Adherence to direct or vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: a long-term observational study.

Our objectives were to measure long-term adherence to oral anticoagulants (OACs) in patients with atrial fibrillation (AF) and to identify patient factors associated with adherence. Using linked, population-based administrative data from British Columbia, Canada, an incident cohort of adults prescribed OACs for AF was identified. We calculated the proportion of days covered (PDC) as a time-dependent covariate for each 90-day window from OAC initiation until the end of follow-up. Associations between patient attributes and adherence were assessed using generalized mixed effect linear regression models. 30,264 patients were included. Mean PDC was 0.69 (SD 0.28) over a median follow-up of 6.7 years. 54% of patients were non-adherent (PDC < 0.8). After controlling for confounders, factors positively associated with adherence were number of drug class switches, history of stroke or transient ischemic attack, history of vascular disease, time since initiation, and age. Age > 75 years at initiation, polypharmacy (among VKA users only), and receiving DOAC (vs. VKA) were negatively associated with adherence. PDC decreased over time for VKA users and increased for DOAC users. Over half of AF patients studied were, on average, nonadherent to OAC therapy and missed 32% of their doses. Several patient factors were associated with higher or lower adherence, and adherence to VKA declined during therapy while DOAC adherence increased slightly over time. To min im ize the risk stroke, adherence-supporting interventions are needed for all patients with AF, particularly those aged > 75 years, those with prior stroke or vascular disease, VKA users with polypharmacy, and DOAC recipients.

Older adults and social prescribing experience, outcomes, and processes: a meta-aggregation systematic review.

OBJECTIVE: Social prescribing is a complex care model, which aims to address unmet non-medical needs and connect people to community resources. The purpose of this systematic review was to synthesize available evidence from qualitative methods (e.g. interviews or focus groups) on experience, outcomes, and processes for social prescribing and older adults (from the person or provider level). STUDY DESIGN: This was a systematic review using the Joanna Brigg's meta-aggregative approach. METHODS: We searched multiple online databases for peer-reviewed studies, which included older adults aged ≥60 years (group mean age) and social prescribing experience, outcomes, or processes. We included all qualitative or mixed methods designs from all years and languages. Date of the last primary search was March 24, 2022. Two authors used online software to conduct the screening independently and then decided on the final list of included studies via notes and online discussion. RESULTS: We screened 376 citations (after duplicates) and included eight publications. There were 197 older adult participants (59% women), and many people were living with chronic health conditions. Few details were provided for participants' ethnicity, education, and related factors. We created five synthesized findings related to (1) the approach of social prescribing; implementation factors such as (2) relationships, (3) behavior change strategies, and (4) the environment; and (5) older adults' perceived health and psychosocial outcomes. CONCLUSIONS: Despite the limited number of available studies, data provide an overview of people and processes involved with social prescribing, identified research and practice gaps, and possible next steps for implementing and evaluating social prescribing for older adults in primary care.

The Experiences of Endurance Athletes With Atrial Fibrillation: Tensions and Takeaways.

BACKGROUND: Growing evidence indicates that chronic high-intensity endurance exercise predisposes male, middle-aged athletes to increased risk of atrial fibrillation (AF). The aetiology of AF in endurance athletes is multifactorial and remains incompletely understood. Despite their unique training demands, AF care in athletes remains largely based on evidence derived from the general population. Understanding the experiences of athletes with AF provides a necessary foundation for addressing challenges in managing their condition and identifying gaps in care. AIM: The purpose of this interpretive descriptive qualitative study was to describe the experiences and perspectives of endurance athletes living with AF. METHOD: Masters athletes diagnosed with AF and aged between 35 and 60 years were recruited internationally through cardiology practices and social media. Ten middle-aged, male endurance athletes with AF and >1,500 lifetime training hours participated in individual, semi-structured interviews. Data were analysed using inductive thematic analysis. RESULTS: Three key themes were constructed: (1) tensions with training, (2) tensions with treatment plans, and (3) tensions with clinicians. Participants experienced a wide range of symptoms from AF that significantly affected their ability to train, and reacted negatively to medical treatment strategies that affected their exercise capacity and training performance. Athletes experienced tensions with providers who failed to acknowledge their athletic needs. CONCLUSIONS: Our results highlight the unique difficulties that male athletes with AF face in navigating between training and their disease, treatment, and clinicians. Shared decision-making between the athlete and provider is likely necessary for effective management of athletic AF.

