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1.  Use of Web-based Shared Medical Records among Patients with HIV 
The American journal of managed care  2013;19(4):e114-e124.
Background
Patient websites with secure access to shared electronic medical records (SMR) may support care of patients with HIV, particularly during heightened need. However, groups disproportionately affected by HIV may be less likely to use them.
Objective & Design
We performed an observational cohort study to compare use of seven SMR features by adult patients with HIV. Automated data from the 36 months following SMR implementation were assessed in two integrated delivery systems.
Participants, Main Measures, Key Results
Most (3888/7398) patients used the SMR at least once. Users were most likely to view medical test results (49%), use secure messaging (43%), or request appointments (31%) or medication refills (30%). Initial use was associated with a new prescription for antiretroviral therapy [rate ratio (RR) 1.65, p <0.001], a recent change to CD4+ count <200 cells/μL (RR 1.34, p <0.02), a new HIV RNA ≥75 copies/mL (RR 1.63, p <0.001), or a recent increase in non-HIV comorbidity score (RR 1.49, p = 0.0001). In age-, sex-, and comorbidity-adjusted analyses, users were less likely to be women (RR 0.49, p=0.0001), injection drug users (RR 0.59, p = 0.0001), or from lower-socioeconomic neighborhoods (RR 0.68, p = 0.0001). Compared with nonusers, users were less likely to be Black (RR 0.38, p = 0.0001), Hispanic (RR 0.52, p = 0.0001) or Asian/Pacific Islander (RR 0.59, p = 0.001).
Conclusions
SMR use was higher among those with HIV who had indicators of recent increases in health care need and lower among several vulnerable populations. Health care providers and systems should support SMR use among patients with HIV as part of broader efforts to improve overall access to care.
PMCID: PMC3951974  PMID: 23725449
HIV; personal health record; health care disparities
2.  Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead 
Annals of internal medicine  2012;157(7):461-470.
Background
Little information exists about what primary care physicians (PCPs) and patients experience if patients are invited to read their doctors’ office notes.
Objective
To evaluate the effect on doctors and patients of facilitating patient access to visit notes over secure Internet portals.
Design
Quasi-experimental trial of PCPs and patient volunteers in a year-long program that provided patients with electronic links to their doctors’ notes.
Setting
Primary care practices at Beth Israel Deaconess Medical Center (BIDMC) in Massachusetts, Geisinger Health System (GHS) in Pennsylvania, and Harborview Medical Center (HMC) in Washington.
Participants
105 PCPs and 13 564 of their patients who had at least 1 completed note available during the intervention period.
Measurements
Portal use and electronic messaging by patients and surveys focusing on participants’ perceptions of behaviors, benefits, and negative consequences.
Results
11 797 of 13 564 patients with visit notes available opened at least 1 note (84% at BIDMC, 92% at GHS, and 47% at HMC). Of 5391 patients who opened at least 1 note and completed a postintervention survey, 77% to 87% across the 3 sites reported that open notes helped them feel more in control of their care; 60% to 78% of those taking medications reported increased medication adherence; 26% to 36% had privacy concerns; 1% to 8% reported that the notes caused confusion, worry, or offense; and 20% to 42% reported sharing notes with others. The volume of electronic messages from patients did not change. After the intervention, few doctors reported longer visits (0% to 5%) or more time addressing patients’ questions outside of visits (0% to 8%), with practice size having little effect; 3% to 36% of doctors reported changing documentation content; and 0% to 21% reported taking more time writing notes. Looking ahead, 59% to 62% of patients believed that they should be able to add comments to a doctor’s note. One out of 3 patients believed that they should be able to approve the notes’ contents, but 85% to 96% of doctors did not agree. At the end of the experimental period, 99% of patients wanted open notes to continue and no doctor elected to stop.
Limitations
Only 3 geographic areas were represented, and most participants were experienced in using portals. Doctors volunteering to participate and patients using portals and completing surveys may tend to offer favorable feedback, and the response rate of the patient surveys (41%) may further limit generalizability.
Conclusion
Patients accessed visit notes frequently, a large majority reported clinically relevant benefits and minimal concerns, and virtually all patients wanted the practice to continue. With doctors experiencing no more than a modest effect on their work lives, open notes seem worthy of widespread adoption.
Primary Funding Source
The Robert Wood Johnson Foundation, the Drane Family Fund, the Richard and Florence Koplow Charitable Foundation, and the National Cancer Institute.
doi:10.7326/0003-4819-157-7-201210020-00002
PMCID: PMC3908866  PMID: 23027317
3.  Online Access to Doctors' Notes: Patient Concerns About Privacy 
Background
Offering patients online access to medical records, including doctors’ visit notes, holds considerable potential to improve care. However, patients may worry about loss of privacy when accessing personal health information through Internet-based patient portals. The OpenNotes study provided patients at three US health care institutions with online access to their primary care doctors’ notes and then collected survey data about their experiences, including their concerns about privacy before and after participation in the intervention.
