Communication About Health Information Technology Use Between Patients and Providers.

BACKGROUND: Although growing, the prevalence of the use of health information technology (HIT) by patients to communicate with their providers is not well understood on the population level, nor whether patients are communicating with their providers about their use of HIT. OBJECTIVE: To understand whether patients are communicating with their providers about HIT use and the patient characteristics associated with the communication. DESIGN: Cross-sectional, self-administered survey of a sample of patients across the state of Indiana. PARTICIPANTS: Nine hundred seventy adult participants from across Indiana, 54% female and 79.5% white. MAIN MEASURES: The survey included sections assessing health information-seeking behavior, use of health information technology, and discussions with doctors about the use of HIT. KEY RESULTS: The survey had a 12% response rate. Sixty-three percent of respondent reported going to the Internet as the first source when seeking health information, while only 19% of respondent reported their doctor was their first source. When communicating with doctors electronically, 31% reported using an electronic health record messaging system, 24% used email, and 18% used text messaging. Only 39% of respondents reported having had any conversation about HIT use with their providers. CONCLUSIONS: There remain many unmet opportunities for patients and providers to communicate about HIT use. More guidance for patients and care teams may both help facilitate these conversations and promote optimal use, such as recommendations to ask simple clarification questions and minimize inefficient, synchronous communication when unnecessary.

The Use of Cancer-Specific Patient-Centered Technologies Among Underserved Populations in the United States: Systematic Review.

BACKGROUND: In the United States, more than 1.6 million new cases of cancer are estimated to be diagnosed each year. However, the burden of cancer among the US population is not shared equally, with racial and ethnic minorities and lower-income populations having a higher cancer burden compared with their counterparts. For example, African Americans have the highest mortality rates and shortest survival rates for most cancers compared with other racial or ethnic groups in the United States. A wide range of technologies (eg, internet-based [electronic health, eHealth] technologies, mobile [mobile health, mHealth] apps, and telemedicine) available to patients are designed to improve their access to care and empower them to participate actively in their care, providing a means to reduce health care disparities; however, little is known of their use among underserved populations. OBJECTIVE: The aim of this study was to systematically review the current evidence on the use of cancer-specific patient-centered technologies among various underserved populations. METHODS: Computer-based search was conducted in the following academic databases: (1) PubMed (cancer subset), (2) MEDLINE, (3) PsycINFO, and (4) CINAHL. We included studies that were peer-reviewed, published in the English language, and conducted in the United States. Each study was individually assessed for relevance, with any disagreements being reconciled by consensus. We used a 3-step inclusion process in which we examined study titles, abstracts, and full-text papers for assessment of inclusion criteria. We systematically extracted information from each paper meeting our inclusion criteria. RESULTS: This review includes 71 papers that use patient-centered technologies that primarily targeted African Americans (n=31), rural populations (n=14), and Hispanics (n=12). A majority of studies used eHealth technologies (n=41) finding them to be leading sources of cancer-related health information and significantly improving outcomes such as screening among nonadherent individuals and increasing knowledge about cancer and cancer screening. Studies on mHealth found that participants reported overall favorable responses to receiving health information via short message service (SMS) text message; however, challenges were experienced with respect to lack of knowledge of how to text among some participants. More complex mobile technologies (eg, a tablet-based risk assessment tool) were also found favorable to use and acceptable among underserved populations; however, they also resulted in more significant barriers, for example, participants expressed concerns regarding security and unfamiliarity with the technology and preferred further instruction and assistance in its use. CONCLUSIONS: There is a growing body of literature exploring patient-centered technology and its influence on care of underserved populations. In this review, we find that these technologies seem to be effective, especially when tailored, in improving patient and care-related outcomes. Despite the potential of patient-centered technologies and the receptivity of underserved populations, challenges still exist with respect to their effective use and usability.

Growth Dynamics of Patient-Provider Internet Communication: Trend Analysis Using the Health Information National Trends Survey (2003 to 2013).

