Shifting Mindsets: The Impact of a Patient Portal on Functioning and Recovery in a Mental Health Setting.

OBJECTIVE: This study aims to understand whether higher use of a patient portal can have an impact on mental health functioning and recovery. METHOD: A mixed methods approach was used for this study. In 2019-2021, patients with mental health diagnoses at outpatient clinics in an academic centre were invited to complete World Health Organization Disability Assessment Scale 12 (WHODAS-12) and Mental Health Recovery Measure surveys at baseline, 3 months, and 6 months after signing up for the portal. At the 3-month time point, patients were invited to a semistructured interview with a member of the team to contextualize the findings obtained from the surveys. Analytics data was also collected from the platform to understand usage patterns on the portal. RESULTS: Overall, 113 participants were included in the analysis. There was no significant change in mental health functioning and recovery scores over the 6-month period. However, suboptimal usage was observed as 46% of participants did not complete any tasks within the portal. Thirty-five participants had low use of the portal (1-9 interactions) and 18 participants had high usage (10+ interactions). There were also no differences in mental health functioning and recovery scores between low and high users of the portal. Qualitative interviews highlighted many opportunities where the portal can support overall functioning and mental health recovery. CONCLUSIONS: Collectively, this study suggests that higher use of a portal had no impact, either positive or negative, on mental health outcomes. While it may offer convenience and improved patient satisfaction, adequate support is needed to fully enable these opportunities for patient care. As the type of interaction with the portal was not specifically addressed, future work should focus on looking at ways to support patient engagement and portal usage throughout their care journey.

Recommendations to Enhance Physical Health for Individuals with Severe Mental Illness in Canadian Healthcare Organizations.

As Canadians with severe mental illness remain underserved and experience a high burden of physical health challenges and premature mortality, there is an unprecedented need to provide better physical healthcare to this population. Ways of addressing this gap include the delivery of physical healthcare in mental health settings ("reverse integration"). However, there is limited guidance on how to enact this integration. In this article, we outline the development of an integrated care strategy in Canada's largest mental health hospital and discuss system- and policy-level recommendations that healthcare organizations could consider in their initiatives.

Changes in Alcohol Consumption in Canada During the COVID-19 Pandemic: Associations With Anxiety and Self-Perception of Depression and Loneliness.

AIM: To examine whether changes in alcohol consumption in Canada since the start of the novel coronavirus disease (COVID-19) pandemic are associated with feelings of anxiety, depression, loneliness and/or with changes in employment due to COVID-19. METHODS: Data collection occurred between 29 May 2020 and 23 March 2021 via a web panel, AskingCanadians, which sampled 5892 adults (≥18 years of age). Data were collected on changes in alcohol consumption compared to before the pandemic (ordinal variable ranging from 1='much less alcohol' to 5='much more alcohol'), anxiety (General Anxiety Disorder-7), self-perceived depression (Center for Epidemiologic Studies Depression Scale), self-perceived loneliness, changes in employment status due to COVID-19 and socio-demographic variables (age, gender, living situation, household income and urban vs rural residence). Multivariate associations were assessed using ordinal logistic regression. Effect modification by gender was tested using likelihood-ratio tests. RESULTS: Changes in alcohol consumption were positively associated with anxiety, feeling depressed and loneliness. In particular, people with mild to moderate (ordered Odds Ratio (OR):1.23, 95% Confidence Interval (CI):1.07, 1.62) or severe anxiety (ordered OR:1.49, 95% CI:1.15, 1.93) had a greater odds of increased drinking than did people with no to low levels of anxiety. Gender, age, household income, living situation and survey wave were also associated with changes in drinking. No effect modifications by gender were observed. CONCLUSION: Given the health harms caused by alcohol use, public health practitioners and primary care physicians should focus health messaging to identify and support individuals at risk of increased alcohol consumption, especially people experiencing depression, loneliness or anxiety.

Tackling the Burden of Electronic Health Record Use Among Physicians in a Mental Health Setting: Physician Engagement Strategy.