Clinical Perspectives on the Development of a Gamified Heart Failure Patient Education Web Site.

Heart failure is a complex, chronic disease that requires self-care to manage, and patients need support and education to perform adequate self-care. Although electronic health interventions to support behavior change and self-care in cardiovascular disease are gaining traction, there is little engaging online education specifically designed for heart failure patients. This paper describes the design and development of a heart failure self-care patient education Web site that integrated gamification, meaning the use of game design elements in a non-game context. We sought feedback on the Web site from a group of heart failure clinicians in a focus group using a semi-structured interview guide, and data were analyzed thematically. Clinician input during the design phase touched on themes such as patients' decision-making in heart failure and older adults' adoption of technology. Clinicians recommended that a narrative gamification technique should reflect real-life dilemmas patients encounter in their self-care. Clinicians also discussed the need to carefully plan reward-based gamification techniques to avoid unintended effects. Overall, a gamified Web site has the potential to support heart failure self-care, but efforts are needed to address the disparity of those with limited computer literacy or access.

Community stakeholder-driven technology solutions towards rural health equity: A concept mapping study in Western Canada.

BACKGROUND: Technology holds great potential for promoting health equity for rural populations, who have more chronic illnesses than their urban counterparts but less access to services. Yet, more participatory research approaches are needed to gather community-driven health technology solutions. The purpose was to collaboratively identify and prioritize action strategies for using technology to promote rural health equity through community stakeholder engagement. METHODS: Concept mapping, a quantitative statistical technique, embedded within a qualitative approach, was used to identify and integrate technological solutions towards rural health equity from community stakeholders in three steps: (1) idea generation; (2) sorting and rating feasibility/importance and (3) group interpretation. Purposeful recruitment strategies were used to recruit key stakeholders and organizational representatives from targeted rural communities. RESULTS: Overall, 34 rural community stakeholders from western Canada (76% female, mean age = 55.4 years) participated in the concept mapping process. In Step 1, 84 ideas were generated that were reduced to a pool of 30. Multidimensional scaling and cluster analysis resulted in a six-cluster map representing how technological solutions can contribute toward rural health equity. The clusters of ideas included technological solutions and applications, but also ideas to make health care more accessible regardless of location, training and support in the use of technology, ensuring digital tools are simplified for ease of use, technologies to support collaboration among healthcare professionals and ideas for overcoming challenges to data sharing across health systems/networks. Each cluster included ideas that were rated as equally important and feasible. Key themes included organizational and individual-level solutions and connecting patients to newly developed technologies. CONCLUSIONS: Overall, the grouping of solutions revealed that technological applications require not only access but also support and collaboration. Concept mapping is a tool that can engage rural community stakeholders in the identification of technological solutions for promoting rural health equity. PATIENT OR PUBLIC CONTRIBUTION: Rural community stakeholders were involved in the generation and interpretation of technological solutions towards rural health equity in a three-step process: (1) individual brainstorming of ideas, (2) sorting and rating all ideas generated and (3) collective interpretation and group consensus on final results.

Internet access is a necessity: a latent class analysis of COVID-19 related challenges and the role of technology use among rural community residents.