BACKGROUND: Communication is key in chronic disease management, and the internet has altered the manner in which patients and providers can exchange information. Adoption of secure messaging differs among patients due to the digital divide that keeps some populations from having effective access to online resources. OBJECTIVE: This study aimed to examine the current state of online patient-provider communication, exploring trends over time in the use of online patient-provider communication tools. METHODS: A 3-part analytic process was used to study the following: (1) reanalysis, (2) close replication across years, and (3) trend analysis extension. During the reanalysis stage, the publicly available Health Information National Trends Survey (HINTS) 1 and 2 data were used with the goal of identifying the precise analytic methodology used in a prior study, published in 2007. The original analysis was extended to add 3 additional data years (ie, 2008, 2011, and 2013) using the original analytical approach with the purpose of identifying trends over time. Multivariate logistic regression was used to analyze pooled data across all years, with year as an added predictor, in addition to a model for each individual data year. RESULTS: The odds of internet users to communicate online with health care providers was significantly and increasingly higher year-over-year, starting in 2003 (2005: odds ratio [OR] 1.31, 95% CI 1.03-1.68; 2008: OR 2.14, 95% CI 1.76-2.59; 2011: OR 2.92, 95% CI 2.33-3.66; and 2013: OR 5.77; 95% CI 4.62-7.20). Statistically significant socio-economic factors found to be associated with internet users communicating online with providers included age, having health insurance, having a history of cancer, and living in an urban area of residence. CONCLUSIONS: The proportion of internet users communicating online with their health care providers has significantly increased since 2003. Although these trends are encouraging, access challenges still exist for some groups, potentially giving rise to a new set of health disparities related to communication.

Environmental market factors associated with electronic health record adoption among cancer hospitals.

BACKGROUND: Although recent literature has explored the relationship between various environmental market characteristics and the adoption of electronic health records (EHRs) among general, acute care hospitals, no such research currently exists for specialty hospitals, including those providing cancer care. PURPOSE: The aim of the study was to examine the relationship between market characteristics and the adoption of EHRs among Commission on Cancer (CoC)-accredited hospitals. METHODS/APPROACH: Secondary data on EHR adoption combined with hospital and environmental market characteristics were analyzed using logistic regression. Using the resource dependence theory, we examined how measures of munificence, complexity, and dynamism are related to the adoption of EHRs among CoC-accredited hospitals and, separately, hospitals not CoC-accredited. FINDINGS: In a sample of 2,670 hospitals, 141 (0.05%) were academic-based CoC-accredited hospitals and 562 (21%) were community-based CoC-accredited hospitals. Measures of munificence such as cancer incidence rates (OR = 0.99, CI [0.99, 1.00], p = .020) and percentage population aged 65+ (OR = 0.99, CI [0.99, 1.00], p = .001) were negatively associated with basic EHR adoption, whereas urban location was positively associated with comprehensive EHR adoption (OR = 3.07, CI [0.89, 10.61], p = .076) for community-based CoC-accredited hospitals. Measures of complexity such as hospitals in areas with less competition were less likely to adopt a basic EHR (OR = 0.33, CI [0.19, 0.96], p = .005), whereas Medicare Managed Care penetration was positively associated with comprehensive EHR adoption (OR = 1.02, CI [1.00, 1.05], p = .070) among community-based CoC-accredited hospitals. Lastly, dynamism, measured as population change, was negatively associated with the adoption of comprehensive EHRs (OR = 0.99, CI [0.99, 1.00], p = .070) among academic-based CoC-accredited hospitals. PRACTICE IMPLICATIONS: A greater understanding of the environment's relationship to health information technology adoption in cancer hospitals will help stakeholders in these institutions make informed strategic decisions about information technology investments guided by their facilities' respective environmental factors. The results of this study may also be useful to hospital chief information officers and chief executive officers seeking to either improve their quality of care or achieve and maintain accreditation in providing cancer care.

Gatekeepers' perceptions of the quality and availability of services for breast and cervical cancer patients in the English-speaking Windward Islands: an exploratory investigation.

