Patient Portal Implementation and Uptake: Qualitative Comparative Case Study.

BACKGROUND: Giving patients access to their health information is a provincial and national goal, and it is critical to the delivery of patient-centered care. With this shift, patient portals have become more prevalent. In Alberta, the Alberta Health Services piloted a portal (MyChart). There was a need to identify factors that promoted the use of this portal. Furthermore, it was imperative to understand why there was variability in uptake within the various clinics that participated in the pilot. OBJECTIVE: This study aims to identify potential factors that could improve the uptake of MyChart from the perspectives of both users and nonusers at pilot sites. We focused on factors that promoted the use of MyChart along with related benefits and barriers to its use, with the intention that this information could be incorporated into the plan for its province-wide implementation. METHODS: A qualitative comparative case study was conducted to determine the feasibility, acceptability, and initial perceptions of users and to identify ways to increase uptake. Semistructured interviews were conducted with 56 participants (27 patients, 21 providers, 4 nonmedical staff, and 4 clinic managers) from 5 clinics. Patients were asked about the impact of MyChart on their health and health care. Providers were asked about the impact on the patient-provider relationship and workflow. Managers were asked about barriers to implementation. The interviews were recorded, transcribed verbatim, and entered into NVivo. A thematic analysis was used to analyze the data. RESULTS: Results from a comparison of factors related to uptake of MyChart in 5 clinics (2 clinics with high uptake, 1 with moderate uptake, 1 with low uptake, and 1 with no uptake) are reported. Some theoretical constructs in our study, such as intention to use, perceived value, similarity (novelty) of the technology, and patient health needs, were similar to findings published by other research teams. We also identified some new factors associated with uptake, including satisfaction or dissatisfaction with the current status quo, performance expectancy, facilitating conditions, behavioral intentions, and use behavior. All these factors had an impact on the level of uptake in each setting and created different opportunities for end users. CONCLUSIONS: There is limited research on factors that influence the uptake of patient portals. We identified some factors that were consistent with those reported by others but also several new factors that were associated with the update of MyChart, a new patient portal, in the clinics we studied. On the basis of our results, we posit that a shared understanding of the technology among patients, clinicians, and managers, along with dissatisfaction with nonportal-based communications, is foundational and must be addressed for patient portals to support improvements in care.

Tracing the Decisions That Shaped the Development of MyChart, an Electronic Patient Portal in Alberta, Canada: Historical Research Study.

BACKGROUND: Understanding how health organizations decide on information technology (IT) investments is imperative to ensure successful implementation and adoption. There is a high rate of failure and a tendency to downplay the complexity of implementation progression. Alberta Health Services introduced a patient portal called MyChart. Although MyChart allows patients to view appointments and selected laboratory results and to communicate with their providers, its uptake varies. OBJECTIVE: The study aimed to examine the institutional decision-making processes that shaped the development and implementation of MyChart. METHODS: A historical study was conducted based on the 7-step framework, where one engages in a rigorous archival critical analysis (including internal and external criticism) of documents and analysis of interviews. We reviewed and analyzed 423 primary and secondary sources and interviewed 10 key decision makers. RESULTS: Supportive leadership, project management, focused scope, appropriate technology and vendor selection, and quick decision making were some of the facilitators that allowed for the growth of proof of concept. The planning and implementation stages did not depend much on the technology itself but on the various actors who influenced the implementation by exerting power. The main barriers were lack of awareness about the technology, proper training, buy-in from diverse system leaders, and centralized government decision making. CONCLUSIONS: Organizational priorities and decision-making tactics influence IT investments, implementation, adoption, and outcomes. Future research could focus on improving the applicability of needs assessments and funding decisions to health care scenarios.

Effects of a Web-Based Patient Portal on Patient Satisfaction and Missed Appointment Rates: Survey Study.