BACKGROUND: Rural and remote communities faced unique access challenges to essential services such as healthcare and highspeed infrastructure pre-COVID, which have been amplified by the pandemic. This study examined patterns of COVID-related challenges and the use of technology among rural-living individuals during the first wave of the COVID-19 pandemic. METHODS: A sample of 279 rural residents completed an online survey about the impact of COVID-related challenges and the role of technology use. Latent class analysis was used to generate subgroups reflecting the patterns of COVID-related challenges. Differences in group membership were examined based on age, gender, education, race/ethnicity, and living situation. Finally, thematic analysis of open-ended qualitative responses was conducted to further contextualize the challenges experienced by rural-living residents. RESULTS: Four distinct COVID challenge impact subgroups were identified: 1) Social challenges (35%), 2) Social and Health challenges (31%), 3) Social and Financial challenges (14%), and 4) Social, Health, Financial, and Daily Living challenges (19%). Older adults were more likely to be in the Social challenges or Social and Health challenges groups as compared to young adults who were more likely to be in the Social, Health, Financial, and Daily Living challenges group. Additionally, although participants were using technology more frequently during the COVID-19 pandemic to address challenges, they were also reporting issues with quality and connectivity as a significant barrier. CONCLUSIONS: These analyses found four different patterns of impact related to social, health, financial, and daily living challenges in the context of COVID. Social needs were evident across the four groups; however, we also found nearly 1 in 5 rural-living individuals were impacted by an array of challenges. Access to reliable internet and devices has the potential to support individuals to manage these challenges.

Living as older adults with mental health concerns in rural British Columbia: A photovoice study.

OBJECTIVES: The purpose of this study was to understand the mental health experiences of adults 50 years of age and older living in a rural community in British Columbia. METHODS: This study used critical social theory and interpretive description. Purposive sampling was used to recruit 8 adults aged 50 years and older. Participants used digital cameras and spent up to five weeks taking photos of representations of their life as an older adult with a mental health concern in a rural community. Semi-structured interviews were used to explore participants' reasons for taking various photos, unveiling their experiences. Constant comparison was used to analyze the data. RESULTS: Four key themes were identified: mental wellbeing (hope, spirituality, and gratitude; nature and losses); stigma; services and supports; and environment. CONCLUSION: There is a significant need for more health care providers for rural older adults' mental health. Additionally, there is a need for integrated services and peer-led supports to address the needs of this population.

The Symptom Experience of Patients With Atrial Fibrillation Before Their Initial Diagnosis.

BACKGROUND: Atrial fibrillation (AF), the most common form of dysrhythmia, steadily increases in prevalence with age. If left untreated, AF significantly increases the risk of stroke, heart failure, and death. Despite the increasing prevalence, there are significant research gaps in the prediagnosis symptom experiences of patients with AF. OBJECTIVE: The purpose of this qualitative descriptive study was to explore the prediagnosis symptom experience of patients with AF. METHODS: Participants 19 years or older with AF diagnosed in the previous year were recruited (n = 26) from outpatient cardiac rehabilitation and AF clinics. Semistructured interviews, broadly guided by the Symptom Experience Model, explored perceptions, evaluations, and responses to AF symptoms. Thematic analysis used a 2-step approach, deductively coding for participants' symptom perceptions, evaluations, and responses and inductively coding within these broader Symptom Experience Model concepts. RESULTS: Perception involved awareness of bodily sensations, ranging from imperceptible noticing to commanding attention, heightened by rest and activity. In evaluation, participants used self-derived theories to explain their symptoms, gathered evidence to support/refute their theories, and formulated alternative theories as symptoms changed over time. Responses consisted of nontreatment, self-treatment, and health seeking; most participants needed repeated healthcare visits before diagnosis. CONCLUSIONS: The current study identified challenges participants experienced in developing awareness of their AF symptoms, the complex cognitive processes associated with evaluation, and barriers that made it difficult to respond to AF symptoms in a timely manner. Understanding the prediagnosis symptom experience from the patient's perspective is essential for the enhancement of current AF screening practices.

Transitions in Atrial Fibrillation Care: A Systematic Review.