PURPOSE: Although extensive screening services for breast and cervical cancers are available in the Caribbean, these cancers continue to be the leading causes of cancer death among women in this region. The purpose of this study was to determine the quality and availability of breast and cervical cancer treatment care and support services from the perspective of the gatekeepers who provide care for the patients in the Windward Islands of Dominica, Grenada, St Lucia, and St. Vincent. METHODS: A qualitative research design using semi-structured, in-depth interviews was used to gather data from gatekeepers who provided oncology prevention and care services to patients for at least one year. Data were collected on availability and quality of cancer care and treatment services and coded using the themes obtained via thematic analysis of the data. RESULTS: Twenty-three current providers participated in the study (Dominica, 5; Grenada, 7; St. Lucia, 5; St. Vincent and the Grenadines, 6). The participants' years of work experience ranged from 2 to 45 years. The codes encompassed a range of social ecological factors that influence breast and cervical cancer screening and treatment in the Windward Islands. The emergent themes were availability of resources, cost of care, and social support. CONCLUSION: The findings of this study emphasize the varying social determinants of health that affect breast and cervical cancer prevention and treatment. It also highlights the disparities in availability of treatment within the wider Caribbean. It is necessary to broaden the perspective on health from a purely biomedical paradigm to a social perspective.

A systematic review of the association between family meals and adolescent risk outcomes.

OBJECTIVE: To conduct a systematic review of the literature examining the relationship between family meals and adolescent health risk outcomes. METHODS: We performed a systematic search of original empirical studies published between January 1990 and September 2013. Based on data from selected studies, we conducted logistic regression models to examine the correlates of reporting a protective association between frequent family meals and adolescent outcomes. RESULTS: Of the 254 analyses from 26 selected studies, most reported a significant association between family meals and the adolescent risk outcome-of-interest. However, model analyses which controlled for family connectedness variables, or used advanced empirical methods to account for family-level confounders, were less likely than unadjusted models to report significant relationships. CONCLUSIONS: The type of analysis conducted was significantly associated with the likelihood of finding a protective relationship between family meals and the adolescent outcome-of-interest, yet very few studies are using such methods in the literature.

Perceptions of colorectal cancer among three ethnic subgroups of US blacks: a qualitative study.

Colorectal cancer (CRC) is currently associated with one of the highest burdens of morbidity and mortality among American men and women. Racial/ethnic disparities are well documented and the subject of intense research and intervention. Our understanding of disparities related to awareness and perceptions about causes, risk factors, and screening for CRC among subgroups of blacks in the United States is limited. This may be in part because grouping US-born blacks and foreign-born blacks as one homogeneous group obscures possible within-group differences. This study aimed to explore the cultural perceptions of CRC among 3 ethnic subgroups of blacks: African Americans (US born), foreign-born blacks from English-speaking Caribbean countries, and Haitian-born blacks. The study was informed by a community-based participatory research approach, using a cross-sectional mixed qualitative and quantitative methods design. A total of 62 individuals from the 3 ethnic subgroups participated in semistructured, in-depth qualitative and structured quantitative interviews. Qualitative findings revealed no stark differences among the 3 ethnic subgroups in their overall perceptions of cancer as well as their attitudes related to barriers, motivation, and resources for CRC screening. However, there were subtle differences in perceptions of curability, preventive practices, and preferred sources of information among the three ethnic subgroups of US blacks. The study has important implications for the design of educational materials and targeted interventions for diverse groups of US blacks.

Effects of mindfulness-based interventions on fatigue in cancer survivors: A systematic review and meta-analysis of randomized controlled trials.

This systematic review and meta-analysis was designed to determine the efficacy of mindfulness-based interventions (MBIs) in improving fatigue-related outcomes in adult cancer survivors. Randomized controlled trials (RCTs) were identified from PubMed, MEDLINE, PsycINFO, CINAHL, Web of Science, and EMBASE databases and reference lists of included studies. Separate random-effects meta-analyses were conducted for fatigue and vitality/vigor. Twenty-three studies reporting on 21 RCTs (N = 2239) met inclusion criteria. MBIs significantly reduced fatigue compared to controls at post-intervention (g = 0.60, 95 % CI [0.36, 0.83]) and first follow-up (g = 0.42, 95 % CI [0.20, 0.64]). Likewise, MBIs significantly improved vitality/vigor at post-intervention (g = 0.39, 95 % CI [0.25, 0.52]) and first follow-up (g = 0.35, 95 % CI [0.03, 0.67]). The evidence grade was low due to risk of bias, substantial heterogeneity, and publication bias among studies. MBIs show promise in improving fatigue and vitality/vigor in cancer survivors. More rigorous trials are needed to address current gaps in the evidence base.

Complexities of HIV Disclosure in Patients Newly Entering HIV Care: A Qualitative Analysis.

