Inviting patients to read their doctors' notes: a quasi-experimental study and a look ahead.

BACKGROUND: Little information exists about what primary care physicians (PCPs) and patients experience if patients are invited to read their doctors' office notes. OBJECTIVE: To evaluate the effect on doctors and patients of facilitating patient access to visit notes over secure Internet portals. DESIGN: Quasi-experimental trial of PCPs and patient volunteers in a year-long program that provided patients with electronic links to their doctors' notes. SETTING: Primary care practices at Beth Israel Deaconess Medical Center (BIDMC) in Massachusetts, Geisinger Health System (GHS) in Pennsylvania, and Harborview Medical Center (HMC) in Washington. PARTICIPANTS: 105 PCPs and 13,564 of their patients who had at least 1 completed note available during the intervention period. MEASUREMENTS: Portal use and electronic messaging by patients and surveys focusing on participants' perceptions of behaviors, benefits, and negative consequences. RESULTS: 11,155 [corrected] of 13,564 patients with visit notes available opened at least 1 note (84% at BIDMC, 82% [corrected] at GHS, and 47% at HMC). Of 5219 [corrected] patients who opened at least 1 note and completed a postintervention survey, 77% to 59% [corrected] across the 3 sites reported that open notes helped them feel more in control of their care; 60% to 78% of those taking medications reported increased medication adherence; 26% to 36% had privacy concerns; 1% to 8% reported that the notes caused confusion, worry, or offense; and 20% to 42% reported sharing notes with others. The volume of electronic messages from patients did not change. After the intervention, few doctors reported longer visits (0% to 5%) or more time addressing patients' questions outside of visits (0% to 8%), with practice size having little effect; 3% to 36% of doctors reported changing documentation content; and 0% to 21% reported taking more time writing notes. Looking ahead, 59% to 62% of patients believed that they should be able to add comments to a doctor's note. One out of 3 patients believed that they should be able to approve the notes' contents, but 85% to 96% of doctors did not agree. At the end of the experimental period, 99% of patients wanted open notes to continue and no doctor elected to stop. LIMITATIONS: Only 3 geographic areas were represented, and most participants were experienced in using portals. Doctors volunteering to participate and patients using portals and completing surveys may tend to offer favorable feedback, and the response rate of the patient surveys (41%) may further limit generalizability. CONCLUSION: Patients accessed visit notes frequently, a large majority reported clinically relevant benefits and minimal concerns, and virtually all patients wanted the practice to continue. With doctors experiencing no more than a modest effect on their work lives, open notes seem worthy of widespread adoption. PRIMARY FUNDING SOURCE: The Robert Wood Johnson Foundation, the Drane Family Fund, the Richard and Florence Koplow Charitable Foundation, and the National Cancer Institute.

Inviting patients to read their doctors' notes: patients and doctors look ahead: patient and physician surveys.

