Collaborative Documentation for Behavioral Healthcare Providers: An Emerging Practice

This article considers the practice of collaborative documentation (CD) for behavioral healthcare providers; the legislative, technological, and philosophical milieu in which it developed; the attributed benefits for providers and clients; and the peer-reviewed research supporting its use. Collaborative documentation has emerged following significant legislative and technological changes in healthcare delivery and shifts toward client-centered healthcare practices including more shared decision-making between clients and practitioners

The Factors That Impact Patient Portal Utilization

Spawned by legislative mandates, such as the American Recovery and Reinvestment Act of 2009’s Health Information Technology for Economic and Clinical Health Act, and individuals desiring to have more personal accountability for their health and healthcare, the introduction and use of electronic personal health information (ePHI) has grown substantially. Given that most ePHI is maintained within the healthcare delivery system, an information portal is required for individuals to have access to the ePHI. As a result, the legislation required the introduction and use of patient portals to grant such access. Despite substantial financial incentives and disincentives for healthcare organizations to provide and promote the use of patient portals, actual utilization of patient portals has fallen significantly short of expectations and desires. It has been posited that limited patient portal utilization may have been related to multiple factors, with no definitive set of factors empirically established as the root cause. While patient age and gender exhibit some relation to patient portal utilization, those factors are not able to be modified, thereby limiting any potential to change utilization. Therefore, there is an interest to identify other variables that can be modified to have an impact on patient portal utilization. The study sought to contribute to the body of knowledge concerning factors that impact the utilization of patient portals, specifically, how patient literacies, i.e., computer/Internet, health, and numeracy impact patient portal utilization. These literacies for 400 University of Maryland Medical System patients were assessed via self-administered surveys, with the results compared to their actual patient portal utilization. The goal was to identify related correlations between literacy scores and utilization, using the correlations to construct a portal use index capable of accurately predicting utilization based on these literacies. However, Kendall tau-b correlation coefficients indicated an absence of significant correlations between patient literacies and patient portal use

Patient Use of Electronic Prescription Refill and Secure Messaging and Its Association With Undetectable HIV Viral Load: A Retrospective Cohort Study

BACKGROUND: Electronic personal health records (PHRs) can support patient self-management of chronic conditions. Managing human immunodeficiency virus (HIV) viral load, through taking antiretroviral therapy (ART) is crucial to long term survival of persons with HIV. Many persons with HIV have difficulty adhering to their ART over long periods of time. PHRs contribute to chronic disease self-care and may help persons with HIV remain adherent to ART. Proportionally veterans with HIV are among the most active users of the US Department of Veterans Affairs (VA) PHR, called My HealtheVet. Little is known about whether the use of the PHR is associated with improved HIV outcomes in this population. OBJECTIVE: The objective of this study was to investigate whether there are associations between the use of PHR tools (electronic prescription refill and secure messaging [SM] with providers) and HIV viral load in US veterans. METHODS: We conducted a retrospective cohort study using data from the VA\u27s electronic health record (EHR) and the PHR. We identified veterans in VA care from 2009-2012 who had HIV and who used the PHR. We examined which ones had achieved the positive outcome of suppressed HIV viral load, and whether achievement of this outcome was associated with electronic prescription refill or SM. From 18,913 veterans with HIV, there were 3374 who both had a detectable viral load in 2009 and who had had a follow-up viral load test in 2012. To assess relationships between electronic prescription refill and viral control, and SM and viral control, we fit a series of multivariable generalized estimating equation models, accounting for clustering in VA facilities. We adjusted for patient demographic and clinical characteristics associated with portal use. In the initial models, the predictor variables were included in dichotomous format. Subsequently, to evaluate a potential dose-effect, the predictor variables were included as ordinal variables. RESULTS: Among our sample of 3374 veterans with HIV who received VA care from 2009-2012, those who had transitioned from detectable HIV viral load in 2009 to undetectable viral load in 2012 tended to be older (P=.004), more likely to be white (P\u3c.001), and less likely to have a substance use disorder, problem alcohol use, or psychosis (P=.006, P=.03, P=.004, respectively). There was a statistically significant positive association between use of electronic prescription refill and change in HIV viral load status from 2009-2012, from detectable to undetectable (OR 1.36, CI 1.11-1.66). There was a similar association between SM use and viral load status, but without achieving statistical significance (OR 1.28, CI 0.89-1.85). Analyses did not demonstrate a dose-response of prescription refill or SM use for change in viral load. CONCLUSIONS: PHR use, specifically use of electronic prescription refill, was associated with greater control of HIV. Additional studies are needed to understand the mechanisms by which this may be occurring