BACKGROUND: Patients with atrial fibrillation (AF) commonly transition between care settings and providers. These transitions are often points in the health care system where errors and clinical deterioration can occur. Anticoagulation interruption or discontinuation and sub-optimal follow-up post-emergency department (ED) discharge are considered major transitional issues. OBJECTIVE: The purpose of this study was to synthesise the evidence examining the impact of transitional care interventions on patient, provider, and health care utilisation outcomes. METHODS: This systematic mixed studies review examined citations from four databases Medline, CINAHL, EMBASE, and Cochrane Central Controlled Register of Trials (CENTRAL) using relevant search terms. Fourteen (14) moderate to high quality articles were selected. RESULTS: The available evidence reporting impacts of transitional interventions on health care utilisation, provider, and patient outcomes in AF patients is mixed and of variable quality. The stronger evidence revealed improvements in patient outcomes including knowledge, quality of life, and medication adherence and increased provider anticoagulant prescriptions resulting from transitional interventions. Hospital admissions and ED visits were not significantly affected by any interventions. CONCLUSIONS: Apps and educational toolkits improved patient knowledge. Pathways increased patient quality of life and provider prescription rates. There is a need for more research to determine the AF transition interventions which maximise patient, provider and health care outcomes.

Navigating Uncertainty in Respiratory Assessment: The Interaction of Culture and Technology During Phase I Postanesthetic Recovery.

PURPOSE: To explore postanesthesia care unit (PACU) nurses' interactions with technology during the critical Phase I recovery period. DESIGN: Interpretive description was used to understand nurses' experiences. METHODS: Nine PACU nurses were recruited from three mid-sized hospitals within the same health authority in a Western Canadian province. Nurse participants were interviewed using a semistructured interview guide. FINDINGS: Nurses' interactions with technology were significantly influenced by PACU culture, as they constantly navigated a level of uncertainly about their patient's respiratory status. Three themes from the study are described. Theme 1 described nurses' confidence and trust in a visual sensory respiratory assessment process and the influence of anesthesia providers. Theme 2 described PACU nurses' guarded trust or rationalized mistrust in technology. Theme 3 highlighted the contextual influences, which sustained nurses' approach to respiratory assessment. CONCLUSIONS: PACU nurses practiced their intuitive sensory assessments with a projected strong sense of expert practice and minimal dependence on technology. PACU nurses expressed frustrations with current PACU bedside technology, particularly the respiratory module and described some experiences with delayed identification of hypoventilation and hypoxia. Rationalized behaviors with technology and alarm suppression were commonplace. Workplace culture sustained PACU nurses' respiratory assessment practices.

Recognition: key to the entrepreneurial strategies of rural coalitions in advancing access to health care.

OBJECTIVES: Considerable evidence has advanced the role of citizen-led coalitions (CLC) in supporting the health and social needs of rural citizens. There has been little research focusing on the experiences and strategies of coalitions, with their limited resources and status, in targeting health inequities in their rural communities. The aim of this study was to understand the entrepreneurial strategies and experiences of rural coalitions to effect change in the delivery of health services for their older adult populations. METHOD: A qualitative descriptive study method was used to generate understanding of the entrepreneurial experiences and strategies of CLCs in advancing health services to meet the health and social needs of their citizens. Seven diverse CLCs (n = 40) from different rural communities participated in focus groups and in individual and coalition-level surveys. Thematic analysis was used to construct themes from the data. RESULTS: Two over-riding themes emerged: entrepreneurial strategies and societal recognition. CLCs engaged in numerous entrepreneurial strategies that enabled actions and outcomes in meeting their health care needs. These strategies included: securing quick wins, leveraging existing resources, and joining forces with stakeholder groups/individuals. However, despite these strategies and successes, coalitions expressed frustration with not being seen and not being heard by decision-makers. This pointed to a key structural barrier to coalition successes -- a broader societal and institutional problem of failing to recognize not only the health needs of rural citizens, but also the legitimacy of the community coalitions to represent and act on those needs. CONCLUSIONS: Despite the potential for coalitions to mobilize and effect change in addressing the inequities of rural health service access for older adults, broader barriers to their recognition, may undermine their entrepreneurial strategies and success.