BACKGROUND: Little is known about what primary care physicians (PCPs) and patients would expect if patients were invited to read their doctors' office notes. OBJECTIVE: To explore attitudes toward potential benefits or harms if PCPs offered patients ready access to visit notes. DESIGN: The PCPs and patients completed surveys before joining a voluntary program that provided electronic links to doctors' notes. SETTING: Primary care practices in 3 U.S. states. PARTICIPANTS: Participating and nonparticipating PCPs and adult patients at primary care practices in Massachusetts, Pennsylvania, and Washington. MEASUREMENTS: Doctors' and patients' attitudes toward and expectations of open visit notes, their ideas about the potential benefits and risks, and demographic characteristics. RESULTS: 110 of 114 participating PCPs (96%), 63 of 140 nonparticipating PCPs (45%), and 37 856 of 90 203 patients (42%) completed surveys. Overall, 69% to 81% of participating PCPs across the 3 sites and 92% to 97% of patients thought open visit notes were a good idea, compared with 16% to 33% of nonparticipating PCPs. Similarly, participating PCPs and patients generally agreed with statements about potential benefits of open visit notes, whereas nonparticipating PCPs were less likely to agree. Among participating PCPs, 74% to 92% anticipated improved communication and patient education, in contrast to 45% to 67% of nonparticipating PCPs. More than one half of participating PCPs (50% to 58%) and most nonparticipating PCPs (88% to 92%) expected that open visit notes would result in greater worry among patients; far fewer patients concurred (12% to 16%). Thirty-six percent to 50% of participating PCPs and 83% to 84% of nonparticipating PCPs anticipated more patient questions between visits. Few PCPs (0% to 33%) anticipated increased risk for lawsuits. Patient enthusiasm extended across age, education, and health status, and 22% anticipated sharing visit notes with others, including other doctors. LIMITATIONS: Access to electronic patient portals is not widespread, and participation was limited to patients using such portals. Response rates were higher among participating PCPs than nonparticipating PCPs; many participating PCPs had small patient panels. CONCLUSION: Among PCPs, opinions about open visit notes varied widely in terms of predicting the effect on their practices and benefits for patients. In contrast, patients expressed considerable enthusiasm and few fears, anticipating both improved understanding and more involvement in care. Sharing visit notes has broad implications for quality of care, privacy, and shared accountability. PRIMARY FUNDING SOURCE: The Robert Wood Johnson Foundation's Pioneer Portfolio, Drane Family Fund, and Koplow Charitable Foundation.

Evaluating the impact of patients' online access to doctors' visit notes: designing and executing the OpenNotes project.

BACKGROUND: Providers and policymakers are pursuing strategies to increase patient engagement in health care. Increasingly, online sections of medical records are viewable by patients though seldom are clinicians' visit notes included. We designed a one-year multi-site trial of online patient accessible office visit notes, OpenNotes. We hypothesized that patients and primary care physicians (PCPs) would want it to continue and that OpenNotes would not lead to significant disruptions to doctors' practices. METHODS/DESIGN: Using a mixed methods approach, we designed a quasi-experimental study in 3 diverse healthcare systems in Boston, Pennsylvania, and Seattle. Two sites had existing patient internet portals; the third used an experimental portal. We targeted 3 key areas where we hypothesized the greatest impacts: beliefs and attitudes about OpenNotes, use of the patient internet portals, and patient-doctor communication. PCPs in the 3 sites were invited to participate in the intervention. Patients who were registered portal users of participating PCPs were given access to their PCPs' visit notes for one year. PCPs who declined participation in the intervention and their patients served as the comparison groups for the study. We applied the RE-AIM framework to our design in order to capture as comprehensive a picture as possible of the impact of OpenNotes. We developed pre- and post-intervention surveys for online administration addressing attitudes and experiences based on interviews and focus groups with patients and doctors. In addition, we tracked use of the internet portals before and during the intervention. RESULTS: PCP participation varied from 19% to 87% across the 3 sites; a total of 114 PCPs enrolled in the intervention with their 22,000 patients who were registered portal users. Approximately 40% of intervention and non-intervention patients at the 3 sites responded to the online survey, yielding a total of approximately 38,000 patient surveys. DISCUSSION: Many primary care physicians were willing to participate in this "real world" experiment testing the impact of OpenNotes on their patients and their practices. Results from this trial will inform providers, policy makers, and patients who contemplate such changes at a time of exploding interest in transparency, patient safety, and improving the quality of care.

Open notes: doctors and patients signing on.

Few patients read their doctors' notes, despite having the legal right to do so. As information technology makes medical records more accessible and society calls for greater transparency, patients' interest in reading their doctors' notes may increase. Inviting patients to review these notes could improve understanding of their health, foster productive communication, stimulate shared decision making, and ultimately lead to better outcomes. Yet, easy access to doctors' notes could have negative consequences, such as confusing or worrying patients and complicating rather than improving patient-doctor communication. To gain evidence about the feasibility, benefits, and harms of providing patients ready access to electronic doctors' notes, a team of physicians and nurses have embarked on a demonstration and evaluation of a project called OpenNotes. The authors describe the intervention and share what they learned from conversations with doctors and patients during the planning stages. The team anticipates that "open notes" will spread and suggests that over time, if drafted collaboratively and signed by both doctors and patients, they might evolve to become contracts for care.

