Online Access to Electronic Medical Records and Service in Primary Care

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1 Online Access to Electronic Medical Records and Service in Primary Care Dr Freda Mold Professor Simon de Lusignan Wednesday, 29 April

2 Contents Overview 1. Research Overview 2. Methods 3. Findings 4. Impact on practice 6. Summary Wednesday, 29 April

3 Definitions Online Access the process of a patient, or their authorised carer or guardian, logging on to access all or part of their medical record and associated transactional services from their home, workplace computer or mobile computing device, in a secure and safe environment. Mold F, Ellis B, de Lusignan S et al. The provision and impact of online patient access to their electronic health records (EHR) and transactional services on the quality and safety of health care: systematic review protocol. Inform Prim Care 2012; 20(4): Transactional Services services such as ordering of repeat prescriptions, online booking and cancelling of appointments, and developing the means for secure communication with the practice. ibid Wednesday, 29 April

4 The Start General Election Wednesday, 29 April

5 Conservative Manifesto 2010 Wednesday, 29 April

6 Manifesto Promise Control/Access to online medical records Wednesday, 29 April

7 Research Overview Context. Manifesto/ Media Wednesday, 29 April

8 Research Questions (simplified) Key Research Question 1: What is the association between online patient access to their own ambulatory care medical record and utilisation of health care and health outcomes Key Research Question 2: What is the association between online patient access to transactional services provided as part of their ambulatory care computerised record and utilisation of health care and health outcomes Key Research Question 3: What is the association between patient adoption of online access and transactional services as part of their ambulatory care and the practitioner and healthcare team being provided with appropriate support? Key Research Question 4: What is the association between IT developments which provide records access, systems to enhance privacy and security, established transactional and novel technologies, and the business process for developing modified systems and patient adoption and utilisation of online access and transactional services? Department of Health Funded via the Royal College of General Practitioners Wednesday, 29 April

9 Methods Study Development Protocol development and published PROSPERO Registered (CRD ) Recruitment of expert panel across institutions/ stakeholders Developed data extraction form to enable reviewer to extract paper core contents Two stage development process incorporating expert feedback Online and Word versions Developed online repository of available evidence (pdf format) Quality assurance process & amendments made to review forms from expert feedback Risk of Bias training and support provided to reviewers Wednesday, 29 April

10 Methods Sources Complex search strings designed (index terms & KW in title and abstract) Conducted searches on major bibliographic databases: Medline Embase CINAHL Cochrane Library DARE EPOC PsychInf OpenGrey DH Nuffield King s Fund From January 1999 September 2012 References imported to Endnote (n=13,784) References after de-duplication (n=9,877) Wednesday, 29 April

11 Inclusion/ Exclusion Criteria Wednesday, 29 April

12 Experimental - Flowchart PRISMA Wednesday, 29 April

13 Analysis Stage 1 Tidy data (completeness & accuracy) 2 nd or 3 rd reviewed (using extraction form) Organise evidence by RQ/ typology by reviewer. Check typology allocation Create basic Evidence Tables (ETs) Stage 2 Code ETs by recurring/ prominent themes (within & across RQs) Rearrange ETs by RQ/ themes & ROB (type of evidence) Additional Analysis GRADE? Contextual evidence in form of supporting tables/ graphs, for example. Wednesday, 29 April