How Do Patients with Mental Health Diagnoses Use Online Patient Portals? An Observational Analysis from the Veterans Health Administration

Online patient portals may be effective for engaging patients with mental health conditions in their own health care. This retrospective database analysis reports patient portal use among Veterans with mental health diagnoses. Unadjusted and adjusted odds of portal feature use was calculated using logistic regressions. Having experienced military sexual trauma or having an anxiety disorder, post-traumatic stress disorder, or depression were associated with increased odds of portal use; bipolar, substance use, psychotic and adjustment disorders were associated with decreased odds. Future research should examine factors that influence portal use to understand diagnosis-level differences and improve engagement with such tools

The impact of digital patient portals on health outcomes, system efficiency, and patient attitudes: Updated systematic literature review

Background: Patient portals are becoming increasingly popular worldwide even though their impact on individual health and health system efficiency is still unclear. Objective: The aim of this systematic review was to summarize evidence on the impact of patient portals on health outcomes and health care efficiency, and to examine user characteristics, attitudes, and satisfaction. Methods: We searched the PubMed and Web of Science databases for articles published from January 1, 2013, to October 31, 2019. Eligible studies were primary studies reporting on the impact of patient portal adoption in relation to health outcomes, health care efficiency, and patient attitudes and satisfaction. We excluded studies where portals were not accessible for patients and pilot studies, with the exception of articles evaluating patient attitudes. Results: Overall, 3456 records were screened, and 47 articles were included. Among them, 11 studies addressed health outcomes reporting positive results, such as better monitoring of health status, improved patient-doctor interaction, and improved quality of care. Fifteen studies evaluated the impact of digital patient portals on the utilization of health services with mixed results. Patient characteristics were described in 32 studies, and it was reported that the utilization rate usually increases with age and female gender. Finally, 30 studies described attitudes and defined the main barriers (concerns about privacy and data security, and lack of time) and facilitators (access to clinical data and laboratory results) to the use of a portal. Conclusions: Evidence regarding health outcomes is generally favorable, and patient portals have the potential to enhance the doctor-patient relationship, improve health status awareness, and increase adherence to therapy. It is still unclear whether the use of patient portals improves health service utilization and efficiency

Patient Engagement to Improve Medication Safety in the Hospital

Purpose: There is a pressing need to enhance patient safety in the hospital environment. While there are many initiatives that focus on improving patient safety, few have studied engaging patients themselves to participate in patient safety efforts. This work was motived by the belief that patients can contribute valuable information to their care and when equipped with the right tools, can play a role in improving medication safety in the hospital. Methods: This research had three aims and used a mixed-methods approach to better understand the concept of engaging patients to improve medication safety. In order to gain insight into whether patients could beneficially contribute to the safety of their hospital care, my first aim was to understand current perspectives on the sharing of clinical information with patients while they were in the hospital. To accomplish this aim, I conducted surveys with clinicians and enrolled patients in a short field study in which they received full access to their clinical chart. In Aim 2, I conducted a study to establish that the Patient Activation Measure (PAM), a common measure of patient engagement in the outpatient setting, showed reliability and validity in the inpatient setting. Building on the knowledge from Aim 1 and using the PAM instrument from Aim 2, my third aim evaluated the impact of providing patients with access to a medication review tool while they were preparing to be admitted to the hospital. Aim 3 was achieved through a randomized controlled trial (RCT) involving 65 patients I recruited from the emergency department at Columbia University Medical Center. I also conducted a survey of admitting clinicians who had patients participate in the trial to identify the impact on clinician practices and to elicit feedback on their perceptions of the intervention. Results: My research findings suggest that increased patient information sharing in the inpatient setting is beneficial and desirable to patients, and generally acceptable to clinicians. The clinician survey from Aim 1 showed that most respondents were comfortable with the idea of providing patients with their clinical information. Some expressed reservations that patients might misunderstand information and become unnecessarily alarmed or offended. In the patient field study from Aim 1, patients reported perceiving the information they received as highly useful, even if they did not fully understand complex medical terms. My primary contribution in Aim 2 was to provide sound evidence that the Patient Activation Measure is a valid and reliable tool for use in the inpatient setting. Establishing the validity and reliability of the PAM instrument in inpatient setting was essential for conducting the RCT in Aim 3, and it will provide a foundation for future clinicians and research investigators to measure and understand hospital patients’ levels of engagement. The results from the RCT in Aim 3 did not support my primary hypothesis that clinicians who had patients participate in their medication review process using an informatics tool would make more changes to the home medication list than clinicians who had patients in the control group. However, the results did suggest that most hospital patients are knowledgeable, willing, and able to contribute useful and important information to the medication reconciliation process. Interestingly, the clinicians I surveyed seemed far less convinced that their patients would be able to beneficially participate in the medication reconciliation process due to low health literacy and other barriers. Nevertheless, the clinicians did seem to believe that in theory, at least, patient involvement in the medication reconciliation process could have positive impacts on their workflow and potentially save them time. Conclusion: The overall theme resulting from my research is that patients can be a valuable resource to improve patient safety in the hospital. Patients are generally knowledgeable and willing to more actively participate in their hospital care. By developing the structures and processes to facilitate greater patient engagement, hospitals can provide an extra layer of safety and error prevention, particularly with respect to the medications patients take at home. As with any medical treatment, active participation in patient safety efforts may not be possible for all patients. However, I believe that if the culture of a hospital encourages openness and transparency, and if patients are given the proper tools and information, the quality and safety of hospital care will improve