Two complementary personal medication management applications developed on a common platform: case report.

BACKGROUND: Adverse drug events are a major safety issue in ambulatory care. Improving medication self-management could reduce these adverse events. Researchers have developed medication applications for tethered personal health records (PHRs), but little has been reported about medication applications for interoperable PHRs. OBJECTIVE: Our objective was to develop two complementary personal health applications on a common PHR platform: one to assist children with complex health needs (MyMediHealth), and one to assist older adults in care transitions (Colorado Care Tablet). METHODS: The applications were developed using a user-centered design approach. The two applications shared a common PHR platform based on a service-oriented architecture. MyMediHealth employed Web and mobile phone user interfaces. Colorado Care Tablet employed a Web interface customized for a tablet PC. RESULTS: We created complementary medication management applications tailored to the needs of distinctly different user groups using common components. Challenges were addressed in multiple areas, including how to encode medication identities, how to incorporate knowledge bases for medication images and consumer health information, how to include supplementary dosing information, how to simplify user interfaces for older adults, and how to support mobile devices for children. CONCLUSIONS: These prototypes demonstrate the utility of abstracting PHR data and services (the PHR platform) from applications that can be tailored to meet the needs of diverse patients. Based on the challenges we faced, we provide recommendations on the structure of publicly available knowledge resources and the use of mobile messaging systems for PHR applications.

Older adults with multi-morbidity: medication management processes and design implications for personal health applications.

BACKGROUND: Older adults often have multiple chronic problems requiring them to manage complex medication regimens overseen by various clinicians. Personal health applications (PHAs) show promise assisting in medication self-management, but adoption of new computer technologies by this population is challenging. Optimizing the utility of PHAs requires a thorough understanding of older adults' needs, preferences, and practices. OBJECTIVE: The objective of our study was to understand the medication self-management issues faced by older adults and caregivers that can be addressed by an electronic PHA. METHODS: We conducted a qualitative analysis of a series of individual and group semistructured interviews with participants who were identified through purposive sampling. RESULTS: We interviewed 32 adult patients and 2 adult family caregivers. We identified 5 core themes regarding medication self-management challenges: seeking reliable medication information, maintaining autonomy in medication treatment decisions, worrying about taking too many medications, reconciling information discrepancies between allopathic and alternative medical therapies, and tracking and coordinating health information between multiple providers. CONCLUSIONS: This study provides insights into the latent concerns and challenges faced by older adults and caregivers in managing medications. The results suggest that PHAs should have the following features to accommodate the management strategies and information preferences of this population: (1) provide links to authoritative and reliable information on side effects, drug interactions, and other medication-related concerns in a way that is clear, concise, and easy to navigate, (2) facilitate communication between patients and doctors and pharmacists through electronic messaging and health information exchange, and (3) provide patients the ability to selectively disclose medication information to different clinicians.

Colorado Care Tablet: the design of an interoperable Personal Health Application to help older adults with multimorbidity manage their medications.

Medication errors are common and cause serious health issues during care transitions, particularly for older adults with multiple chronic conditions. In this paper, we discuss the design and evaluation of the Colorado Care Tablet, a Personal Health Application (PHA) that helps older adults and their lay caregivers manage their medication regimes during care transitions. We created a PHA that older adults with limited computing experience could easily use by designing an application based on their real world artifacts and workflows.

Expectations of patients and physicians regarding patient-accessible medical records.