The burden associated with using the electronic health record system continues to be a critical issue for physicians and is potentially contributing to physician burnout. At a large academic mental health hospital in Canada, we recently implemented a Physician Engagement Strategy focused on reducing the burden of electronic health record use through close collaboration with clinical leadership, information technology leadership, and physicians. Built on extensive stakeholder consultation, this strategy highlights initiatives that we have implemented (or will be implementing in the near future) under four components: engage, inspire, change, and measure. In this viewpoint paper, we share our process of developing and implementing the Physician Engagement Strategy and discuss the lessons learned and implications of this work.

Identifying and adapting interventions to reduce documentation burden and improve nurses' efficiency in using electronic health record systems (The IDEA Study): protocol for a mixed methods study.

BACKGROUND: Although EHR systems have become a critical part of clinical care, nurses are experiencing a growing burden due to documentation requirements, taking time away from other important clinical activities. There is a need to address the inefficiencies and challenges that nurses face when documenting in and using EHRs. The objective of this study is to engage nurses in generating ideas on how organizations can support and optimize nurses' experiences with their EHR systems, thereby improving efficiency and reducing EHR-related burden. This work will ensure the identified solutions are grounded in nurses' perspectives and experiences and will address their specific EHR-related needs. METHODS: This mixed methods study will consist of three phases. Phase 1 will evaluate the accuracy of the EHR system's analytics platform in capturing how nurses utilize the system in real-time for tasks such as documentation, chart review, and medication reconciliation. Phase 2 consists of a retrospective analysis of the nursing-specific analytics platform and focus groups with nurses to understand and contextualize their usage patterns. These focus groups will also be used to identify areas for improvement in the utilization of the EHR. Phase 3 will include focus groups with nurses to generate and adapt potential interventions to address the areas for improvement and assess the perceived relevance, feasibility, and impact of the potential interventions. DISCUSSION: This work will generate insights on addressing nurses' EHR-related burden and burnout. By understanding and contextualizing inefficiencies and current practices, opportunities to improve EHR systems for nursing professional practice will be identified. The study findings will inform the co-design and implementation of interventions that will support adoption and impact. Future work will include the evaluation of the developed interventions, and research on scaling and disseminating the interventions for use in different organizations, EHR systems, and jurisdictions in Canada.

Digitization of Measurement-Based Care Pathways in Mental Health Through REDCap and Electronic Health Record Integration: Development and Usability Study.

BACKGROUND: The delivery of standardized self-report assessments is essential for measurement-based care in mental health. Paper-based methods of measurement-based care data collection may result in transcription errors, missing data, and other data quality issues when entered into patient electronic health records (EHRs). OBJECTIVE: This study aims to help address these issues by using a dedicated instance of REDCap (Research Electronic Data Capture; Vanderbilt University)-a free, widely used electronic data capture platform-that was established to enable the deployment of digitized self-assessments in clinical care pathways to inform clinical decision making. METHODS: REDCap was integrated with the primary clinical information system to facilitate the real-time transfer of discrete data and PDF reports from REDCap into the EHR. Both technical and administrative components were required for complete implementation. A technology acceptance survey was also administered to capture physicians' and clinicians' attitudes toward the new system. RESULTS: The integration of REDCap with the EHR transitioned clinical workflows from paper-based methods of data collection to electronic data collection. This resulted in significant time savings, improved data quality, and valuable real-time information delivery. The digitization of self-report assessments at each appointment contributed to the clinic-wide implementation of the major depressive disorder integrated care pathway. This digital transformation facilitated a 4-fold increase in the physician adoption of this integrated care pathway workflow and a 3-fold increase in patient enrollment, resulting in an overall significant increase in major depressive disorder integrated care pathway capacity. Physicians' and clinicians' attitudes were overall positive, with almost all respondents agreeing that the system was useful to their work. CONCLUSIONS: REDCap provided an intuitive patient interface for collecting self-report measures and accessing results in real time to inform clinical decisions and an extensible backend for system integration. The approach scaled effectively and expanded to high-impact clinics throughout the hospital, allowing for the broad deployment of complex workflows and standardized assessments, which led to the accumulation of harmonized data across clinics and care pathways. REDCap is a flexible tool that can be effectively leveraged to facilitate the automatic transfer of self-report data to the EHR; however, thoughtful governance is required to complement the technical implementation to ensure that data standardization, data quality, patient safety, and privacy are maintained.

