the individuals (n=12,615, 32.9%, 95% CI: [32.3%,33.3%]) with T2DM used the portals. An increased portal usage was observed before and after a physician visit, and on weekdays compared to weekends (p<0.001). In general, we found associations of age, race, income, and the number of chronic conditions with portal usage, and several other predictors modified these effects (ps<0.05). After PSM, both groups showed a non-linear decline of HbA1c over time (p<.001), and the portal users (n=4,924) demonstrated a greater decrease and better maintenance than the non-users (n=4,924, p<.001). Conclusions: Our findings highlight the promising effect of a patient portal on clinical glycemic control in persons with T2DM. Disparities in patient portals need to be addressed to bridge the existing gaps in diabetes outcomes. Future study should explore mechanisms through which the portal contributes to better clinical outcomes to guide evidence-based portal design and implementation

Rural Aging: The Geographic Reach of Service Access in Utah, Identifying Barriers and Solutions

This dissertation includes two studies of rural age-related services in the state of Utah. The first study combines geospatial, demographic data (number of people over 55) and age-related services (hospitals, hospice providers, nursing homes, senior centers, and Areas Agencies on Aging) at the county level and census-tract level to determine localized differences in proportional access to age-related services. Higher and lower proportions are then predicted by contextual factors including rural/urban gradient, economic industry, and broadband access. Results demonstrate that broadband access was significantly associated with higher access to age-related services, but being a retirement destination (increase in people over 65 in county from 2000-2010) was associated with lower spatial access to age-related services. The second study involved in-depth interviews with stakeholders from communities across Utah, and qualitative analysis to identify specific barriers to age-related service access in their communities. This approach generated knowledge about challenges to accessing services and stakeholder-supported starting points and solutions for overcoming some of the identified barriers to age-related services in these communities. Taken together, the spatial data and responses from persons living and serving older adults in rural communities complement an understanding of facilitators and barriers to service access, paired with solutions

Electronic Health Record (EHR) Data Quality and Type 2 Diabetes Mellitus Care

Indiana University-Purdue University Indianapolis (IUPUI)Due to frequent utilization, high costs, high prevalence, and negative health outcomes, the care of patients managing type 2 diabetes mellitus (T2DM) remains an important focus for providers, payers, and policymakers. The challenges of care delivery, including care fragmentation, reliance on patient self-management behaviors, adherence to care management plans, and frequent medical visits are well-documented in the literature. T2DM management produces numerous clinical data points in the electronic health record (EHR) including laboratory test values and self-reported behaviors. Recency or absence of these data may limit providers’ ability to make effective treatment decisions for care management. Increasingly, the context in which these data are being generated is changing. Specifically, telehealth usage is increasing. Adoption and use of telehealth for outpatient care is part of a broader trend to provide care at-a-distance, which was further accelerated by the COVID-19 pandemic. Despite unknown implications for patients managing T2DM, providers are increasingly using telehealth tools to complement traditional disease management programs and have adapted documentation practices for virtual care settings. Evidence suggests the quality of data documented during telehealth visits differs from that which is documented during traditional in-person visits. EHR data of differential quality could have cascading negative effects on patient healthcare outcomes. The purpose of this dissertation is to examine whether and to what extent levels of EHR data quality are associated with healthcare outcomes and if EHR data quality is improved by using health information technologies. This dissertation includes three studies: 1) a cross-sectional analysis that quantifies the extent to which EHR data are timely, complete, and uniform among patients managing T2DM with and without a history of telehealth use; 2) a panel analysis to examine associations between primary care laboratory test ages (timeliness) and subsequent inpatient hospitalizations and emergency department admissions; and 3) a panel analysis to examine associations between patient portal use and EHR data timeliness

‘The Going Digital Study’ – The implementation of electronic patient records in a paediatric tertiary hospital: Understanding the benefits and challenges for patients, parents and staff and the practical, ethical and legal implications

BACKGROUND: The Going Digital Study uniquely captured the experiences of all user groups before and after digital transformation of Great Ormond Street Hospital for Children (GOSH) whilst implementing an electronic patient record (EPR) system with a tethered patient portal in April 2019. This was critical and core to GOSH becoming a digital hospital, with benefits anticipated, yet challenges for all. AIM: To investigate the practical, ethical and legal considerations of implementing an EPR in a children’s tertiary hospital involving three stakeholder groups: children and young people (CYP), parents and staff. METHODS: A three phase, concurrent mixed methods, pre/post study design was utilised including both quantitative (survey) and qualitative (World Café workshops/interviews/focus group) data collection, analysis and synthesis. A systematic review of the literature was also conducted and was key to informing the examination of the experiences of users of an electronic patient record system in a children’s hospital setting and interpretation of the findings. RESULTS: Despite the challenges experienced by all stakeholders, including ethical and legal issues associated with CYP and parents accessing health data for the first time through the patient portal, meaningful portal access can be achieved from the age of 12 years of age. Families need support accessing health information via the portal. Clinicians need to have early conversations with parents about truth-telling and sharing diagnoses and/or prognoses, supporting families through the process of disclosure. Staff need prolonged support to balance clinical demands during implementation of and adjustment to the new clinical system, whilst continuing care provision and managing families’ expectations. CONCLUSION: Implementation and transition to an EPR system with a tethered patient portal is complex and takes time to embed. Setting realistic expectations and involving all stakeholders at all stages is paramount if benefits for all are to be fully realised. Managing this change process well, with prolonged engagement over time with all stakeholders, is essential if future utility is to be achieved. This requires an inclusive culture, in which the voice of all children and young people and parents is valued, and enabled through investment of appropriate resources, with equity of access a key priority