BACKGROUND: Middle class populations have supported shared medical records, including Internet-accessible medical records. The attitudes of lower income populations, and of physicians, are less clear. OBJECTIVES: The objective of this study was to compare the attitudes toward shared outpatient medical records among (1) socioeconomically disadvantaged patients in community health centers, (2) insured patients in primary care offices, and (3) a broad range of physicians in outpatient practice. METHODS: Written questionnaires were provided to patients in the waiting rooms of six primary care practices in the metropolitan Denver, Colorado area. Three practices were community health centers, and three practices were primary care clinics of an academic medical center. Questionnaires were also mailed to primary care physicians in the state of Colorado. RESULTS: There was a 79% response rate for patient surveys (601 surveys returned) and a 53% response rate for physician surveys (564 surveys returned). Academic medical center patients and community health center patients were equally likely to endorse shared medical records (94% vs 96%) and Internet-accessible records (54% vs 57%). Community health center patients were more likely than academic medical center patients to anticipate the benefits of shared medical records (mean number of expected benefits = 7.9 vs 7.1, P < .001), and they were also somewhat more likely to anticipate problems with shared records. Significant predictors of patient endorsement of Internet-accessible records were previous use of the Internet (OR = 2.45, CI 1.59-3.79), the number of expected benefits (OR = 1.12 per unit, CI 1.03-1.21), anticipation of asking more questions between visits (OR = 1.73, CI 1.18-2.54), and anticipation of finding the doctors' notes to be confusing (OR = 1.50, CI 1.01-2.22). Physicians were significantly more likely than patients to anticipate that access to records would cause problems. Physicians were significantly less likely than patients to anticipate benefits (mean number of expected benefits = 4.2 vs 7.5, P < .001). CONCLUSIONS: Interest in shared medical records is not confined to a white, middle class population. Shared medical records are almost universally endorsed across a broad range of ethnic and socioeconomic groups. A majority of patients are also interested in Internet-accessible records, but a substantial minority is not. The primary determinants of support of Internet-accessible records are not age, race, or education level; rather, they are previous experience with the Internet and patients' expectations of the benefits and drawbacks of reading their medical records. Physicians have more concerns about shared medical records and see less potential for benefit. The attitudes of patients and physicians may need to be reconciled for widespread adoption of shared medial records to be achieved.

An Internet-based patient-provider communication system: randomized controlled trial.

BACKGROUND: Internet-based interactive websites for patient communication (patient portals) may improve communication between patients and their clinics and physicians. OBJECTIVE: The aim of the study was to assess the impact of a patient portal on patients' satisfaction with access to their clinic and clinical care. Another aim was to analyze the content and volume of email messages and telephone calls from patients to their clinic. METHODS: This was a randomized controlled trial with 606 patients from an academic internal medicine practice. The intervention "portal" group used a patient portal to send secure messages directly to their physicians and to request appointments, prescription refills, and referrals. The control group received usual care. We assessed patient satisfaction at the end of the 6-month trial period and compared the content of telephone and portal communications. RESULTS: Portal group patients reported improved communication with the clinic (portal: 77/174 [44%] "a little better" or "a lot better;" control: 18/146 [12%]; chi2 = 38.8, df = 1, P < .001) and higher satisfaction with overall care (portal: 103/174 [59%] "very good" or "excellent;" control: 78/162 [48%]; chi2 = 4.1, df = 1, P = .04). Portal group patients also reported higher satisfaction with each of the portal's services. Physicians received 1 portal message per day for every 250 portal patients. Total telephone call volume was not affected. Patients were more likely to send informational and psychosocial messages by portal than by phone. Of all surveyed patients, 162/341 (48%) were willing to pay for online correspondence with their physician. Of those willing to pay, the median amount cited was 2 USD per message. CONCLUSIONS: Portal group patients demonstrated increased satisfaction with communication and overall care. Patients in the portal group particularly valued the portal's convenience, reduced communication barriers, and direct physician responses. More online messages from patients contained informational and psychosocial content compared to telephone calls, which may enhance the patient-physician relationship.

The effects of promoting patient access to medical records: a review.

The Health Insurance Privacy and Portability Act (HIPPA) stipulates that patients must be permitted to review and amend their medical records. As information technology makes medical records more accessible to patients, it may become more commonplace for patients to review their records routinely. This article analyzes the potential benefits and drawbacks of facilitating patient access to the medical record by reviewing previously published research. Previous research includes analysis of clinical notes, surveys of patients and practitioners, and studies of patient-accessible medical records. Overall, studies suggest the potential for modest benefits (for instance, in enhancing doctor-patient communication). Risks (for instance, increasing patient worry or confusion) appear to be minimal in medical patients. The studies, however, were of limited quality and low statistical power to detect the variety of outcomes that may result from implementation of a patient-accessible medical record. The data from these studies lay the foundation for future research.