BACKGROUND: Although electronic medical record (EMR)-tethered patient portals are common in other countries, they are still emerging in Canada. OBJECTIVE: We aimed to report user satisfaction and the effects of a patient portal on medical appointment attendance in a Canadian cohort of patients within our publicly funded health care system. METHODS: Two surveys were deployed, via email, at 2 weeks and 6 months following the first recorded patient portal access. Database audits of visit attendance were used to supplement and cross reference survey data. RESULTS: Between January 2016 and July 2018, 4296 patients accessed the patient portal. During the study, 28% (957/3421) consented patient portal users responded to one or more semistructured electronic surveys. Of respondents, 93% (891/957) reported that the patient portal was easy to use, 51% (492/975) reported it saved time when scheduling an appointment, and 40% (382/957) reported that they had to repeat themselves less during appointments. Respondents reported patient portal-related changes in health system use, with 48% (462/957) reporting avoiding a clinic visit and 2.7% (26/957) avoiding an emergency department visit. Across 19,968 visits in clinics where the patient portal was introduced, missed appointments were recorded in 9.5% (858/9021) of non-patient portal user visits, compared with 4.5% (493/9021) for patient portal users, representing a 53% relative reduction in no-show rates. CONCLUSIONS: Early experience with an EMR-tethered patient portal showed strong reports of positive patient experience, a self-reported decrease in health system use, and a measured decrease in missed appointment rates. Implications on the expanded use of patient portals requires more quantitative and qualitative study in Canada.

Validation of the Work Observation Method By Activity Timing (WOMBAT) method of conducting time-motion observations in critical care settings: an observational study.

BACKGROUND: Electronic documentation handling may facilitate information flows in health care settings to support better coordination of care among Health Care Providers (HCPs), but evidence is limited. Methods that accurately depict changes to the workflows of HCPs are needed to assess whether the introduction of a Critical Care clinical Information System (CCIS) to two Intensive Care Units (ICUs) represents a positive step for patient care. To evaluate a previously described method of quantifying amounts of time spent and interruptions encountered by HCPs working in two ICUs. METHODS: Observers used PDAs running the Work Observation Method By Activity Timing (WOMBAT) software to record the tasks performed by HCPs in advance of the introduction of a Critical Care clinical Information System (CCIS) to quantify amounts of time spent on tasks and interruptions encountered by HCPs in ICUs. RESULTS: We report the percentages of time spent on each task category, and the rates of interruptions observed for physicians, nurses, respiratory therapists, and unit clerks. Compared with previously published data from Australian hospital wards, interdisciplinary information sharing and communication in ICUs explain higher proportions of time spent on professional communication and documentation by nurses and physicians, as well as more frequent interruptions which are often followed by professional communication tasks. CONCLUSIONS: Critical care workloads include requirements for timely information sharing and communication and explain the differences we observed between the two datasets. The data presented here further validate the WOMBAT method, and support plans to compare workflows before and after the introduction of electronic documentation methods in ICUs.

Critical care providers refer to information tools less during communication tasks after a critical care clinical information system introduction.

Electronic documentation methods may assist critical care providers with information management tasks in Intensive Care Units (ICUs). We conducted a quasi-experimental observational study to investigate patterns of information tool use by ICU physicians, nurses, and respiratory therapists during verbal communication tasks. Critical care providers used tools less at 3 months after the CCIS introduction. At 12 months, care providers referred to paper and permanent records, especially during shift changes. The results suggest potential areas of improvement for clinical information systems in assisting critical care providers in ensuring informational continuity around their patients.

Impact of a critical care clinical information system on interruption rates during intensive care nurse and physician documentation tasks.

Computerized documentation methods in Intensive Care Units (ICUs) may assist Health Care Providers (HCP) with their documentation workload, but evaluating impacts remains problematic. A Critical Care clinical Information System (CCIS) is an electronic charting tool designed for ICUs that may fit seamlessly into HCP work. Observers followed ICU nurses and physicians in two ICUs in Edmonton, Canada, in which a CCIS had recently been introduced. Observers recorded amounts of time HCPs spent on documentation related tasks, interruptions encountered by HCPs, and contextual information in field notes. Interruption rates varied depending on the charting medium used, with physicians being interrupted less frequently when performing documentation tasks using the CCIS, than when performing documentation tasks using other methods. In contrast, nurses were interrupted more frequently when charting using the CCIS than when using other methods. Interruption rates coupled with qualitative observations suggest that physicians utilize strategies to avoid interruptions if interfaces for entering textual notes are not well adapted to interruption-rich environments such as ICUs. Potential improvements are discussed such that systems like the CCIS may better integrate into ICU work.