The Influence of Electronic Health Record Use on Physician Burnout: Cross-Sectional Survey.

BACKGROUND: Physician burnout has a direct impact on the delivery of high-quality health care, with health information technology tools such as electronic health records (EHRs) adding to the burden of practice inefficiencies. OBJECTIVE: The aim of this study was to determine the extent of burnout among physicians and learners (residents and fellows); identify significant EHR-related contributors of physician burnout; and explore the differences between physicians and learners with regard to EHR-related factors such as time spent in EHR, documentation styles, proficiency, training, and perceived usefulness. In addition, the study aimed to address gaps in the EHR-related burnout research methodologies by determining physicians' patterns of EHR use through usage logs. METHODS: This study used a cross-sectional survey methodology and a review of administrative data for back-end log measures of survey respondents' EHR use, which was conducted at a large Canadian academic mental health hospital. Chi-square and Fisher exact tests were used to examine the association of EHR-related factors with general physician burnout. The survey was sent out to 474 individuals between May and June 2019, including physicians (n=407), residents (n=53), and fellows (n=14), and we measured physician burnout and perceptions of EHR stressors (along with demographic and practice characteristics). RESULTS: Our survey included 208 respondents, including physicians (n=176) and learners (n=32). The response rate was 43.2% for physicians (full-time: 156/208, 75.0%; part-time: 20/199, 10.1%), and 48% (32/67) for learners. A total of 25.6% (45/176) of practicing physicians and 19% (6/32) of learners reported having one or more symptoms of burnout, and 74.5% (155/208) of all respondents who reported burnout symptoms identified the EHR as a contributor. Lower satisfaction and higher frustration with the EHRs were significantly associated with perceptions of EHR contributing toward burnout. Physicians' and learners' experiences with the EHR, gathered through open-ended survey responses, identified challenges around the intuitiveness and usability of the technology as well as workflow issues. Metrics gathered from back-end usage logs demonstrated a 13.6-min overestimation in time spent on EHRs per patient and a 5.63-hour overestimation of after-hours EHR time, when compared with self-reported survey data. CONCLUSIONS: This study suggests that the use of EHRs is a perceived contributor to physician burnout. There should be a focus on combating physician burnout by reducing the unnecessary administrative burdens of EHRs through efficient implementation of systems and effective postimplementation strategies.

Electronic Health Record-Related Burnout among Clinicians: Practical Recommendations for Canadian Healthcare Organizations.

The use of electronic health record (EHR) systems has led to numerous discussions about their possible contribution to clinician burnout. However, discussions regarding effective strategies to reduce burnout of this nature have been few. This article reviews initiatives and strategies aimed at combatting EHR-related burnout and provides recommendations for Canadian contexts. While approaches for measuring and reducing EHR-related physician burnout were identified, this paper highlights a paucity of evidence surrounding EHR-associated burnout among non-physician clinicians and the efficacy of interventions aimed at reducing burnout. Based on the findings, this article proposes recommendations for optimizing EHR usage to potentially reduce burnout.

Utilizing an Informatics Engagement Strategy as an Approach to Sustain and Retain the Nursing Workforce.

The purpose of this paper is to describe a nursing informatics engagement strategy at an academic teaching hospital in Canada aimed at sustaining and retaining the nursing workforce by (1) enhancing nursing engagement and leadership in informatics decision making; (2) improving nurses' experiences using the electronic health record (EHR) by creating a process of rapid handling of technology issues; (3) leveraging data about nurses' EHR system use to identify opportunities to further streamline documentation; and (4) enhancing and optimizing informatics education/training and communication strategies. The nursing informatics strategy aims to improve engagement among nursing staff, as well as decrease the burden of using the EHR as a way of addressing possible causes of burnout.

Accuracy of Physician Electronic Health Record Usage Analytics using Clinical Test Cases.