Use of a patient-accessible electronic medical record in a practice for congestive heart failure: patient and physician experiences.

OBJECTIVE: The aim of this study was to evaluate the experiences of patients and physicians in a clinical trial of an online electronic medical record (SPPARO, System Providing Patients Access to Records Online). DESIGN: Quantitative data were obtained from questionnaires. Qualitative data were obtained from individual interviews and focus groups. MEASUREMENTS: Questionnaire items were based on issues identified by patients and physicians in previous studies. Individual interviews and focus groups were performed using a semistructured format developed through an iterative process. RESULTS: Of the eight physicians who participated in the trial, seven completed questionnaires and interviews. Of the 394 patients in the practice, 107 enrolled in the study, and 54 were assigned randomly to the intervention group. Of these, 41 used SPPARO during the trial period. In questionnaires and interviews, patients were significantly more likely than physicians to anticipate benefits of SPPARO and less likely to anticipate problems. Attitudes of subjects did not diverge from controls after the intervention period. In posttrial focus groups, SPPARO users described its practical benefits. Comprehending medical jargon was a minor obstacle. Physicians anticipated that implementing SPPARO might increase their workload and distort their clinical interactions. In posttrial interviews, physicians and staff reported no change in their workload and no adverse consequences. All of the physicians ultimately supported the concept of giving patients online access to their clinical notes and test results. CONCLUSION: SPPARO was useful for a number of patients. Physicians initially voiced a number of concerns about implementing SPPARO, but their experience with it was far more positive.

Providing a web-based online medical record with electronic communication capabilities to patients with congestive heart failure: randomized trial.

BACKGROUND: It is possible to provide patients with secure access to their medical records using the Internet. Such access may assist patients in the self-management of chronic diseases such as heart failure. OBJECTIVE: To assess how a patient-accessible online medical record affects patient care and clinic operations. The SPPARO (System Providing Access to Records Online) software consisted of a web-based electronic medical record, an educational guide, and a messaging system enabling electronic communication between the patient and staff. METHODS: A randomized controlled trial was conducted in a specialty practice for patients with heart failure. Surveys assessing doctor-patient communication, adherence, and health status were conducted at baseline, 6 months, and 1 year. Use of the system, message volume, utilization of clinical services, and mortality were monitored. RESULTS: One hundred and seven patients were enrolled (54 intervention and 53 controls). At 12 months, the intervention group was not found to be superior in self-efficacy (KCCQ self-efficacy score 91 vs. 85, p=0.08), but was superior in general adherence (MOS compliance score 85 vs. 78, p=0.01). A trend was observed for better satisfaction with doctor-patient communication. The intervention group had more emergency department visits (20 vs. 8, p=0.03), but these visits were not temporally related to use of the online medical record. There were no adverse effects from use of the system. CONCLUSIONS: Providing patients with congestive heart failure access to an online medical record was feasible and improved adherence. An effect on health status could not be demonstrated in this pilot study.

Effects of health information exchange adoption on ambulatory testing rates.