Emergency Physician Use of the Alberta Netcare Portal, a Province-Wide Interoperable Electronic Health Record: Multi-Method Observational Study.

BACKGROUND: The adoption and use of an electronic health record (EHR) can facilitate real-time access to key health information and support improved outcomes. Many Canadian provinces use interoperable EHRs (iEHRs) to facilitate health information exchange, but the clinical use and utility of iEHRs has not been well described. OBJECTIVE: The aim of this study was to describe the use of a provincial iEHR known as the Alberta Netcare Portal (ANP) in 4 urban Alberta emergency departments. The secondary objectives were to characterize the time spent using the respective electronic tools and identify the aspects that were perceived as most useful by emergency department physicians. METHODS: In this study, we have included 4 emergency departments, 2 using paper-based ordering (University of Alberta Hospital [UAH] and Grey Nuns Community Hospital [GNCH]) and 2 using a commercial vendor clinical information system (Peter Lougheed Centre [PLC] and Foothills Medical Centre [FMC]). Structured clinical observations of ANP use and system audit logs analysis were compared at the 4 sites from October 2014 to March 2016. RESULTS: Observers followed 142 physicians for a total of 566 hours over 376 occasions. The median percentage of observed time spent using ANP was 8.5% at UAH (interquartile range, IQR, 3.7%-13.3%), 4.4% at GNCH (IQR 2.4%-4.4%), 4.6% at FMC (IQR 2.4%-7.6%), and 5.1% at PLC (IQR 3.0%-7.7%). By combining administrative and access audit data, the median number of ANP screens (ie, results and reports displayed on a screen) accessed per patient visit were 20 at UAH (IQR 6-67), 9 at GNCH (IQR 4-29), 7 at FMC (IQR 2-18), and 5 at PLC (IQR 2-14). When compared with the structured clinical observations, the statistical analysis of screen access data showed that ANP was used more at UAH than the other sites. CONCLUSIONS: This study shows that the iEHR is well utilized at the 4 sites studied, and the usage patterns implied clinical value. Use of the ANP was highest in a paper-based academic center and lower in the centers using a commercial emergency department clinical information system. More study about the clinical impacts of using iEHRs in the Canadian context including longer term impacts on quality of practice and safety are required.

A BMP-mediated transcriptional cascade involving Cash1 and Tlx-3 specifies first-order relay sensory neurons in the developing hindbrain.

The divergent homeobox-containing transcription factor, Tlx-3 (also known as Hox11L2/Rnx), is required for proper formation of first-order relay sensory neurons in the developing vertebrate brainstem. To date, however, the inductive signals and transcriptional regulatory cascade underlying their development are poorly understood. We previously isolated the chick Tlx-3 homologue and showed it is expressed early (i.e. beginning at HH15) in distinct subcomponents of both the trigeminal/solitary and vestibular nuclei. Here we show via in vivo rhombomere inversions that expression of Tlx-3 is under control of local environmental signals. Our RNA in situ analysis shows expression of the BMP-specific receptor, Bmpr-1b, correlates well with Tlx-3. Furthermore, manipulation of the BMP signaling pathway in vivo via electroporation of expression vectors encoding either BMP or NOGGIN coupled with MASH1 gain-of-function experiments demonstrate that a BMP-mediated transcriptional cascade involving Cash1 and Tlx-3 specifies first-order relay sensory neurons in the developing brainstem. Notably, high-level Noggin misexpression results in an increase in newly differentiated Tlx-3+ neurons that correlates with a corresponding increase in the number of Calretinin+ neurons in vestibular nuclei at later developmental stages strongly suggesting that Tlx-3, in addition to being required for proper formation of somatic as well as visceral sensory neurons in the trigeminal and solitary nuclei, respectively, is sufficient for proper formation of special somatic sensory neurons in vestibular nuclei.

Adaptations in the walking pattern of spinal cord injured rats.