Objective
To identify patients’ attitudes toward privacy when given electronic access to their medical records, including visit notes.
Methods
The design used a nested cohort study of patients surveyed at baseline and after a 1-year period during which they were invited to read their visit notes through secure patient portals. Participants consisted of 3874 primary care patients from Beth Israel Deaconess Medical Center (Boston, MA), Geisinger Health System (Danville, PA), and Harborview Medical Center (Seattle, WA) who completed surveys before and after the OpenNotes intervention. The measures were patient-reported levels of concern regarding privacy associated with online access to visit notes.
Results
32.91% of patients (1275/3874 respondents) reported concerns about privacy at baseline versus 36.63% (1419/3874 respondents) post-intervention. Baseline concerns were associated with non-white race/ethnicity and lower confidence in communicating with doctors, but were not associated with choosing to read notes or desire for continued online access post-intervention (nearly all patients with notes available chose to read them and wanted continued access). While the level of concern among most participants did not change during the intervention, 15.54% (602/3874 respondents, excluding participants who responded “don’t know”) reported more concern post-intervention, and 12.73% (493/3874 respondents, excluding participants who responded “don’t know”) reported less concern.
Conclusions
When considering online access to visit notes, approximately one-third of patients had concerns about privacy at baseline and post-intervention. These perceptions did not deter participants from accessing their notes, suggesting that the benefits of online access to medical records may outweigh patients’ perceived risks to privacy.
doi:10.2196/jmir.2670
PMCID: PMC3785972  PMID: 24072335
electronic medical records; patient access to records; patient portals; privacy; consumer health informatics; personal health records
4.  Inviting Patients to Read Their Doctors' Notes: Patients and Doctors Look Ahead 
Annals of internal medicine  2011;155(12):811-819.
Background
Little is known about what primary care physicians (PCPs) and patients would expect if patients were invited to read their doctors' office notes.
Objective
To explore attitudes toward potential benefits or harms if PCPs offered patients ready access to visit notes.
Design
The PCPs and patients completed surveys before joining a voluntary program that provided electronic links to doctors' notes.
Setting
Primary care practices in 3 U.S. states.
Participants
Participating and nonparticipating PCPs and adult patients at primary care practices in Massachusetts, Pennsylvania, and Washington.
Measurements
Doctors' and patients' attitudes toward and expectations of open visit notes, their ideas about the potential benefits and risks, and demographic characteristics.
Results
110 of 114 participating PCPs (96%), 63 of 140 nonparticipating PCPs (45%), and 37 856 of 90 826 patients (42%) completed surveys. Overall, 69% to 81% of participating PCPs across the 3 sites and 92% to 97% of patients thought open visit notes were a good idea, compared with 16% to 33% of nonparticipating PCPs. Similarly, participating PCPs and patients generally agreed with statements about potential benefits of open visit notes, whereas nonparticipating PCPs were less likely to agree. Among participating PCPs, 74% to 92% anticipated improved communication and patient education, in contrast to 45% to 67% of nonparticipating PCPs. More than one half of participating PCPs (50% to 58%) and most nonparticipating PCPs (88% to 92%) expected that open visit notes would result in greater worry among patients; far fewer patients concurred (12% to 16%). Thirty-six percent to 50% of participating PCPs and 83% to 84% of nonparticipating PCPs anticipated more patient questions between visits. Few PCPs (0% to 33%) anticipated increased risk for lawsuits. Patient enthusiasm extended across age, education, and health status, and 22% anticipated sharing visit notes with others, including other doctors.
Limitations
Access to electronic patient portals is not widespread, and participation was limited to patients using such portals. Response rates were higher among participating PCPs than nonparticipating PCPs; many participating PCPs had small patient panels.
Conclusion
Among PCPs, opinions about open visit notes varied widely in terms of predicting the effect on their practices and benefits for patients. In contrast, patients expressed considerable enthusiasm and few fears, anticipating both improved understanding and more involvement in care. Sharing visit notes has broad implications for quality of care, privacy, and shared accountability.
doi:10.7326/0003-4819-155-12-201112200-00003
PMCID: PMC3772715  PMID: 22184688
5.  Randomized Trial of Depression Follow-Up Care by Online Messaging 
Background
Quality of antidepressant treatment remains disturbingly poor. Rates of medication adherence and follow-up contact are especially low in primary care, where most depression treatment begins. Telephone care management programs can address these gaps, but reliance on live contact makes such programs less available, less timely, and more expensive.
Objective
Evaluate the feasibility, acceptability, and effectiveness of a depression care management program delivered by online messaging through an electronic medical record.
Design
Randomized controlled trial comparing usual primary care treatment to primary care supported by online care management
Setting
Nine primary care clinics of an integrated health system in Washington state
Participants
Two hundred and eight patients starting antidepressant treatment for depression.
Intervention
Three online care management contacts with a trained psychiatric nurse. Each contact included a structured assessment (severity of depression, medication adherence, side effects), algorithm-based feedback to the patient and treating physician, and as-needed facilitation of follow-up care. All communication occurred through secure, asynchronous messages within an electronic medical record.