OBJECTIVE: To determine the effects of the adoption of ambulatory electronic health information exchange (HIE) on rates of laboratory and radiology testing and allowable charges. DESIGN: Claims data from the dominant health plan in Mesa County, Colorado, from 1 April 2005 to 31 December 2010 were matched to HIE adoption data on the provider level. Using mixed effects regression models with the quarter as the unit of analysis, the effect of HIE adoption on testing rates and associated charges was assessed. RESULTS: Claims submitted by 306 providers in 69 practices for 34 818 patients were analyzed. The rate of testing per provider was expressed as tests per 1000 patients per quarter. For primary care providers, the rate of laboratory testing increased over the time span (baseline 1041 tests/1000 patients/quarter, increasing by 13.9 each quarter) and shifted downward with HIE adoption (downward shift of 83, p<0.01). A similar effect was found for specialist providers (baseline 718 tests/1000 patients/quarter, increasing by 19.1 each quarter, with HIE adoption associated with a downward shift of 119, p<0.01). Even so, imputed charges for laboratory tests did not shift downward significantly in either provider group, possibly due to the skewed nature of these data. For radiology testing, HIE adoption was not associated with significant changes in rates or imputed charges in either provider group. CONCLUSIONS: Ambulatory HIE adoption is unlikely to produce significant direct savings through reductions in rates of testing. The economic benefits of HIE may reside instead in other downstream outcomes of better informed, higher quality care.

Effects of clinical pathways for common outpatient infections on antibiotic prescribing.

BACKGROUND: Antibiotic overuse in the primary care setting is common. Our objective was to evaluate the effect of a clinical pathway-based intervention on antibiotic use. METHODS: Eight primary care clinics were randomized to receive clinical pathways for upper respiratory infection, acute bronchitis, acute rhinosinusitis, pharyngitis, acute otitis media, urinary tract infection, skin infections, and pneumonia and patient education materials (study group) versus no intervention (control group). Generalized linear mixed effects models were used to assess trends in antibiotic prescriptions for non-pneumonia acute respiratory infections and broad-spectrum antibiotic use for all 8 conditions during a 2-year baseline and 1-year intervention period. RESULTS: In the study group, antibiotic prescriptions for non-pneumonia acute respiratory infections decreased from 42.7% of cases at baseline to 37.9% during the intervention period (11.2% relative reduction) (P<.0001) and from 39.8% to 38.7%, respectively, in the control group (2.8% relative reduction) (P=.25). Overall use of broad-spectrum antibiotics in the study group decreased from 26.4% to 22.6% of cases, respectively (14.4% relative reduction) (P<.0001) and from 20.0% to 19.4%, respectively, in the control group (3.0% relative reduction) (P=.35). There were significant differences in the trends of prescriptions for acute respiratory infections (P<.0001) and broad-spectrum antibiotic use (P=.001) between the study and control groups during the intervention period, with greater declines in the study group. CONCLUSIONS: This intervention was associated with declining antibiotic prescriptions for non-pneumonia acute respiratory infections and use of broad-spectrum antibiotics over the first year. Evaluation of the impact over a longer study period is warranted.

Designing a personal health application for older adults to manage medications: a comprehensive case study.

Older adults with multiple chronic conditions often go through care transitions where they move between care facilities or providers during their treatment. These transitions are often uncoordinated and can imperil patients by omitted, duplicative, or contradictory care plans. Older adults sometimes feel overwhelmed with the new responsibility of coordinating the care plan with providers and changing their medication regimes. In response, we developed a Lesser General Public License (LGPL) open source, web-based Personal Health Application (PHA) using an iterative participatory design process that provided older adults and their caregivers the ability to manage their personal health information. In this paper, we document the PHA design process from low-fidelity prototypes to high-fidelity prototypes over the course of six user studies. Our findings establish the imperative need for interdisciplinary research and collaboration among all stakeholders to create effective PHAs. We conclude with design guidelines that encourage researchers to gradually increase functionality as users become more proficient.

Improving personal health records for patient-centered care.

OBJECTIVE: To assess the patient-centeredness of personal health records (PHR) and offer recommendations for best practice guidelines. DESIGN: Semi-structured interviews were conducted in seven large early PHR adopter organizations in 2007. Organizations were purposively selected to represent a variety of US settings, including medium and large hospitals, ambulatory care facilities, insurers and health plans, government departments, and commercial sectors. MEASUREMENTS: Patient-centeredness was assessed against a framework of care that includes: (1) respect for patient values, preferences, and expressed needs; (2) information and education; (3) access to care; (4) emotional support to relieve fear and anxiety; (5) involvement of family and friends; (6) continuity and secure transition between healthcare providers; (7) physical comfort; (8) coordination of care. Within this framework we used evidence for patient preferences (where it exists) to compare existing PHR policies, and propose a best practice model. RESULTS: Most organizations enable many patient-centered functions such as data access for proxies and minors. No organization allows patient views of clinical progress notes, and turnaround times for PHR reporting of normal laboratory results can be up to 7 days. CONCLUSION: Findings suggest patient-centeredness for personal health records can be improved, and recommendations are made for best practice guidelines.