Walking ability is a measure of recovery used in many studies that test experimental strategies to treat injuries or diseases of the central nervous system (CNS) in animal models. A common measure in the rat animal model of thoracic spinal cord injury (SCI) is visual inspection and scoring of hind limb activity, which allows the documentation of movements associated with the recovery of locomotor function. In this study, we expand on previously documented visible changes in the locomotor pattern following SCI. The spontaneous recovery of locomotion in rats with thoracic SCIs of variable extent was evaluated using electromyographic (EMG) and kinematic analysis while rats walked on an elevated runway. Comparisons with pre-lesion walking sequences revealed changes in the kinematics and in the muscle activation pattern of various muscles, including enhanced fore limb extensor activity, possibly reflecting an increased contribution to propulsion, altered recruitment of back muscles inserting into the hip (possibly to support stepping movements), and elevated posture during stance, which may compensate for deficits in weight support. These changes were noted in spinal cord injured rats with varying degrees of impairment, including animals with no visually detectable deficit in open-field walking. In summary, the presented results demonstrate that spinal cord injured rats develop alternative locomotor patterns following SCI that cannot be discriminated by the use of qualitative visually based analysis, thus urging the use of quantitative outcome measures in assessing motor function after SCI.

Task specific adaptations in rat locomotion: runway versus horizontal ladder.

In walking quadrupeds the alternating activity pattern of antagonistic leg muscles and the coordination between legs is orchestrated by central pattern generating networks within the spinal cord. These networks are activated by tonic input from the reticular formation in the brainstem. Under more challenging conditions, such as walking on a horizontal ladder, successful locomotion relies upon additional context dependent input from pathways such as the cortico- and rubro-spinal tracts. In this study we used electromyographic and kinematic approaches to characterize the adaptations in the walking pattern in adult uninjured rats crossing a horizontal ladder. We found that the placement of a hind limb on a rung precisely followed the placement of the ipsilateral fore limb. This is different to normal walking where the hind limb is placed behind the position of the ipsilateral fore limb. The increased reach of the hind limbs is achieved by increased flexion of the hip and rotation of the pelvis during the swing phase. Electromyographic observations showed decreased burst duration in Tibialis anterior an ankle flexor muscle. Further changes in the muscle activity pattern were likely due to the reduced stepping frequency during ladder walking. Following a lesion of the dorsal column, containing major parts of the corticospinal tract, we found an increased number of stepping errors and changes in the stepping strategy. The step length of the fore limbs was reduced and the hind limbs were frequently positioned on rungs other than those occupied by the fore limb.

Physicians' use of computerized clinical decision supports to improve medication management in the elderly - the Seniors Medication Alert and Review Technology intervention.

BACKGROUND: Elderly people (aged 65 years or more) are at increased risk of polypharmacy (five or more medications), inappropriate medication use, and associated increased health care costs. The use of clinical decision support (CDS) within an electronic medical record (EMR) could improve medication safety. METHODS: Participatory action research methods were applied to preproduction design and development and postproduction optimization of an EMR-embedded CDS implementation of the Beers' Criteria for medication management and the Cockcroft-Gault formula for estimating glomerular filtration rates (GFR). The "Seniors Medication Alert and Review Technologies" (SMART) intervention was used in primary care and geriatrics specialty clinics. Passive (chart messages) and active (order-entry alerts) prompts exposed potentially inappropriate medications, decreased GFR, and the possible need for medication adjustments. Physician reactions were assessed using surveys, EMR simulations, focus groups, and semi-structured interviews. EMR audit data were used to identify eligible patient encounters, the frequency of CDS events, how alerts were managed, and when evidence links were followed. RESULTS: Analysis of subjective data revealed that most clinicians agreed that CDS appeared at appropriate times during patient care. Although managing alerts incurred a modest time burden, most also agreed that workflow was not disrupted. Prevalent concerns related to clinician accountability and potential liability. Approximately 36% of eligible encounters triggered at least one SMART alert, with GFR alert, and most frequent medication warnings were with hypnotics and anticholinergics. Approximately 25% of alerts were overridden and ~15% elicited an evidence check. CONCLUSION: While most SMART alerts validated clinician choices, they were received as valuable reminders for evidence-informed care and education. Data from this study may aid other attempts to implement Beers' Criteria in ambulatory care EMRs.