Main Measures
An online survey approximately five months after randomization assessed the primary outcome (depression severity according to the Symptom Checklist scale) and satisfaction with care, a secondary outcome. Additional secondary outcomes (antidepressant adherence and use of health services) were assessed using computerized medical records.
Key Results
Patients offered the program had higher rates of antidepressant adherence (81% continued treatment more than 3 months vs. 61%, p = 0.001), lower Symptom Checklist depression scores after 5 months (0.95 vs. 1.17, p = 0.043), and greater satisfaction with depression treatment (53% “very satisfied” vs. 33%, p = 0.004).
Limitations
The trial was conducted in one integrated health care system with a single care management nurse. Results apply only to patients using online messaging.
Conclusions
Our findings suggest that organized follow-up care for depression can be delivered effectively and efficiently through online messaging.
doi:10.1007/s11606-011-1679-8
PMCID: PMC3138593  PMID: 21384219
depression; randomized; follow-up; online messaging
6.  ACCURACY OF BLOOD PRESSURE MEASUREMENTS REPORTED IN AN ELECTRONIC MEDICAL RECORD DURING ROUTINE PRIMARY CARE VISITS 
Electronic medical records (EMRS) allow for real time access to blood pressure information on a population basis and improved identification and treatment of individuals with hypertension. Despite the potential uses of the data available from EMRs relatively little research has examined the reliability of this data. To address this gap, we examined the reliability of blood pressure taken at primary care visits and recorded in an electronic medical record with those taken at a research study visit at which standard protocols were used to measure blood pressure among all adults as well as by gender and age. Systolic blood pressure (BP) averaged 3.7 (17.3) points and diastolic BP was 2.8 (10.6) points lower in the EMR than in the study visit across age and gender groups with all differences statistically significant. For this cohort of patients with a diagnosis of hypertension there was moderate correlation between BP measurements taken in clinic and at research. However BP control for individuals, as defined by a BP of less the 140 mm Hg systolic and 90 mm Hg diastolic, differed by almost 25%. Known variability of BP and clinic procedures for measuring and recording BP may account for these differences.
doi:10.1111/j.1751-7176.2011.00528.x
PMCID: PMC3211104  PMID: 22051427
blood pressure; hypertension; electronic medical record; reliability
7.  Stakeholder engagement: a key component of integrating genomic information into electronic health records 
Integrating genomic information into clinical care and the electronic health record can facilitate personalized medicine through genetically guided clinical decision support. Stakeholder involvement is critical to the success of these implementation efforts. Prior work on implementation of clinical information systems provides broad guidance to inform effective engagement strategies. We add to this evidence-based recommendations that are specific to issues at the intersection of genomics and the electronic health record. We describe stakeholder engagement strategies employed by the Electronic Medical Records and Genomics Network, a national consortium of US research institutions funded by the National Human Genome Research Institute to develop, disseminate, and apply approaches that combine genomic and electronic health record data. Through select examples drawn from sites of the Electronic Medical Records and Genomics Network, we illustrate a continuum of engagement strategies to inform genomic integration into commercial and homegrown electronic health records across a range of health-care settings. We frame engagement as activities to consult, involve, and partner with key stakeholder groups throughout specific phases of health information technology implementation. Our aim is to provide insights into engagement strategies to guide genomic integration based on our unique network experiences and lessons learned within the broader context of implementation research in biomedical informatics. On the basis of our collective experience, we describe key stakeholder practices, challenges, and considerations for successful genomic integration to support personalized medicine.
doi:10.1038/gim.2013.127
PMCID: PMC3909653  PMID: 24030437
electronic health records; genomics; health information technology; personalized medicine; stakeholder engagement; translational medical research
8.  Evaluating the impact of patients' online access to doctors' visit notes: designing and executing the OpenNotes project 
Background
Providers and policymakers are pursuing strategies to increase patient engagement in health care. Increasingly, online sections of medical records are viewable by patients though seldom are clinicians' visit notes included. We designed a one-year multi-site trial of online patient accessible office visit notes, OpenNotes. We hypothesized that patients and primary care physicians (PCPs) would want it to continue and that OpenNotes would not lead to significant disruptions to doctors' practices.
Methods/Design
Using a mixed methods approach, we designed a quasi-experimental study in 3 diverse healthcare systems in Boston, Pennsylvania, and Seattle. Two sites had existing patient internet portals; the third used an experimental portal. We targeted 3 key areas where we hypothesized the greatest impacts: beliefs and attitudes about OpenNotes, use of the patient internet portals, and patient-doctor communication. PCPs in the 3 sites were invited to participate in the intervention. Patients who were registered portal users of participating PCPs were given access to their PCPs' visit notes for one year. PCPs who declined participation in the intervention and their patients served as the comparison groups for the study. We applied the RE-AIM framework to our design in order to capture as comprehensive a picture as possible of the impact of OpenNotes. We developed pre- and post-intervention surveys for online administration addressing attitudes and experiences based on interviews and focus groups with patients and doctors. In addition, we tracked use of the internet portals before and during the intervention.