The role of HIV disclosure and its influence on engagement in HIV care after initial linkage to care is not well understood. We conducted 28 in-depth interviews with patients newly entering HIV care. Gaining access to social support was a key reason that many patients disclosed their HIV status. For some, HIV disclosure improved support networks related to engagement in care at the time of care entry, in the form of appointment reminders, emotional support, and confidence to disclose more widely. However, some participants cited anticipated stigma as a barrier to disclosure, as they feared rejection or further disclosure without their permission. Early access to social support and skill building related to stigma reduction and coping can be useful resources to help patients manage HIV, as they initiate care. In addition, incorporating support for smart disclosure decisions into interventions may improve access to social support, ultimately improving engagement in care.

Usefulness and Usability of a Personal Health Record and Survivorship Care Plan for Colorectal Cancer Survivors: Survey Study.

BACKGROUND: As a result of improvements in cancer screening, treatment, and supportive care, nearly two-thirds of individuals diagnosed with colorectal cancer (CRC) live for 5 years after diagnosis. An ever-increasing population of CRC survivors creates a need for effective survivorship care to help manage and mitigate the impact of CRC and its treatment. Personal health records (PHRs) and survivorship care plans provide a means of supporting the long-term care of cancer survivors. OBJECTIVE: The purpose of this study is to characterize the usefulness of a CRC PHR and survivorship care plan and to describe the usability of these technologies in a population of CRC survivors. To our knowledge, this is the first study to assess a PHR and survivorship care plan specifically targeting CRC survivors. METHODS: Twenty-two patients with CRC were recruited from surgery clinics of an academic medical center and Veterans Affairs hospital in Indianapolis and provided access to an online Colorectal Cancer Survivor's Personal Health Record (CRCS-PHR). Survey data were collected to characterize the usefulness of the CRCS-PHR and describe its usability in a population of CRC survivors. CRC survivors were surveyed 6 months after being provided online access. Means and proportions were used to describe the usefulness and ease of using the CRC website. Open-ended questions were qualitatively coded using the constant comparative method. RESULTS: CRC survivors perceived features related to their health care (ie, summary of cancer treatment history, follow-up care schedule, description of side effects, and list of community resources) to be more useful than communication features (ie, creating online relationships with family members or caregivers, communicating with doctor, and secure messages). CRC survivors typically described utilizing traditional channels (eg, via telephone or in person) to communicate with their health care provider. Participants had overall positive perceptions with respect to ease of use and overall satisfaction. Major challenges experienced by participants included barriers to system log-in, lack of computer literacy or experience, and difficulty entering their patient information. CONCLUSIONS: For CRC, survivors may find the greater value in a PHR's medical content than the communication functions, which they have available elsewhere. These findings regarding the usefulness and usability of a PHR for the management of CRC survivorship provide valuable insights into how best to tailor these technologies to patients' needs. These findings can inform future design and development of PHRs for purposes of both cancer and chronic disease management.

Factors Associated with Adherence to Mammography Screening Among Insured Women Differ by Income Levels.

BACKGROUND: Breast cancer is the second leading cause of cancer mortality, yet mammography screening rates remain less than optimal and differ by income levels. The purpose of this study was to compare factors predicting mammography adherence across income groups. METHODS: Women 41 to 75 years of age (N = 1,681) with health insurance and with no mammogram in the last 15 months were enrolled to participate in an interventional study. Binary logistic regression was used to estimate multivariable-adjusted odds ratios (ORs) for demographic and health belief factors predicting mammography adherence for each income group: 1) low, less than $30,000, 2) middle, $30,000 to 75,000, and 3) high, greater than $75,000 per year. RESULTS: Being in the contemplation stage (vs. precontemplation) of obtaining a mammogram predicted mammography adherence across all income groups and was the only predictor in the middle-income group (OR, 3.9; 95% CI, 2.61-5.89). Increase in age was associated with 5% increase (per year increase in age) in mammography adherence for low-income (OR, 1.05; 95% CI, 1.01-1.09) and high-income (OR, 1.05; 95% CI, 1.02-1.08) women. Having a doctor recommendation predicted mammography adherence only in low-income women (OR, 10.6; 95% CI, 2.33-48.26), whereas an increase in perceived barriers predicted mammography adherence only among high-income women (OR, 0.96; 95% CI, 0.94-0.99). In a post hoc analysis, high-income women reported difficulty in remembering appointments (53%) and lack of time to get a mammogram (24%) as key barriers. CONCLUSIONS: For all income groups, being in contemplation of obtaining a mammogram predicted mammography adherence; however, age predicted mammography adherence for low- and high-income groups, whereas doctor recommendation and perceived barriers were unique predictors for low- and high-income women, respectively. Health care providers should be aware of differences in factors and emphasize strategies that increase mammography adherence for each income group.

