Impact on patient-provider relationship and documentation practices when mental health patients access their electronic health records online: a qualitative study among health professionals in an outpatient setting.

BACKGROUND: Patient accessible electronic health records (PAEHR) hold the potential to increase patient empowerment, especially for patients with complex, long-term or chronic conditions. However, evidence of its benefits for patients who undergo mental health treatment is unclear and inconsistent, and several concerns towards use of PAEHR emerged among health professionals. This study aimed at exploring the impact of PAEHR among mental health professionals in terms of patient-provider relationship, changes in the way of writing in the electronic health records and reasons for denying access to information. METHODS: In-depth qualitative interviews with health professionals working in two mental health outpatient clinics at Helgelandssykehuset in Northern Norway, one of the first hospitals in Norway to implement the PAEHR in 2015. The interviews were conducted by phone or videoconferencing, audio recorded and transcribed verbatim. Data were analyzed by a multidisciplinary research team using the Framework Method. RESULTS: A total of 16 in-depth qualitative interviews were conducted in April and May 2020. The PAEHR implemented in Norway was seen as a tool to increase transparency and improve the patient-provider relationship. The PAEHR was seen to have negative consequences only in limited situations, such as for patients with severe mental conditions, for child protective services when parents access their children's journal, or for patients with abusive partners. The functionality to deny access to the journal was used rarely. A more common practice for making information not immediately available was to delay the final approval of the notes. The documentation practices changed over the years, but it was not clear to what extent the changes were attributable to the introduction of the PAEHR. Health professionals write their notes keeping in mind that patients might read them, and they try to avoid unclear language, information about third parties, and hypotheses that might create confusion. CONCLUSIONS: The concerns voiced by mental health professionals regarding the impact of the PAEHR on the patient-provider relationship and practices to deny access to information were not supported by the results of this study. Future research should explore changes in documentation practices by analysing the content of the electronic health records.

How Do Users of Modern EHR Perceive the Usability, User Resistance and Productivity Five Years or More After Implementation?

The Electronic Health Record (EHR) has been a principal component in transforming healthcare from traditional pen-and-paper documentation procedures to highly digitalized and interoperable environments. Implementation of EHR is complicated, and success is dependent on the users accepting and utilizing the system to its potential. The present qualitative multi-center study investigated health professionals perceived system usability, user resistance and productivity five to eight years after implementation of a modern EHR, across three European cites. Data was collected with semi-structured interviews with experienced health professionals that had work experience before and after implementation of the EHR. Overall, the respondents considered their EHR to have good usability, reported a low degree of user resistance, and were ambiguous on how the EHR affected their perceived workload at the present, but retrospectively reported that the road towards the present state of satisfaction was not without hurdles.

How to Retain Participants in User-Centered Design? Towards Recommendations for Minimizing Dropouts.

Dropout and fatigue is present in most research projects. The present project Chronic Pain includes Fibromyalgia patients and applies a user-centered design approach. Surprisingly to the research group, two years into the project there is zero dropout. As a step towards designing a survey to investigate the patient adherence to the project, the characteristics of the user-centered design process are described in this paper.

User-Centred Design with a Remote Approach: Experiences from the Chronic Pain Project.

User-centred design involves end-users or user groups during all the parts of the development process. The research project Chronic Pain aims to develop a shared decision making application for patients and physicians, addressing individually adapted pain treatment. The project employs a user-centred design process, and in middle of it, Covid-19 pandemic social distancing restrictions were imposed. This paper presents how the user-centred design process together with a patient organisation was transformed to a digital approach and the experiences from performing a remote co-creation user workshop. The digital approximation had a satisfactory result and the main contribution lies in the sharing of recommendations for how to practically apply a remote user-centred design methodology.

User-Centred Design of a Mobile Application for Chronic Pain Management.

Chronic pain patients constitute a large and heterogeneous patient group and it is important to build tools and methods that can identify efficient treatment options for each individual patient. It is estimated that 20-30% of the population has suffered from chronic pain and this imposes enormous costs on society and the national welfare programs. The research project Chronic Pain addresses the problem of how to provide patients and physicians with relevant, valid and adapted decision alternatives in a shared decision making tool. This paper presents the results from co-creation workshops early in the user-centred design process of the chronic pain mobile application. The end-users contributed in mapping the user needs and requirements, and made paper prototyping of the user interface. The main contribution lies on how a user-centred design methodology can be applied in a clinical development context.

Open or Closed: A Project Proposal for Investigating Two Different EHR Platform Approaches.

Technical platforms form the fundament on which IT systems and Electronic Health Records (EHRs) are implemented. The use of either open or proprietary standards and technologies for information modelling and interoperability have implications for how clinical and health data is handled and made available for the system users. In Norway, two different EHRs are procured in different health regions of the Specialist healthcare service. The two platforms are characterized as one being open platform-based and the other being closed platform-based. The study aims to identify and describe consequences and implications related to two different platform approaches for EHRs from an end-user perspective. The study will employ three methods of data capturing; scoping study, interviews, and questionnaires. Data will be systematically analyzed through proven methods. Interviews and questionnaire data will be gathered from European hospitals having implemented EHRs in recent years. Results will be compared to the Norwegian context. The technical platform used for health IT systems in general, and the EHR specifically, can have substantial consequences for clinicians and organization of work. Closed platform-based EHRs still constitutes the majority of the market, but open platform approaches are rapidly gaining popularity. An assessment of the consequences related to different platform designs can shed light on the implications the chosen technical approach will have on clinical and organizational practice.