14 Findings - Context and Quality Wednesday, 29 April

15 Study Characteristics - Experimental Wednesday, 29 April

16 Contextual Graphs Full Review Wednesday, 29 April

17 Patient Issues & Risk Of Bias Summary Graph Wednesday, 29 April

18 Practice Issues & Risk Of Bias Summary Graph Wednesday, 29 April

19 Findings four key research questions Wednesday, 29 April

20 Findings RQ1 Key Research Question 1: What is the association between online patient access to their own ambulatory care medical record and utilisation of health care and health outcomes? Utilisation of HC: Use themes Attendance Reduced frequency and length of consultations Ease of use Preparation for next visit System acceptance Technological issues Health Outcomes: Equivocal Interoperable more powerful Patient health? Patient Safety: Medication & EPR errors - Accuracy/ Interaction - Medication safety Doing harm Confusion, worry & anxiety Unauthorised access Misuses of data Snooping abusers charter Security of records Patient safety about PX and errors in record Errors being errors and omissions Patient Experience: Positive Patient initiated/ patient led. Self-care attitudes/expectations of before and after use Understand records Self efficacy & motivation Patient Satisfaction: Clinician-patient relationship - Communication - Strengthened relations - Facilitated trust/ Partnership of Trust Sharing information - Want to share/ print - Don t want to share Usability - satisfaction paradigm Adherence: With Tx &Px Equity: Patient groups (users/non users) Rates of enrolment Female gender bias in uptake Children >10years Low rates of use in vulnerable groups Chronic disease Opinion of potential users Wednesday, 29 April

21 Findings RQ2 Key Research Question 2: What is the association between online patient access to transactional services provided as part of their ambulatory care computerised record and utilisation of health care and health outcomes Utilisation o f HC: Health Outcomes: Patient Experience: Adherence: - With Px - With attendance Use themes Ease of use Used for Text reminders Preparedness for next visit Method - Portal - Forms - Urgency Non urgent Preventative care Convenience Rate of uptake Time saving System acceptance Endorsement by HCP Motivation Resistance Appropriateness Little evidence from RCTs that prevention and self-management of chronic conditions can be translated into routine clinical care Patient Safety: Medication accuracy Adverse events detected Safeguarding in Seriousness of results Px most wanted Patient initiated patient-led Empowered/ Activated Dialogue direction - Willingness to pay fell Patient Satisfaction: Interaction Timely response Convenience & flexibility Expression of themes Clinician-patient relationship Communication Equity: - Different providers vary in their response to - Ethnicity Patient groups (users/ non users) Users = Older female & chronic disease Users = Higher Edu & income, & good health Non-users = Ethnicity Non-users = Lower Edu level/ rural Infrequent = Older, Male, fair-poor health See workflow use Wednesday, 29 April

22 Findings RQ3 Key Research Question 3: What is the association between patient adoption of online access and transactional services as part of their ambulatory care and the practitioner and healthcare team being provided with appropriate support? Education & Training: To reverse fears/negative docs Keeps being raised - but no outcome data System Acceptance based on knowledge Self-efficacy (own ability to complete tasks/ reach goals) Links to quality education material Need to learn to conduct Internet consultations/ CPD Workload & Workflow: U-shaped use ill & healthier Overall effect on workload: Increase Decrease (FU letter, telephone, office visits) Equivocal Lower threshold to contact Dr Key transactions Test results Repeat Px Timeliness of response Time delay Improve efficiencies Issues to consider Integration/ incorporating new systems into workflow of office additional burden on practice Aligning organisational policies with h/c requirements Different specialties Drs perspectives (rewarding) Complying with Regulations & IG: guidance LIST UK (or other) Policy and contractual context Security & IG Clarity/ responsibility for information/ system Concerns with medico-legal risks Lack of practitioner knowledge Written policies Business Process Change: Some issues resolved in one transaction BUT some returning pts i.e. collect Px & 17% come back in 7d Recovering fees / reimbursement Transacts the medical model Strategic vision/ fit Productivity Interaction Timely response Medical authority Greater detail directness / Asynchronous Changes in how the dialogue is directed Changes in style of written notes Wednesday, 29 April

23 Findings RQ4 Key Research Question 4: What is the association between IT developments which provide records access, systems to enhance privacy and security, established transactional and novel technologies, and the business process for developing modified systems and patient adoption and utilisation of online access and transactional services? Usability/ Ease of Access: Ease of communication (although aysn) Internet reliability/ access Uptake rates 6% Security & Privacy Issues: Authorisation Trade off vs. multiple login steps Child access (Gillick competence) Authentication Encryption to secure confidentiality Novel Technologies: Automated test results Video Images X-ray pictures User interface Text messaging to prompt and service requests Web-based triage Security obstacles The better the online service the greater the use PIN Number and Text Waiting room technology Business Process for Technical Developments: Infrastructure change to support on-line access Patient access t o (private) technology Clinician and patient technical skill Current technologies (& policy) don t match Pt & Dr on-line requirements Substitution or complement current services System design Patient feedback Linking data between systems Wednesday, 29 April