Usage log data are an important data source for characterizing the potential burden related to use of the electronic health record (EHR) system. However, the utility of this data source has been hindered by concerns related to the real-world validity and accuracy of the data. While time-motion studies have historically been used to address this concern, the restrictions caused by the pandemic have made it difficult to carry out these studies in-person. In this regard, we introduce a practical approach for conducting validation studies for usage log data in a controlled environment. By developing test runs based on clinical workflows and conducting them within a test EHR environment, it allows for both comparison of the recorded timings and retrospective investigation of any discrepancies. In this case report, we describe the utility of this approach for validating our physician EHR usage logs at a large academic teaching mental health hospital in Canada. A total of 10 test runs were conducted across 3 days to validate 8 EHR usage log metrics, finding differences between recorded measurements and the usage analytics platform ranging from 9 to 60%.

The Impact of the COVID-19 Pandemic on Physician Electronic Health Record Use and Burden at a Canadian Mental Health Hospital.

The COVID-19 Pandemic has significantly changed the delivery of care through new workflows and models of care. However, the impact of these changes on the usage of electronic health record (EHR) systems remains unclear. This mixed method study aims to understand how EHR usage patterns changed between the pandemic onset and the pre-pandemic period at a Canadian mental health hospital, using an analysis of EHR usage log data and a qualitative focus group. An increase in after-hours EHR usage and documentation time per patient was observed, as well as a decrease in order time. Virtual care (VC) use also had an impact on time spent per patient within the EHR and after-hours EHR usage. Qualitative results highlighted physician concerns related to VC workflows and documentation, which contributed to additional EHR burden. Future work should focus on different contexts and developing relevant interventions to address these issues.

Planning for the Future of Digital Mental Health in Canada: Priorities of Canadians Affected by Mental Health Conditions.

Digital mental health tools have the potential to support people affected by mental health conditions. A pan-Canadian survey was conducted to understand the current and future digital health needs. The results show that Canadians prioritized tools that support them in navigating the physical and digital mental healthcare systems and that are integrated into their care.

Canadian perspectives of digital mental health supports: Findings from a national survey conducted during the COVID-19 pandemic.

Objectives: The impact of the COVID-19 pandemic on population mental health has highlighted the potential for digital mental health to support the needs of those requiring care. This study sought to understand the digital mental health experiences and priorities of Canadians affected by mental health conditions (i.e. seekers, patients, and care partners). Methods: A national cross-sectional electronic survey of Canadians was administered through a market research firm's survey panel. Seekers, patients, and care partners were asked about their digital mental health experiences (e.g. uptake, barriers to access) and priorities. Survey responses were summarized using descriptive statistics. Results: Overall, 1003 participants completed the survey. 70.2% of participants routinely use digital mental health supports to support themselves or those they care for; however, only 28.6% of participants are satisfied with the available digital mental health supports. Most participants (73.3%) have encountered some barriers when accessing digital mental health supports. Awareness of digital mental health supports was a top barrier identified by participants. The top digital mental health priorities consisted of digital mental health curation, navigation, and a digital mental health passport. Conclusions: Most participants use digital mental health supports for themselves or others, however, many are unaware of digital mental health supports available. Efforts to improve navigating access to digital and in-person mental health services are seen as a top priority, highlighting the need to enable seekers, patients, and care partners to find the appropriate support and make decisions on how to best improve their mental health.

Household composition and anxiety symptoms during the COVID-19 pandemic: A population-based study.

INTRODUCTION: Household composition may be an important factor associated with anxiety during the COVID-19 pandemic as people spend more time at home due to physical distancing and lockdown restrictions. Adults living with children-especially women-may be particularly vulnerable to anxiety as they balance additional childcare responsibilities and homeschooling with work. The objective of this study was to examine the association between household composition and anxiety symptoms during the COVID-19 pandemic and explore gender as an effect modifier. METHODS: Data were derived from seven waves of a national online survey of Canadian adults aged 18+ years from May 2020 to March 2021, which used quota sampling by age, gender, and region proportional to the English-speaking Canadian population (n = 7,021). Multivariable logistic and modified least-squares regression models were used. RESULTS: Compared to those living alone, significantly greater odds of anxiety symptoms were observed among single parents/guardians (aOR = 2.00; 95%CI: 1.41-2.84), those living with adult(s) and child(ren) (aOR = 1.39; 95%CI: 1.10-1.76), and those living with adult(s) only (aOR = 1.22; 95%CI: 1.00-1.49). Gender was a significant effect modifier on the additive scale (p = 0.0487) such that the association between living with child(ren) and anxiety symptoms was stronger among men than women. CONCLUSION: Additional tailored supports are needed to address anxiety among adults living with children-especially men-during the COVID-19 pandemic and future infectious disease events.