Atrial fibrillation care in rural communities: a mixed methods study of physician and patient perspectives.

BACKGROUND: Atrial fibrillation (AF) is a serious heart arrhythmia associated with devastating outcomes such as stroke. Inequitable rural AF care may put patients at risk. Virtually delivered specialty AF care offers a viable option, but stakeholder perceptions of this option within the context of rural AF care is unknown. The study purpose was to obtain patient and primary care physician perspectives of rural AF care and virtually delivered AF care as a potential option. METHODS: Using a mixed methods design, AF patients (n = 101) and physicians (n = 15) from three rural communities participated in focus groups and/or surveys. Focus group data were thematically analyzed, survey data were descriptively analyzed, and data were triangulated. RESULTS: Findings captured patients' and physicians' perceptions of prioritized, needs, concerns and problems in AF management, available/unavailable services, and their ideas about virtual AF care. Patients and physicians identified eclectic problems in managing AF. Overall, patients felt ill informed about managing their AF and their most salient problems related to fatigue, exercise intolerance, weight maintenance, sleep apnea, and worry about stroke and bleeding. Physicians found treating patients with co-morbidities and cognitive decline problematic and balancing risks related to anticoagulation challenging. Patients and physicians identified education as a pressing need, which physicians lacked time and resources to meet. Despite available rural services, access to primary and cardiology care was a recurring challenge, and emergency department (ED) use highly contentious but often the only option for accessing care. Physicians' managed AF care and varied in the referrals they made, often reserving them for complex situations to avoid patient travel. Patients and providers supported a broad approach to virtual AF care, tailored to an inclusive rural patient demographic. CONCLUSIONS: The study offered valuable physician and patient perspectives on AF care in rural communities including diverse management challenges, gaps in access to primary and specialty services that made ED an often used but contentious option. Findings point to the potential value of virtual care designed to reach patients with AF across the spectrum and geared to local contexts that preserve the vital role of primary care physicians in AF care in their communities.

Nurses' attitudes towards older people care: An integrative review.

AIMS AND OBJECTIVES: To examine hospital nurses' attitudes towards caring for older adults and delineate associated factors contributing to their attitudes. BACKGROUND: Population ageing is of international significance. A nursing workforce able to care for the ageing population is critical for ensuring quality older adult care. A synthesis of research related to nurses' attitudes towards older adult care is important for informing care quality and the nursing workforce issues. METHODS: A systematic integrative review process guided the review. Cumulative Index of Nursing and Allied Health Literature and Medline databases were searched for primary research published between 2005-2017. A total of 1,690 papers were screened with 67 papers read in-depth and eight selected for this review that met the inclusion/exclusion criteria. RESULTS: Nurses' held coexisting positive and negative attitudes towards generic and specific aspects of older adult care. Negative attitudes, in particular, were directed at the characteristics of older adults, their care demands or reflected in nurses' approaches to care. Across jurisdictions, work environment, education, experience and demographics emerged as influences on nurses' attitudes. CONCLUSION: There is a paucity of research examining nurses' attitudes towards older adult care. The limited evidence indicates that attitudes towards older people care are complex and contradictory. Influences on nurses' attitudes need further study individually and collectively to build a strong evidence base. Interventional studies are needed as are the development of valid and reliable instruments for measuring nurses' attitudes towards older adult care. RELEVANCE TO CLINICAL PRACTICE: Bolstering postgraduate gerontological preparation is critical for promoting nurses' attitudes towards older adult care. Creating age-friendly work environments, including appropriate resource allocation, is important to support older people care and facilitate positive nursing attitudes.

Orientation and transition programme component predictors of new graduate workplace integration.