Results
PCP participation varied from 19% to 87% across the 3 sites; a total of 114 PCPs enrolled in the intervention with their 22,000 patients who were registered portal users. Approximately 40% of intervention and non-intervention patients at the 3 sites responded to the online survey, yielding a total of approximately 38,000 patient surveys.
Discussion
Many primary care physicians were willing to participate in this "real world" experiment testing the impact of OpenNotes on their patients and their practices. Results from this trial will inform providers, policy makers, and patients who contemplate such changes at a time of exploding interest in transparency, patient safety, and improving the quality of care.
doi:10.1186/1472-6947-12-32
PMCID: PMC3351950  PMID: 22500560
Patient access to records; Electronic health records; Primary care physicians; Internet; Medical records; Medical informatics; Patient participation
9.  Patient Web Services Integrated with a Shared Medical Record: Patient Use and Satisfaction 
Objectives
This study sought to describe the evolution, use, and user satisfaction of a patient Web site providing a shared medical record between patients and health professionals at Group Health Cooperative, a mixed-model health care financing and delivery organization based in Seattle, Washington.
Design
This study used a retrospective, serial, cross-sectional study from September 2002 through December 2005 and a mailed satisfaction survey of a random sampling of 2,002 patients.
Measurements
This study measured the adoption and use of a patient Web site (MyGroupHealth) from September 2002 through December 2005.
Results
As of December 2005, 25% (105,047) of all Group Health members had registered and completed an identification verification process enabling them to use all of the available services on MyGroupHealth. Identification verification was more common among patients receiving care in the Integrated Delivery System (33%) compared with patients receiving care in the network (7%). As of December 2005, unique monthly user rates per 1,000 adult members were the highest for review of medical test results (54 of 1,000), medication refills (44 of 1,000), after-visit-summaries (32 of 1,000), and patient–provider clinical messaging (31 of 1,000). The response rate for the patient satisfaction survey was 46% (n = 921); 94% of survey respondents were satisfied or very satisfied with MyGroupHealth overall. Patients reported highest satisfaction (satisfied or very satisfied) for medication refills (96%), patient–provider messaging (93%), and medical test results (86%).
Conclusion
Use and satisfaction with MyGroupHealth were greatest for accessing services and information involving ongoing, active care and patient–provider communication. Tight integration of Web services with clinical information systems and patient–provider relationships may be important in meeting the needs of patients.
doi:10.1197/jamia.M2302
PMCID: PMC2213480  PMID: 17712090
10.  KNOWLEDGE OF CERVICAL CANCER RISK FACTORS AMONG CHINESE IMMIGRANTS IN SEATTLE 
Journal of community health  2003;28(1):41-57.
Chinese American immigrants are a growing part of the United States population. Cervical cancer is a significant cause of morbidity and mortality among Chinese Americans. Pap smear testing is less common in Chinese American immigrants than in the general population. During 1999, we conducted a community-based survey of Chinese American women living in Seattle. We assessed knowledge of cervical cancer risk factors and history of Pap smear testing along with socioeconomic and acculturation characteristics. The overall estimated response rate was 64%, and the cooperation rate was 72%. Our study sample included 472 women. Most cervical cancer risk factors were recognized by less than half of our participants. Factors independently associated with knowledge of cervical cancer risk factors included marital status, employment, and education. Respondents with the highest knowledge had greater odds of ever receiving a Pap smear, compared to those respondents with the lowest knowledge (OR 2.5; 95% CI: 1.1,5.8). Our findings suggest a need for increased recognition of cervical cancer risk factors among Chinese American immigrants. Culturally and linguistically appropriate educational interventions for cervical cancer risk factors should be developed, implemented and evaluated.
PMCID: PMC1618780  PMID: 12570172
cervix neoplasms; Chinese Americans; risk factors
11.  Use of a Shared Medical Record With Secure Messaging by Older Patients With Diabetes 
Diabetes Care  2010;33(11):2314-2319.
OBJECTIVE
Evaluate use of a web-based shared medical record (SMR) between older patients with diabetes and providers.
RESEARCH DESIGN AND METHODS
This was a retrospective cohort study. Health records and SMR use patterns of 6,185 enrollees aged ≥65 years with diabetes were analyzed from implementation of a SMR in August 2003 through December 2007. We analyzed baseline predictors of age, sex, distance from clinic, socioeconomic status, insulin use, morbidity, and associated primary care provider's (PCP) secure messaging use on patients' initial and subsequent use of the SMR. Changes in morbidity, PCP, or diabetes treatment were evaluated for impact on outcomes.