Attitudes and beliefs about hand hygiene among paediatric residents: a qualitative study.

BACKGROUND: Despite the knowledge that contaminated hands play an important role in the transmission of healthcare-associated pathogens, and that hand hygiene (HH) reduces the transmission of these organisms, healthcare worker's adherence with HH is poor. OBJECTIVE: To understand the common beliefs and attitudes held by paediatric residents about HH. DESIGN: Qualitative study design. SETTING: Tertiary care paediatric hospital in Edmonton, Canada. METHODS: Semistructured interviews were conducted and themes were identified from interviews. PARTICIPANTS: 22 paediatric residents. RESULTS: Paediatric residents self-reported their HH adherence at 70-99% and perceived hospital-wide adherence at 45-80%. Four major themes were identified during interviews including the importance of role modelling, balancing time spent on HH with other competing factors, self-protection as a driving factor for HH and cues as an important part of habit that stimulate HH. CONCLUSIONS: Staff physicians were viewed as integral to initiating group HH events, but at times, the first person in the room acted as a role model for the rest of the group. In certain instances, such as a cardiac arrest, decreased adherence with HH was viewed as acceptable. Residents engaged in HH to protect their own health. Residents relied on personal cues, which they integrated into their own HH habit. Future HH adherence strategies should ensure that the physician training environments permit the formation of good attitudes and habits towards HH. There are no additional data available.

Spontaneous locomotor recovery in spinal cord injured rats is accompanied by anatomical plasticity of reticulospinal fibers.

Although injured axons in mammalian spinal cords do not regenerate, some recovery of locomotor function following incomplete injury can be observed in patients and animal models. Following a lateral hemisection injury of the thoracic spinal cord, rats spontaneously recover weight-bearing stepping in the hind limb ipsilateral to the injury. The mechanisms behind this recovery are not completely understood. Plasticity in the reticulospinal tract (RtST), the tract responsible for the initiation of walking, has not been studied. In this study, rats received lateral thoracic hemisection of the spinal cord, and RtST projections were compared in two groups of rats, one early in recovery (7 days) and the other at a time point when weight-bearing stepping was fully regained (42 days). We found that this recovery occurs in parallel with increased numbers of collaterals of spared RtST fibers entering the intermediate lamina below the injury at L2. Sprouting of injured RtST fibers above the lesion was not found. In conclusion, our study suggests that sprouting of spared RtST fibers might be involved in the recovery of locomotion following incomplete spinal cord injury.

The unilateral 6-OHDA rat model of Parkinson's disease revisited: an electromyographic and behavioural analysis.

The characteristic locomotor disturbances of Parkinson's disease (PD) include shuffling gait, short steps and low walking velocity. In this study we investigated features of walking and turning in a rat model of PD caused by unilateral infusion of the neurotoxin 6-hydroxydopamine (6-OHDA). We assessed gait and electromyographic (EMG) patterns of the ankle flexor tibialis anterior and the knee extensor vastus lateralis of the hindlimb, and triceps brachii of the forelimb, during overground locomotion, spontaneous rotation (turning) and apomorphine-induced rotation. When compared with control rats, rats with unilateral dopamine depletion displayed a shuffling gait and short stride lengths. This locomotor pattern was accompanied by prolonged ankle flexor activity on the ipsilateral side, and prolonged activity of knee extensors on the contralateral side. The dopamine depletion also led to enhanced contraversive rotations after an apomorphine challenge. The EMG recordings during drug-induced rotation suggested that hindlimb stepping was a reflective response to an active drive produced by forelimbs. The EMG recordings of the contralateral side during rotation were marked by reduced ankle flexor activity and increased knee extensor activity. Furthermore, EMG recordings indicated that dopamine-agonists induce rotational bias by altering the coupling between ipsi- and contralateral hindlimbs, and between forelimbs. In straight walking, however, the gait of 6-OHDA lesion animals reflected normal, coupled hindlimb stepping as controlled by spinal pattern generators. The data suggest that the unilateral rat model of PD resembles key features of human parkinsonian gait, and that asymmetric descending input may underlie the observed changes in gait patterns.