Age differences in the association between loneliness and anxiety symptoms during the COVID-19 pandemic.

Loneliness and associated mental health problems are of particular concern during the COVID-19 pandemic due to physical distancing and lockdown restrictions. Loneliness is most common among young adults and women during the pandemic, but it is unclear if the association between loneliness and mental health problems, notably anxiety, is strongest in these groups. The objective of this study was to examine whether the association between loneliness and anxiety differed by age and/or gender during the pandemic. We analyzed data from a multi-wave national online survey of Canadians aged 18+ years from May 2020 to March 2021 (n = 7,021). Multivariable modified least-squares regression was used to examine whether the association between loneliness and moderate to severe anxiety symptoms (GAD-7 10+) differed by age and/or gender on the additive scale, controlling for socio-demographic factors, depression, hopefulness, and survey wave. Age significantly moderated the association between loneliness and anxiety symptoms while gender did not. Loneliness was associated with anxiety symptoms for all age groups, but the association was not as strong among those aged 70+ years compared to other age groups. Evidence-based loneliness interventions that target younger adults are needed to mitigate the mental health effects of infectious disease events such as COVID-19.

Daily cannabis use during the novel coronavirus disease (COVID-19) pandemic in Canada: a repeated cross-sectional study from May 2020 to December 2020.

BACKGROUND: Daily cannabis use is most strongly implicated in the cannabis-attributable burden of disease. In the context of the novel coronavirus disease (COVID-19) pandemic in Canada, we characterized trends in daily cannabis use in the overall sample and various population subgroups, and examined risk characteristics associated with daily cannabis use. METHODS: A cross-sectional design was operationalized using data from six waves of a national, online survey of adults residing in Canada who spoke English (N = 6,021; May-08 2020 to December-01 2020). Trends were characterized using the Cochran-Armitage test and risk characteristics were identified using chi-square test and logistic regression analysis. RESULTS: Daily cannabis use in the overall sample remained stable (5.34% - 6.10%; p = 0.30). This pattern of findings extended to various population subgroups as well. The odds of daily cannabis use were higher for those who: were males (Odds Ratio; 95% Confidence Interval: 1.46; 1.15 - 1.85), were between 18 - 29 years (2.36; 1.56 - 3.57), 30 - 39 years (2.65; 1.93 - 3.64) or 40-49 years (1.74; 1.19 - 2.54), self-identified as white (1.97; 1.47 - 2.64), had less than college or university completion (1.78; 1.39 - 2.28), engaged in heavy episodic drinking (2.05; 1.62 - 2.61), had a job that increased the risk of contracting COVID-19 (1.38; 1.01 - 1.88), experienced loneliness 5-7 days in the past week (1.86; 1.26 - 2.73) and felt very worried (2.08; 1.21 - 3.58) or somewhat worried (1.83; 1.11 - 3.01) about the pandemic's impact on their financial situation. CONCLUSIONS: Daily cannabis use did not change in the overall sample or various population subgroups during the pandemic. Pandemic-related risks and impacts were associated with daily cannabis use.

Patient and Family Engagement Approaches for Digital Health Initiatives: Protocol for a Case Study.