AIM: To examine the relationships between selected components of new graduate nurse transition programmes and transition experiences. BACKGROUND: Transition support for new graduates is growing increasingly multifaceted; however, an investigation of the effectiveness of the constituent components of the transition process is lacking. METHODS: An online survey was disseminated to new graduates working in acute care settings and included questions related to new graduate transition programmes. The Casey Fink Graduate Nurse Experience Survey was used to quantify the transition experience. RESULTS: New graduate nurses who participated in a formal new graduate (NG) transition programme had significantly higher total transition scores than non-programme nurses. The orientation length and the average number of hours worked in a two week period were significant predictors of transition; the percentage of preceptored shifts was statistically insignificant. CONCLUSIONS: New graduate transition is enhanced with participation in a formal transition programme. Orientation should be at least four weeks in length, and new graduates should work at least 49 hours in a two week period. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers are in key positions to advocate for new graduate nurse transition programmes with adequate resources to support a four week orientation phase and shift scheduling to ensure an adequate number of hours over two week periods to facilitate transition.

Vascular Access Transition: Experiences of Patients on Hemodialysis.

An interpretive descriptive design was used to explore the experiences of patients on hemodialysis who had utilized and transitioned from a central venous catheter (CVC) to an arteriovenous fistula (AVF). Eleven patients participated in semi-structured interviews that were analyzed using constant comparison. Within the larger context of living with end stage renal disease, participants described their vascular access experiences according to three main themes: impact, coping, and influencing factors. Accesses had physical, psychosocial, and lifestyle-related impacts that participants coped with primarily by exercising control and gradually accepting, and were influenced by education, trust in healthcare providers, and family. Findings revealed a cumulative burden for many participants with AVF and the need to improve the patient experience of vascular accesses especially for those living in rural communities.

The academic librarian as co-investigator on an interprofessional primary research team: a case study.

OBJECTIVE: The objective of this study was to explore the role librarians play on research teams. The experiences of a librarian and a faculty member are situated within the wider literature addressing collaborations between health science librarians and research faculty. METHODS: A case study approach is used to outline the involvement of a librarian on a team created to investigate the best practices for integrating nurses into the workplace during their first year of practice. RESULTS: Librarians contribute to research teams including expertise in the entire process of knowledge development and dissemination including the ability to navigate issues related to copyright and open access policies of funding agencies. DISCUSSION: The librarian reviews the various tasks performed as part of the research team ranging from the grant application, to working on the initial literature review as well as the subsequent manuscripts that emerged from the primary research. The motivations for joining the research team, including authorship and relationship building, are also discussed. Recommendations are also made in terms of how librarians could increase their participation on research teams. CONCLUSION: The study shows that librarians can play a key role on interprofessional primary research teams.

Intensive care unit patients in the postanesthesia care unit: a case study exploring nurses' experiences.

PURPOSE: The purpose of this study was to understand the experiences of postanesthesia nurses caring for intensive care unit (ICU) patients in the postanesthesia care unit (PACU). DESIGN: Qualitative interpretive description. METHODS: Six PACU nurses participated in semi-structured interviews. Interviews were digitally recorded, transcribed verbatim, and analyzed using constant comparative analysis. Quality of the data collection and analysis process was maintained through constructing codes and themes jointly by several investigators and taking interpretive accounts back to participants. FINDING: Three main themes were constructed: expert mind-set, specialty practice, and identity and relationships. The expert mind-set described knowing but not doing and straddling concurrent foci and duties. Specialty practice entailed doing but not knowing and the unsupportive context that perpetuated this. Identity and relationships described the lost identity of postanesthesia nursing and tension in the relationships with ICU. CONCLUSIONS: Findings illuminate the challenges expert nurses face when an unplanned practice change is implemented.

New graduate nurse transition programs: Relationships with bullying and access to support.