A Randomized Trial to Compare a Tailored Web-Based Intervention and Tailored Phone Counseling to Usual Care for Increasing Colorectal Cancer Screening.

BACKGROUND: Colorectal cancer mortality could be decreased with risk-appropriate cancer screening. We examined the efficacy of three tailored interventions compared with usual care for increasing screening adherence. METHODS: Women (n = 1,196) ages 51 to 74, from primary care networks and nonadherent to colorectal cancer guidelines, were randomized to (1) usual care, (2) tailored Web intervention, (3) tailored phone intervention, or (4) tailored Web + phone intervention. Average-risk women could select either stool test or colonoscopy, whereas women considered at higher than average risk received an intervention that supported colonoscopy. Outcome data were collected at 6 months by self-report, followed by medical record confirmation (attrition of 23%). Stage of change for colorectal cancer screening (precontemplation or contemplation) was assessed at baseline and 6 months. RESULTS: The phone (41.7%, P < 0.0001) and combined Web + phone (35.8%, P < 0.001) interventions significantly increased colorectal cancer screening by stool test compared with usual care (11.1%), with ORs ranging from 5.4 to 6.8 in models adjusted for covariates. Colonoscopy completion did not differ between groups except that phone significantly increased colonoscopy completion compared with usual care for participants in the highest tertile of self-reported fear of cancer. CONCLUSIONS: A tailored phone with or without a Web component significantly increased colorectal cancer screening compared with usual care, primarily through stool testing, and phone significantly increased colonoscopy compared with usual care but only among those with the highest levels of baseline fear. IMPACT: This study supports tailored phone counseling with or without a Web program for increasing colorectal cancer screening in average-risk women.

The impact of health information technology on cancer care across the continuum: a systematic review and meta-analysis.

INTRODUCTION: Health information technology (HIT) has the potential to play a significant role in the management of cancer. The purpose of this review is to identify and examine empirical studies that investigate the impact of HIT in cancer care on different levels of the care continuum. METHODS: Electronic searches were performed in four academic databases. The authors used a three-step search process to identify 122 studies that met specific inclusion criteria. Next, a coding sheet was used to extract information from each included article to use in an analysis. Logistic regression was used to determine study-specific characteristics that were associated with positive findings. RESULTS: Overall, 72.4% of published analyses reported a beneficial effect of HIT. Multivariate analysis found that the impact of HIT differs across the cancer continuum with studies targeting diagnosis and treatment being, respectively, 77 (P = .001) and 39 (P = .039) percentage points less likely to report a beneficial effect when compared to those targeting prevention. In addition, studies targeting HIT to patients were 31 percentage points less likely to find a beneficial effect than those targeting providers (P = .030). Lastly, studies assessing behavior change as an outcome were 41 percentage points less likely to find a beneficial effect (P = .006), while studies targeting decision making were 27 percentage points more likely to find a beneficial effect (P = .034). CONCLUSION: Based on current evidence, HIT interventions seem to be more successful when targeting physicians, care in the prevention phase of the cancer continuum, and/or decision making. An agenda for future research is discussed.

Family structure and risk behaviors: the role of the family meal in assessing likelihood of adolescent risk behaviors.