Systematic review of health information exchange in primary care practices.

BACKGROUND: Unprecedented federal interest and funding are focused on secure, standardized, electronic transfer of health information among health care organizations, termed health information exchange (HIE). The stated goals are improvements in health care quality, efficiency, and cost. Ambulatory primary care practices are essential to this process; however, the factors that motivate them to participate in HIE are not well studied, particularly among small practices. METHODS: We conducted a systematic review of the literature about HIE participation from January 1990 through mid-September 2008 to identify peer-reviewed and non-peer-reviewed publications in bibliographic databases and websites. Reviewers abstracted each publication for predetermined key issues, including stakeholder participation in HIE, and the benefits, barriers, and overall value to primary care practices. We identified themes within each key issue, then grouped themes and identified supporting examples for analysis. RESULTS: One hundred and sixteen peer-reviewed, non-peer-reviewed, and web publications were retrieved, and 61 met inclusion criteria. Of 39 peer-reviewed publications, one-half reported original research. Among themes of cost savings, workflow efficiency, and quality, the only benefits to be reliably documented were those regarding efficiency, including improved access to test results and other data from outside the practice and decreased staff time for handling referrals and claims processing. Barriers included cost, privacy and liability concerns, organizational characteristics, and technical barriers. A positive return on investment has not been documented. CONCLUSIONS: The potential for HIE to reduce costs and improve the quality of health care in ambulatory primary care practices is well recognized but needs further empiric substantiation.

Health information exchange in small-to-medium sized family medicine practices: motivators, barriers, and potential facilitators of adoption.

PURPOSE: For small-to-medium sized primary care practices (those with 20 or fewer clinicians), determine desired functions of health information exchange (HIE) and potential motivators, barriers, and facilitators of adoption. METHODS: Case study approach with mixed quantitative and qualitative methods. Nine practices in Colorado were purposively selected. Five used paper records and four were already participating in health information exchange. RESULTS: Practices particularly desired HIE functions to allow anywhere/anytime lookup of test results and to consolidate delivery of test results. HIE-generated quality reporting was the least desired function. Practices were motivated to adopt HIE to improve the quality and efficiency of care, although they did not anticipate financial gains from adoption. The greatest facilitator of HIE adoption would be technical assistance and support during and after implementation. Financial incentives were also valued. Trust in HIE partners was a major issue, and practices with rich professional and social networks appeared to be especially favorable settings for HIE adoption. CONCLUSIONS: These findings may assist policymakers in promoting adoption of HIE among small-to-medium sized primary care practices, a major component of the US healthcare system.

Patient acceptance of a novel preventive care delivery system.

OBJECTIVE: To determine patient acceptance of a preventive care model employing outreach by non-physician experts outside of clinic visits. METHODS: Questionnaire completed in 2005 by patients in the waiting room of an academic general medicine practice associated with the University of Colorado Health Sciences Center. Topics included the role of primary care providers in coordinating health care; interest in being contacted by non-PCPs between visits; and willingness to communicate with such experts by phone, e-mail, and internet. RESULTS: 95% of the patients completed the survey (n=354). 93% of these affirmed either that requiring primary care provider involvement in preventive health care is not always necessary, is inconvenient, or represents an unnecessary expense. More than 70% were open to a non-PCP-centered method of receiving preventive services. Socioeconomically disadvantaged patients and those with poorer self-rated health, however, were less likely to express interest in the concept. CONCLUSION: Our patients were open to a non-traditional model of delivering preventive care. This model could improve delivery of preventive services. In instituting this system, it would be important to pay close attention to the concerns of vulnerable populations.