RESULTS
A total of 32.2% of enrollees used the SMR; median rate was 1.02 user-days/month. Numbers of users and rate of use continued to increase. In adjusted analyses, likelihood of SMR use was associated with younger age, male sex, and higher socioeconomic status neighborhood, as well as clinical characteristics of overall morbidity and assigned PCP's use of secure messaging. Initial SMR use was more likely within 3 months of an increase in morbidity (hazard ratio 1.61, 95% CI 1.28–2.01) and within 1 month of changing to a PCP with higher use (3.02, 1.66–5.51).
CONCLUSIONS
Four years after implementation, one-third of older individuals with diabetes had used the web-based SMR. Higher morbidity predicted initial and continued use of SMR services. Providers' use of the communication feature was associated with higher likelihood of SMR engagement by their patients. Web-based SMRs may be an effective form of non–visit-based health care for older individuals with diabetes.
doi:10.2337/dc10-1124
PMCID: PMC2963486  PMID: 20739686
12.  Effectiveness of Home Blood Pressure Monitoring, Web Communication, and Pharmacist Care on Hypertension Control 
Context
Treating hypertension decreases mortality and disability from cardiovascular disease; but most hypertension remains inadequately controlled.
Objective
To determine if a new model of care that uses patient Web services, and adds home BP monitoring and pharmacist-assisted care, improves blood pressure control.
Design
The Electronic Communications and Home Blood Pressure Monitoring (e-BP) study was a three-arm randomized controlled trial based on the Chronic Care Model and delivered over a secure patient website from June 2005 to December 2007.
Setting
Integrated group practice in Washington state.
Participants
778 participants age 25–75 with uncontrolled essential hypertension and Internet access.
Interventions
Participants were randomly assigned to: (1) usual care (UC); (2) home BP monitoring and secure patient website training (BPM-Web); (3) this plus pharmacist care management delivered through Web communications (BPM-Web-Pharm).
Main Outcome Measures
Percentage of patients with controlled BP (<140/90 mm Hg) and changes in systolic and diastolic BP at 12 months.
Results
730 patients (94%) completed the 1-year follow-up visit. Patients assigned to BPM-Web had a nonsignificant increase in the percentage with controlled BP (<140/90 mm Hg) compared to UC (36%; [95% CI, 30% to 42%] versus 31% [95% CI, 25% to 37%], P = .21). Adding Web-based pharmacy care to home BP monitoring (BPM-Web-Pharm) significantly increased the percentage with controlled BP (56% [95% CI, 49% to 62%]) compared to usual care (P <.001) and home BP monitoring (P <.001). Diastolic BP was also decreased with BPM-Web-Pharm compared to UC and BPM-Web; and systolic BP was decreased stepwise from UC to BPM-Web to BPM-Web-Pharm. For patients with baseline systolic BP ≥160 mm Hg, BPM-Web-Pharm had greater net reduction in systolic BP (−13.3 mm Hg [95% CI, −19.5 to −7.1], P <.001) and diastolic BP (−5.1 mm Hg [95% CI, −8.5 to −1.8], P <.001), and BP control improved by 34.2% (95% CI, 15.7% to 50.2%).
Conclusions
Pharmacist care management delivered through secure patient Web communications improved BP control in patients with hypertension.
doi:10.1001/jama.299.24.2857
PMCID: PMC2715866  PMID: 18577730
13.  Patient Ability and Willingness to Participate in a Web-Based Intervention to Improve Hypertension Control 
Background
Patient-shared electronic health records provide opportunities for care outside of office visits. However, those who might benefit may be unable to or choose not to use these resources, while others might not need them.
Objective
Electronic Communications and Home Blood Pressure Monitoring (e-BP) was a randomized trial that demonstrated that Web-based pharmacist care led to improved blood pressure (BP) control. During recruitment we attempted to contact all patients with hypertension from 10 clinics to determine whether they were eligible and willing to participate. We wanted to know whether particular subgroups, particularly those from vulnerable populations, were less willing to participate or unable to because they lacked computer access.
Methods
From 2005 to 2006, we sent invitation letters to and attempted to recruit 9298 patients with hypertension. Eligibility to participate in the trial included access to a computer and the Internet, an email address, and uncontrolled BP (BP ≥ 140/90 mmHg). Generalized linear models within a modified Poisson regression framework were used to estimate the relative risk (RR) of ineligibility due to lack of computer access and of having uncontrolled BP.
Results
We were able to contact 95.1% (8840/9298) of patients. Those refusing participation (3032/8840, 34.3%) were significantly more likely (P < .05) to be female, be nonwhite, have lower levels of education, and have Medicaid insurance. Among patients who answered survey questions, 22.8% (1673/7354) did not have computer access. Older age, minority race, and lower levels of education were risk factors for lack of computer access, with education as the strongest predictor (RR 2.63, 95% CI 2.30-3.01 for those with a high school degree compared to a college education). Among hypertensive patients with computer access who were willing to participate, African American race (RR 1.22, 95% CI 1.06-1.40), male sex (RR 1.28, 95% CI 1.18-1.38), and obesity (RR 1.53, 95% CI 1.31-1.79) were risk factors for uncontrolled BP.