BACKGROUND: Previous literature has asserted that family meals are a key protective factor for certain adolescent risk behaviors. It is suggested that the frequency of eating with the family is associated with better psychological well-being and a lower risk of substance use and delinquency. However, it is unclear whether there is evidence of causal links between family meals and adolescent health-risk behaviors. PURPOSE: The purpose of this article is to review the empirical literature on family meals and adolescent health behaviors and outcomes in the US. DATA SOURCES: A SEARCH WAS CONDUCTED IN FOUR ACADEMIC DATABASES: Social Sciences Full Text, Sociological Abstracts, PsycINFO®, and PubMed/MEDLINE. STUDY SELECTION: We included studies that quantitatively estimated the relationship between family meals and health-risk behaviors. DATA EXTRACTION: Data were extracted on study sample, study design, family meal measurement, outcomes, empirical methods, findings, and major issues. DATA SYNTHESIS: Fourteen studies met the inclusion criteria for the review that measured the relationship between frequent family meals and various risk-behavior outcomes. The outcomes considered by most studies were alcohol use (n=10), tobacco use (n=9), and marijuana use (n=6). Other outcomes included sexual activity (n=2); depression, suicidal ideation, and suicide attempts (n=4); violence and delinquency (n=4); school-related issues (n=2); and well-being (n=5). The associations between family meals and the outcomes of interest were most likely to be statistically significant in unadjusted models or models controlling for basic family characteristics. Associations were less likely to be statistically significant when other measures of family connectedness were included. Relatively few analyses used sophisticated empirical techniques available to control for confounders in secondary data. CONCLUSION: More research is required to establish whether or not the relationship between family dinners and risky adolescent behaviors is an artifact of underlying confounders. We recommend that researchers make more frequent use of sophisticated methods to reduce the problem of confounders in secondary data, and that the scope of adolescent problem behaviors also be further widened.

A foundation for public health ethics at Tuskegee University in the 21st century.

This commentary is a reflection on Tuskegee University's National Center for Bioethics in Research and Health Care on the health and ethical challenges of the 21st century. The Center has dedicated the last 10 years to addressing the unresolved biomedicine and public health issues and/or the ethical dilemmas that plague the nation's health. The authors believe that health disparities continue to worsen because the approach under-appreciates the ethical dilemma that plagues health policy and health disparities. The authors discuss synergies and the paradigmatic differences between science and medicine, religion, spirituality, and faith. They also discuss the importance of considering these relationships if improvements in the health of people of African descent are expected. The concept of Optimal Health is explored.

Is social support from family associated with PSA testing? An exploratory analysis using the Health Information National Trends Survey (HINTS) 2005.

African American and White men have the highest rates of prostate cancer in the United States. Families represent important social contexts within which illness occurs.The purpose of this study is to explore whether prostate-specific antigen (PSA) testing is associated with instrumental and informational social support from family members among a sample of Black and White men aged 45 and older. Data from the 2005 Health Information National Trends Survey were analyzed using logistic regression. The dependent variable was having a PSA test within the past year or less. The independent variables consisted of selected demographic and family informational and instrumental social support variables. The statistically significant variables included age and having a family member with cancer. Additional studies to elucidate the mechanisms of social support from family for prostate cancer are needed.

Exploring disparities and variability in perceptions and self-reported colorectal cancer screening among three ethnic subgroups of U. S. Blacks.

PURPOSE/OBJECTIVES: To explore perceptions of colorectal cancer (CRC) and self-reported CRC screening behaviors among ethnic subgroups of U. S. blacks. DESIGN: Descriptive, cross-sectional, exploratory, developmental pilot. SETTING: Medically underserved areas in Hillsborough County, FL. SAMPLE: 62 men and women aged 50 years or older. Ethnic subgroup distribution included 22 African American, 20 English-speaking Caribbean-born, and 20 Haitian-born respondents. METHODS: Community-based participatory research methods were used to conduct face-to-face individual interviews in the community. MAIN RESEARCH VARIABLES: Ethnic subgroup, health access, perceptions of CRC (e.g., awareness of screening tests, perceived risk, perceived barriers to screening), healthcare provider recommendation, and self-reported CRC screening. FINDINGS: Awareness of CRC screening tests, risk perception, healthcare provider recommendation, and self-reported use of screening were low across all subgroups. However, only 55% of Haitian-born participants had heard about the fecal occult blood test compared to 84% for English-speaking Caribbean-born participants and 91% for African Americans. Similarly, only 15% of Haitian-born respondents had had a colonoscopy compared to 50% for the English-speaking Caribbean and African American subgroups. CONCLUSIONS: This exploratory, developmental pilot study identified lack of awareness, low risk perception, and distinct barriers to screening. The findings support the need for a larger community-based study to elucidate and address disparities among subgroups. IMPLICATIONS FOR NURSING: Nurses play a major role in reducing cancer health disparities through research, education, and quality care. Recognition of the cultural diversity of the U. S. black population can help nurses address health disparities and contribute to the health of the community.