BACKGROUND: Digital health initiatives such as patient portals, virtual care platforms, and smartphone-based apps are being implemented at a rapid pace in health care organizations worldwide. This is often done to improve access beyond traditional in-person care and enhance care quality. Recent studies have indicated that better outcomes of using these initiatives and technologies may be achieved when patients and their family members are engaged in all aspects of planning, implementation, use, and evaluation. However, little guidance exists for how health care administrators can achieve effective engagement in digital health initiatives specifically. OBJECTIVE: The objective of this study is to document processes related to planning and implementing patient and family engagement (PFE) in digital health initiatives. This information will be used to develop tangible resources (eg, a field guide) that other organizations can use to implement PFE approaches for digital health initiatives in their organizations. METHODS: A previously developed multidimensional conceptual framework for PFE in health and health care contexts will be used to guide this work. To understand the intricacies involved in using PFE approaches in digital health strategies, a case study will be conducted. More specifically, this work will employ an embedded single-case design with PFE in digital health initiatives at a large Canadian mental health and addictions teaching hospital. Multiple digital health projects being undertaken at the study site will be explored to better understand where the PFE is intended to support the design, implementation, and operation of the digital health platform or technology. These projects will form the individual units of analysis. Data collection will involve field notes and artifact collection by a participant observer and interviews with the various digital health project teams. Data analysis will include a content and thematic analysis, triangulation of the findings, and a chronological mapping of data to a PFE process. RESULTS: Funding for this work was provided by the Canadian Institutes of Health Research (CIHR), via a Health System Impact Fellowship. As of August 2020, digital health projects that will form the case study units have been identified, and the participant observer has started to embed themselves into these projects. Although the development and collection of field notes and artifacts, respectively, have begun, interviews have not been conducted. The study is expected to conclude in September 2021. Once this study is complete, the development of a field guide and resources to support the uptake of PFE strategies in digital health will begin. CONCLUSIONS: By better understanding the processes involved in PFE in digital health projects, guidance can be provided to relevant stakeholders and organizations about how to do this work in an effective manner. It is then anticipated that with the increasing use of PFE approaches, there may be improved uptake, experience, and outcomes associated with using digital health technologies. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/24274.

Identifying technology industry-led initiatives to address digital health equity.

Objective: The COVID-19 pandemic has highlighted various barriers to health and the necessity of having access to digital health services. The technology industry can support addressing health barriers, promoting health equity and partnering with organizations to ensure access to digital health services for underserviced communities. The main objective of this study was to 1) identify what initiatives have been developed within the technology industry to address digital health equity; and to 2) determine whether these initiatives have been effective. Methods: A rapid review and a grey literature scan were conducted. The academic searches were performed using four databases, including Ovid MEDLINE, Scopus, CINAHL and PsychInfo. Two reviewers screened the articles for inclusion criteria. The grey literature scan was performed through Google and Million Short. Searches of technology industry initiatives were completed through scanning technology companies listed on the New York Stock Exchange, the Toronto Stock Exchange and iShares Expanded Tech Sector - Exchange Traded Fund. Results: Within the technology industry, 39 companies had relevant initiatives. These were identified as having one or more of the following: 1) having health-related collaborations with other companies, 2) promoting access to technology infrastructure and 3) delivering programs that supported notable inequities within the social determinants of health. Limited data are available on the effectiveness of these initiatives in reducing health inequities. Conclusions: As technology in the delivery of health services continues to evolve, health equity initiatives must be supported through innovative strategies. Partnering with the technology industry may be one way of addressing these health equity challenges.

EHR "SWAT" teams: a physician engagement initiative to improve Electronic Health Record (EHR) experiences and mitigate possible causes of EHR-related burnout.

This case report describes an initiative implemented to improve physicians' experience with Electronic Health Records (EHRs), and is one of several strategies within our organization developed to reduce physician burnout attributed to the EHR. The EHR SWAT Team-a 10-member team-with interdisciplinary representation from clinical informatics, pharmacy informatics, health information management, clinical applications, and project management, is a direct feedback channel for all physicians to express their EHR challenges and have their requests reviewed, prioritized, and fixed in a timely manner. Through in-person divisional meetings, we gathered 118 requests, 36.4% of which were related to re-education and 17% of which were quick fixes. Popular requests included keyword search functionality, minimizing freezing, auto-faxing and auto-save. Our brief evaluation of 46 physicians demonstrated that physicians were satisfied with the initiative, with 61.3% physicians reporting that it increased their proficiency in using EHR functionalities. Lessons learned from this initiative include the importance of buy-in from Information Technology (IT) and physician leadership, extensive physician engagement, and leveraging project management techniques for coordination. Next steps include measuring the impact of this SWAT initiative on EHR-related burnout through a post-intervention organizational wide survey and objective back-end usage logs.