Conclusion
Older age, lower socioeconomic status, and lower levels of education were associated with decreased access to and willingness to participate in a Web-based intervention to improve hypertension control. Failure to ameliorate this may worsen health care disparities.
Trial Registration
Clinicaltrials.gov NCT00158639; http://www.clinicaltrials.gov/ct2/show/NCT00158639 (Archived by WebCite at http://www.webcitation.org/5v1jnHaeo)
doi:10.2196/jmir.1625
PMCID: PMC3217242  PMID: 21371993
electronic medical record
14.  Development and Evaluation of CAHPS® Questions to Assess the Impact of Health Information Technology on Patient Experiences with Ambulatory Care 
Medical care  2012;50(Suppl):S11-S19.
Background
Little is known about whether health information technology (HIT) affects patient experiences with health care.
Objective
To develop HIT questions that assess patients care experiences not evaluated by existing ambulatory CAHPS measures.
Research Design
We reviewed published articles and conducted focus groups and cognitive testing to develop survey questions. We collected data, using mail and the internet, from patients of 69 physicians receiving care at an academic medical center and two regional integrated delivery systems in late 2009 and 2010. We evaluated questions and scales about HIT using factor analysis, item-scale correlations, and reliability (internal consistency and physician-level) estimates.
Results
We found support for three HIT composites: doctor use of computer (2 items), e-mail (2 items), and helpfulness of provider’s website (4 items). Corrected item-scale correlations were 0.37 for the two doctor use of computer items and 0.71 for the two e-mail items, and ranged from 0.50 to 0.60 for the provider’s website items. Cronbach’s alpha was high for e-mail (0.83) and provider’s website (0.75), but only 0.54 for doctor use of computer. As few as 50 responses per physician would yield reliability of 0.70 for e-mail and provider’s website. Two HIT composites, doctor use of computer (p<0.001) and provider’s website (p=0.02), were independent predictors of overall ratings of doctors.
Conclusions
New CAHPS HIT items were identified that measure aspects of patient experiences not assessed by the CAHPS C&G 1.0 survey.
doi:10.1097/MLR.0b013e3182610a50
PMCID: PMC3525454  PMID: 23064271
CAHPS®; health information technology; personal health records; patient experiences of care
15.  Diabetes Quality of Care and Outpatient Utilization Associated With Electronic Patient-Provider Messaging: A Cross-Sectional Analysis 
Diabetes Care  2009;32(7):1182-1187.
OBJECTIVE
To test the hypothesis that electronic patient-provider messaging is associated with high care quality for diabetes and lower outpatient utilization.
RESEARCH DESIGN AND METHODS
We conducted a cross-sectional analysis of electronic patient-provider messaging over a 15-month period between 1 January 2004 and 31 March 2005. The study was set at Group Health Cooperative—a consumer-governed, nonprofit health care system that operates in Washington and Idaho. Participants included all patients aged ≥18 years with a diagnosis of diabetes. In addition to usual care, all patients had the option to use electronic messaging to communicate with their care providers. The primary outcome measures were diabetes-related quality-of-care indicators (A1C, blood pressure, and LDL cholesterol) and outpatient visits (primary care, specialty care, and emergency).
RESULTS
Nineteen percent of patients with diabetes used electronic messaging to communicate with their care providers during the study period (n = 2,924) (overall study cohort: 15,427 subjects). In multivariate models, frequent use of electronic messaging was associated with A1C <7% (relative risk [RR] 1.36 [95% CI 1.16–1.58]). Contrary to our hypothesis, frequent use of electronic messaging was also associated with a higher rate of outpatient visits (1.39 [1.26–1.53]).
CONCLUSIONS
Frequent use of electronic secure messaging is associated with better glycemic control and increased outpatient utilization. Electronic patient-provider communication may represent one strategy to meet the health care needs of this unique population. More research is necessary to assess the effect of electronic messaging on care quality and utilization.
doi:10.2337/dc08-1771
PMCID: PMC2699712  PMID: 19366959
16.  Web-Based Collaborative Care for Type 1 Diabetes: A Pilot Randomized Trial 
Abstract
Background
To determine whether a Web-based diabetes case management program based in an electronic medical record can improve glycemic control (primary outcome) and diabetes-specific self-efficacy (secondary outcome) in adults with type 1 diabetes, a pilot randomized controlled trial was conducted.
Methods
A 12-month randomized trial tested a Web-based case management program in a diabetes specialty clinic. Patients 21–49 years old with type 1 diabetes receiving multiple daily injections with insulin glargine and rapid-acting analogs who had a recent A1C >7.0% were eligible for inclusion. Participants were randomized to receive either (1) usual care plus the nurse-practitioner-aided Web-based case management program (intervention) or (2) usual clinic care alone (control). We compared patients in the two study arms for changes in A1C and self-efficacy measured with the Diabetes Empowerment Scale.