New graduate nurses are often targets of bullying and horizontal violence. The support offered by new graduate nurse transition programs may moderate the effects of bullying and limit its negative impact on new graduate nurse transition. This study examined the relationships between access to support, workplace bullying and new graduate nurse transition within the context of new graduate transition programs. As part of a mixed methods study, an online survey was administered to new graduates (N = 245) approximately a year from starting employment. Bullied new graduate nurses were less able to access support when needed and had poorer transition experiences than their non-bullied peers. Participation in a formal transition program improved access to support and transition for bullied new graduate nurses. People supports within transition programs positively influenced the new graduate nurse transition experience. Formal transition programs provide support that attenuates the impact of bullying on new graduate nurses and improves transition.

The Landscape of Health Technology for Equity Deserving Groups in Rural Communities: A Systematic Review.

BACKGROUND: Equity-deserving groups face well-known health disparities that are exacerbated by rural residence. Health technologies have shown promise in reducing disparities among these groups, but there has been no comprehensive evidence synthesis of outcomes. PURPOSE: The purpose of this systematic review was to examine the patient, healthcare, and economic outcomes of health technology applications with rural living equity-deserving groups. RESEARCH DESIGN: The databases searched included Medline and Embase. Articles were assessed for bias using the McGill mixed methods appraisal tool. ANALYSIS: Data were synthesized narratively using a convergent integrated approach for qualitative and quantitative findings. RESULTS: This evidence synthesis includes papers (n = 21) that reported on health technologies targeting rural equity-deserving groups. Overall, patient outcomes - knowledge, self-efficacy, weight loss, and clinical indicators - improved. Healthcare access improved with greater convenience, flexibility, time and travel savings, though travel was still occasionally necessary. All studies reported satisfaction with health technologies. Technology challenges reported related to connectivity and infrastructure issues influencing appointment quality and modality options. While some studies reported additional costs, overall, studies indicated cost savings for patients. CONCLUSIONS: There is a paucity of research on health technologies targeting rural equity-deserving groups, and the available research has primarily focused on women. While current evidence was primarily of high quality, research is needed inclusive of equity-deserving groups and interventions co-designed with users that integrate culturally sensitive approaches. Review registered with Prospero ID = CRD42021285994.

Personal Health Record implementation in rural primary care: A descriptive exploratory study using RE-AIM framework.

Demand is emerging for personal health records (PHRs), a patient-centric digital tool for engaging in shared decision-making and healthcare data management. This study uses a RE-AIM framework to explore rural patients and providers' perceptions prior to and following implementation of a PHR. Health care providers and their patients were recruited from early-adopter patient medical home clinics and a local patient advisory group. Focus groups were used to explore patient and provider pre-implementation perceptions of PHRs and post-implementation provider perspectives. Patients were invited through participating clinics to use the PHR. An implementation process evaluation was conducted. Multiple methods and data sources were used and included pre-/post-intervention patient surveys, provider interviews, and PHR/EHR administrative data. Both patient and provider focus groups described PHRs as providing a comprehensive health story and enhanced communication. Patients prioritized collection of health promotion data while providers endorsed health-related, clinical data. Both groups expressed the need for managing expectations and setting boundaries on PHR use. The evaluation indicated Reach: 16% of targeted patients participated and an additional 127 patients used the PHR as a tool during the COVID-19 pandemic. Effectiveness: Patient satisfaction with use was neutral, with no significant changes to quality of life, self-efficacy, or patients' activation. Adoption: 44% of eligible clinics participated, primarily those operated publicly versus privately, in smaller communities, and farther from a regional hospital. Implementation: Despite system interoperability expectations, at time of roll out, information exchange standards had not been reached. Additional implementation complications arose from the onset of the pandemic. One clinic on-boarded additional patients resulting in a rapid spike in PHR use. Maintenance: All clinics discontinued PHR within the study period, citing several key barriers to use. RE-AIM offers a valuable process evaluation framework for a comprehensive depiction of impact, and how to drive future success. Interoperability, patient agency and control, and provider training and support are critical obstacles to overcome in PHR implementation.