24 Implications for Research and Practice (a) Practice + ve Online access to may subtly change the patient physician relationship. Patients may find online services more convenient. Patients have greater ownership over their medical record; something they can view and print. Shift in thought about medical records no longer being the sole provenance of physician. - ve Online access may make it easier to always consult rather than self-manage. Online access may result in variations in service utilisation (especially by specific population groups). Clinicians have to write more carefully/ considered records (more informative/ moderated language). Managers will have to learn what models of delivery ( , face to face, telephone, new technologies) increase or reduce overall workload From this knowledge what approaches might control it. Wednesday, 29 April

25 Implications for Research and Practice (b) Research Health Outcomes Research into online access and services has yet to demonstrate how health outcomes can be improved. Research is also needed for patients with specific long-term conditions (diabetes) which may offer greater insights regarding facilitating better health outcomes. Business Process The wider business process in primary care (the organisation and delivery of health care). To what extent can online services replace/ complement existing care. Technological Advancements To ensure privacy/prevention of abuse issues involved in providing both online access and services How practices can facilitate patients use of technologies. How advancements can integrate into the existing technological infrastructure And whether such technology is efficient and cost-effective. Wednesday, 29 April

26 Implications for Research and Practice (c) Research Willingness to Pay Studies that look at willingness to pay show online access to be of low value (however little research in this area). In the UK s NHS willingness to pay issues might be less relevant (however, again little work has been undertaken in the UK). It may be possible to undertake further research as to whether there is a place for fee paying compared with the UK norm of publicly funded health care. Patient Safety Encouraging patients to access online EHR and services are a promising way to enhance safety. Further research is needed into how patients use their access to EHR, how patient-added data are used, how they may improve care by providing insight (health beliefs and knowledge about condition). While there have been a number of trials conducted in the US, such evidence from the UK is scarce. Further research into the feasibility of implementing complete online access (record access and transactional services) across the UK would provide valuable insight into how to implement such a service. Wednesday, 29 April

27 Summary Patients Ultimately patients online access to their EHR and services reported increased convenience and satisfaction. This access positively impacted on patient safety. Patients report specific benefits of record access Enabling better self-care Enabling better patient clinician communication, However.patients were unwilling to pay for these services. Professionals Prior to implementation of online systems clinicians were concerned about any possible workload rise. However, post-intervention work suggests clinicians concerns are largely unrealised. The nature of the medical record and the role of the clinician may need to evolve to give greater value to patients and to ensure greater equity in uptake. Organisation The business model for primary care may need to change to enable more effective utilisation of information technology in everyday practice. Wednesday, 29 April

28 Media - NHS, DT, BMA, Guardian Wednesday, 29 April

29 Publications Mold F, de Lusignan S et al. Patients' online access to their electronic health records and linked online services: a systematic review in primary care. Br J Gen Pract Mar; 65 (632): e Lusignan S, Mold F, Sheikh A, et al. Patients online access to their electronic health records and linked online services: a systematic interpretative review. BMJ Open 2014; 4: (9) e Mold F, Ellis B, de Lusignan S et al. The provision and impact of online patient access to their electronic health records (EHR) and transactional services on the quality and safety of health care: systematic review protocol. Inform Prim Care 2012; 20(4): Wednesday, 29 April

30 Funding This study was part funded by the RCGP as a component of a larger piece of work developing a Road Map to online access to medical records (http://www.rcgp.org. uk/patientonline), and commissioned and funded by the Department of Health. PROSPERO (International Prospective Register of Systematic Reviews) Registration Number: CRD Wednesday, 29 April

31 Questions? Wednesday, 29 April

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