Results
A total of 77 patients were recruited from the diabetes clinic and enrolled in the trial. The mean baseline A1C among study participants was 8.0%. We observed a nonsignificant decrease in average A1C (−0.48; 95% confidence interval −1.22 to 0.27; P = 0.160) in the intervention group compared to the usual care group. The intervention group had a significant increase in diabetes-related self-efficacy compared to usual care (group difference of 0.30; 95% confidence interval 0.01 to 0.59; P = 0.04).
Conclusions
Use of a Web-based case management program was associated with a beneficial treatment effect on self-efficacy, but change in glycemic control did not reach statistical significance in this trial of patients with moderately poorly controlled type 1 diabetes. Larger studies may be necessary to further clarify the intervention's impact on health outcomes.
doi:10.1089/dia.2008.0063
PMCID: PMC2989842  PMID: 19344195
17.  Patient Use of Secure Electronic Messaging Within a Shared Medical Record: A Cross-sectional Study 
ABSTRACT
BACKGROUND
Most patients would like to be able to exchange electronic messages with personal physicians. Few patients and providers are exchanging electronic communications.
OBJECTIVE
To evaluate patient characteristics associated with the use of secure electronic messaging between patients and health care providers.
DESIGN, SETTING, AND PATIENTS
Cross-sectional cohort study of enrollees over 18 years of age who were enrolled in an integrated delivery system in 2005.
MEASUREMENTS AND MAIN RESULTS
Among eligible enrollees, 14% (25,075) exchanged one or more secure messages with a primary or specialty care provider between January 1, 2004 and March 31, 2005. Higher secure messaging use by enrollees was associated with female gender (OR, 1.15; 95% CI, 1.10–1.19), greater overall morbidity (OR, 5.64; 95% CI, 5.07–6.28, comparing high or very high to very low overall morbidity), and the primary care provider’s use of secure messaging with other patients (OR, 1.94; 95% CI, 1.67–2.26, comparing 20–50% vs. ≤10% encounters through secure messaging). Less secure messaging use was associated with enrollee age over 65 years (OR, 0.65; CI, 0.59–0.71) and Medicaid insurance vs. commercial insurance (OR, 0.81; 95% CI, 0.68–0.96).
CONCLUSIONS
In this integrated group practice, use of patient–provider secure messaging varied according to individual patient clinical and sociodemographic characteristics. Future studies should clarify variation in the use of electronic patient–provider messaging and its impact on the quality and cost of care received.
doi:10.1007/s11606-008-0899-z
PMCID: PMC2642567  PMID: 19137379
physician–patient relations; electronic mail; healthcare disparities
18.  Web-Based Collaborative Care for Type 2 Diabetes 
Diabetes Care  2009;32(2):234-239.
OBJECTIVE—To test Web-based care management of glycemic control using a shared electronic medical record with patients who have type 2 diabetes.
RESEARCH DESIGN AND METHODS—We conducted a trial of 83 adults with type 2 diabetes randomized to receive usual care plus Web-based care management or usual care alone between August 2002 and May 2004. All patients had GHb ≥7.0%, had Web access from home, and could use a computer with English language–based programs. Intervention patients received 12 months of Web-based care management. The Web-based program included patient access to electronic medical records, secure e-mail with providers, feedback on blood glucose readings, an educational Web site, and an interactive online diary for entering information about exercise, diet, and medication. The primary outcome was change in GHb.
RESULTS—GHb levels declined by 0.7% (95% CI 0.2−1.3) on average among intervention patients compared with usual-care patients. Systolic blood pressure, diastolic blood pressure, total cholesterol levels, and use of in-person health care services did not differ between the two groups.
CONCLUSIONS—Care management delivered through secure patient Web communications improved glycemic control in type 2 diabetes.
doi:10.2337/dc08-1220
PMCID: PMC2628685  PMID: 19017773
19.  Providers’ Experience with an Organizational Redesign Initiative to Promote Patient-Centered Access: A Qualitative Study 
Journal of General Internal Medicine  2008;23(11):1778-1783.
Background
Patient-centered access is a philosophy and a method that supports efforts to redesign health-care delivery systems to deliver higher quality care and to better meet the needs and preferences of patients. Since mid-2000, Group Health Cooperative has pursued an ensemble of strategic initiatives aimed at promoting patient-centered access, referred to as the Access Initiative. In support of this strategy, Group Health has also engaged in enterprise implementation of an electronic medical record and clinical information system that is integrated with their patient Web site, MyGroupHealth.
Objective
To elicit, describe, and characterize providers’ perceptions of the effects of the Access Initiative, an information technology-enabled organizational redesign initiative intended to promote patient-centered access.
Design
Thematic analysis of semi-structured in-depth interviews.
Participants
Twenty-two care providers representing 14 primary care, medical, and surgical specialties at Group Health Cooperative, an integrated health-care system based in Seattle, Washington.