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

Leveraging patient-provided data to improve understanding of disease risk

Patient-provided data are crucial to achieving the goal of precision medicine. These data, which include family medical history, race and ethnicity, and social and behavioral determinants of health, are essential for disease risk assessment. Despite the well-established importance of patient-provided data, there are many data quality challenges that affect how this information can be used for biomedical research. To determine how to best use patient-provided data to assess disease risk, the research reflected in this dissertation was divided into three overarching aims. In Aim 1, I focused on determining the quality of race and ethnicity, family history and smoking status in clinical databases. In Aim 2, I assessed the impact of various interventions on the quality of these data, including policy changes such as the implementation of the requirements imposed by the Meaningful Use program, and patient-facing tools for collecting and sharing information with patients. In addition to these evaluations, I also developed and evaluated a method “Relationship Inference from the Electronic Health Record” (RIFTEHR), that infers familial relationships from clinical datasets. In Aim 3, I used patient-provided data to assess disease risk both at a population level, by estimating disease heritability, and at an individual level, by identifying high-risk individuals eligible for additional screening for a common disease (diabetes mellitus) and a rare disease (celiac disease). My research uncovered several data quality concerns for patient-provided data in clinical databases. When assessing the impact of interventions on the quality of these data, I found that policy interventions led to more data collection, but not necessarily to better data quality. In contrast, patient-facing tools did increase the quality of the patient-provided data. In the absence of high-quality patient-provided data for family medical history, I developed and evaluated a method for inferring this information from large clinical databases. I demonstrated that electronic health record data can be used to infer familial relationships accurately. Moreover, I showed how the use of clinical data in conjunction with the inferred familial relationships could determine disease risk in two studies. In the first study, I successfully computed disease heritability estimates for 500 conditions, some of which had not been previously studied. In the second study, I identified that screening rates among family members that are considered to be at high-risk for disease development were low for both diabetes mellitus and celiac disease. In summary, the work represented in this dissertation contributes to the understanding of the quality of patient-provided data, how interventions affect the quality of these data, and how novel methods can be applied to troves of existing clinical data to generate new knowledge to support research and clinical care

Factors Affecting Patients’ Use of Electronic Personal Health Records

England has recently introduced a nationwide electronic personal health record (ePHR) called Patient Online. Although ePHRs are widely available, adoption rates of ePHRs are usually low. Understanding the factors affecting patients’ use of ePHRs is considered important to increase adoption rates and improve the implementation success of ePHRs. Therefore, the current study aims to examine the factors that affect patients’ adoption of ePHRs in England. A systematic review was conducted to identify factors that affect patients’ adoption of ePHRs. Then, the most common theories and models relevant to technology adoption and human behaviour were reviewed to select an appropriate theory and use it as a theoretical lens for examining the factors in the current study. The Unified Theory of Acceptance and Use of Technology (UTAUT) was selected and tailored to the context of ePHRs by including the most influential factors identified by the systematic review. A cross-sectional survey of 624 patients in four general practices in West Yorkshire was carried out to empirically examine the proposed model via structural equation modelling. The results showed that performance expectancy, effort expectancy, and perceived privacy and security were significant predictors of behavioural intention. The relationship between social influence and behavioural intention was not statistically significant. Both facilitating conditions and behavioural intention affected use behaviour. Performance expectancy was also a significant mediator of the effect of both effort expectancy and perceived privacy and security on behavioural intention. Eleven relationships were moderated by age, sex, income, education, ethnicity, and internet access. The proposed model accounted for 76% and 48% of the variance in behavioural intention and use behaviour, respectively. The current study makes a significant contribution by adapting and validating a theoretical model (UTAUT) in a new context (ePHRs). Further, this study contributes to practices by providing several implications for developers, marketers, and GP practices