Findings
Analyses of the interview transcripts revealed nine emergent themes, five of which have particular relevance for health-care organizations pursuing patient-centered access: the Access Initiative improved patient satisfaction, improved the quality of encounter-based care, compromised providers’ focus on population health, created additional work for providers, and decreased job satisfaction for primary care providers and some medical specialists.
Conclusions
Providers like that the Access Initiative is mostly good for their patients, but dislike the negative effects on their own quality of life – especially in primary care. These reforms may not be sustainable under current models of organization and financing.
doi:10.1007/s11606-008-0761-3
PMCID: PMC2585688  PMID: 18769981
patient-centered access; information technology; qualitative evaluation; organizational redesign; informatics
20.  Electronic Communications and Home Blood Pressure Monitoring (e-BP) study: Design, delivery, and evaluation framework 
Contemporary clinical trials  2007;29(3):376-395.
Background
Randomized controlled trials have provided unequivocal evidence that treatment of hypertension decreases mortality and major disability from cardiovascular disease; however, blood pressure remains inadequately treated in most affected individuals. This large gap continues despite the facts that more than 90% of adults with hypertension have health insurance, and hypertension is the leading cause of visits to the doctor. New approaches are needed to improve hypertension care.
Objectives
The Electronic Communications and Home Blood Pressure Monitoring (e-BP) study is a three-arm randomized controlled trial designed to determine whether care based on the Chronic Care Model and delivered over the Internet improves hypertension care. The primary study outcomes are systolic, diastolic, and blood pressure control; secondary outcomes are medication adherence, patient self-efficacy, satisfaction and quality of life, and healthcare utilization and costs.
Methods
Hypertensive patients receiving care at Group Health medical centers are eligible if they have uncontrolled blood pressure on two screening visits and access to the Web and an e-mail address. Study participants are randomly assigned to three intervention groups: (a) usual care; (b) home blood pressure monitoring receipt and proficiency training on its use and the Group Health secure patient website (with secure e-mail access to their healthcare provider, access to a shared medical record, prescription refill and other services); or (c) this plus pharmacist care management (collaborative care management between the patient, the pharmacist, and the patient’s physician via a secure patient website and the electronic medical record).
Conclusion
We will determine whether a new model of patient-centered care that leverages Web communications, self-monitoring, and collaborative care management improves hypertension control. If this model proves successful and cost-effective, similar interventions could be used to improve the care of large numbers of patients with uncontrolled hypertension.
doi:10.1016/j.cct.2007.09.005
PMCID: PMC2645352  PMID: 17974502
23.  Patients' experience with a diabetes support programme based on an interactive electronic medical record: qualitative study 
BMJ : British Medical Journal  2004;328(7449):1159.
Objective To describe the experiences of patients with type 2 diabetes in a web based disease management programme based on an interactive electronic medical record.
Design Qualitative analysis of semistructured interviews with patients enrolled in a diabetes care module that included access to their electronic medical record, secure email, ability to upload blood glucose readings, an education site with endorsed content, and an interactive online diary for entering exercise, diet, and medication.
Setting Patients' homes in Washington state, United States.
Participants Nine participants aged 45-65 completed interviews before and after they used the programme.
Results Six themes emerged: feeling that non-acute concerns are uniquely valued; enhanced sense of security about health and health care; frustration with unmet expectations; feeling more able to manage; valuing feedback; and difficulty fitting the programme into activities of daily life. Three themes—valuing non-acute concerns, feeling secure, and unmet expectations—have particular relevance to the design and use of web based tools for care of patients with diabetes and chronic medical conditions.
Conclusion Participants' experiences support further study of open access to the electronic medical record and online communication between patients and their care providers. The development of web based disease management programmes should take into account the specific needs and expectations of patients, and patients and providers should have candid discussions about what web based care can and cannot provide.
PMCID: PMC411089  PMID: 15142919
24.  Defining Core Issues in Utilizing Information Technology to Improve Access: Evaluation and Research Agenda 
Journal of General Internal Medicine  2011;26(Suppl 2):623-627.
The Department of Veterans Affairs (VA) has been at the vanguard of information technology (IT) and use of comprehensive electronic health records. Despite the widespread use of health IT in the VA, there are still a variety of key questions that need to be answered in order to maximize the utility of IT to improve patient access to quality services. This paper summarizes the potential of IT to enhance healthcare access, key gaps in current evidence linking IT and access, and methodologic challenges for related research. We also highlight four key issues to be addressed when implementing and evaluating the impact of IT interventions on improving access to quality care: 1) Understanding broader needs/perceptions of the Veteran population and their caregivers regarding use of IT to access healthcare services and related information. 2) Understanding individual provider/clinician needs/perceptions regarding use of IT for patient access to healthcare. 3) System/Organizational issues within the VA and other organizations related to the use of IT to improve access. 4) IT integration and information flow with non-VA entities. While the VA is used as an example, the issues are salient for healthcare systems that are beginning to take advantage of IT solutions.
doi:10.1007/s11606-011-1789-3
PMCID: PMC3191219  PMID: 21989613
access to care; medical informatics; veterans

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