Blame it on the weather? The association between pain in fibromyalgia, relative humidity, temperature and barometric pressure.

Self-reported pain levels in patients with fibromyalgia may change according to weather conditions. Previous studies suggest that low barometric pressure (BMP) is significantly related to increased pain, but that the contribution of changes in BMP has limited clinical relevance. The present study examined whether BMP influenced variability in perceived stress, and if stress levels moderated or mediated the relationship between BMP and pain. Forty-eight patients with fibromyalgia enrolled in a randomized controlled trail (RCT) reported pain and emotional state three times daily with mobile phone messages for a 30-consecutive day period prior to the start of the treatment in the RCT. The patients were unaware that weather data were collected simultaneously with pain and emotional reports. The results showed that lower BMP and increased humidity were significantly associated with increased pain intensity and pain unpleasantness, but only BMP was associated with stress levels. Stress levels moderated the impact of lower BMP on pain intensity significantly, where higher stress was associated with higher pain. Significant individual differences were present shown by a sub-group of patients (n = 8) who reacted opposite compared to the majority of patients (n = 40) with increased pain reports to an increase in BMP. In sum, lower BMP was associated with increased pain and stress levels in the majority of the patients, and stress moderated the relationship between BMP and pain at the group-level. Significant individual differences in response to changes in BMP were present, and the relation between weather and pain may be of clinical relevance at the individual level.

No Effect of 2 mA Anodal tDCS Over the M1 on Performance and Practice Effect on Grooved Pegboard Test and Trail Making Test B

Previous studies suggest that transcranial direct current stimulation (tDCS) can facilitate motor performance and learning. In this double-blind experiment, 60 healthy human subjects (29 females) were randomized into three groups (active tDCS, sham tDCS, and no-treatment control group) in order to investigate the effect of a 20 min session of 2 mA tDCS over the motor cortex contralateral to the dominant hand on practice effect and performance on the Grooved Pegboard Test (GPT) and Trail Making Test (TMT). Performance was operationalized as the time to complete the tests before, during, and after stimulation. The practice effect was termed as the difference in time to complete the tests from pretest to post-test. Data on body mass index (BMI), head circumference, sleep status, interelectrode impedance, and caffeine and nicotine use were sampled to control for the influence of individual differences on the effect of tDCS. Adverse effects were registered using a standardized form. The results indicated no effect of tDCS on performance and practice effects on the GPT and TMT. For all groups, BMI was a predictor for a practice effect on the TMT. In the active tDCS group, high caffeine intake and low impedance predicted a practice effect on the GPT for the dominant hand. The present results suggest that impedance levels in tDCS studies should be routinely reported in future studies, as it might not only provide valuable information on the efficacy of the blinding conditions and participant discomfort, but also correlate with individual differences that are relevant to the outcome of the stimulation.

Transcranial direct current stimulation as a treatment for patients with fibromyalgia: a randomized controlled trial.

Previous studies suggest that transcranial direct current stimulation (tDCS) over the primary motor cortex (M1) reduces chronic pain levels. In this randomized controlled trial, we investigated the effects of 5 consecutive 20-minute sessions of 2-mA anodal tDCS directed to the M1 in 48 patients (45 females) with fibromyalgia. Changes in pain, stress, daily functioning, psychiatric symptoms, and health-related quality of life were measured. Pain and stress were measured 30 days before treatment, at each treatment, and 30 days after treatment by using short message service on mobile phones. Patients were randomized to the active or sham tDCS group by receiving individual treatment codes associated either with the sham or active tDCS in the stimulator. Adverse effects were registered using a standardized form. A small but significant improvement in pain was observed under the active tDCS condition but not under the sham condition. Fibromyalgia-related daily functioning improved in the active tDCS group compared with the sham group. The stimulation was well tolerated by the patients, and no significant difference in the adverse effects between the groups was observed. The results suggest that tDCS has the potential to induce statistically significant pain relief in patients with fibromyalgia, with no serious adverse effects, but small effect sizes indicate that the results are unlikely to reflect clinically important changes.

The effect of transcranial direct current stimulation on experimentally induced heat pain.

Transcranial direct current stimulation (tDCS) is a non-invasive neuromodulatory technique that can affect human pain perception. Placebo effects are present in most treatments and could therefore also interact with treatment effects in tDCS. The present study investigated whether short-term tDCS reduced heat pain intensity, stress, blood pressure and increased heat pain thresholds in healthy volunteers when controlling for placebo effects. Seventy-five (37 females) participants were randomized into three groups: (1) active tDCS group receiving anodal tDCS (2 mA) for 7 min to the primary motor cortex (M1), (2) placebo group receiving the tDCS electrode montage but only active tDCS stimulation for 30 s and (3) natural history group that got no tDCS montage but the same pain stimulation as the active tDCS and the placebo group. Heat pain was induced by a PC-controlled thermode attached to the left forearm. Pain intensity was significantly lower in the active tDCS group when examining change scores (pretest-posttest) for the 47 °C condition. The placebo group displayed lower pain compared with the natural history group, displaying a significant placebo effect. In the 43 and 45 °C conditions, the effect of tDCS could not be separated from placebo effects. The results revealed no effects on pain thresholds. There was a tendency that active tDCS reduced stress and systolic blood pressure, however, not significant. In sum, tDCS had an analgesic effect on high-intensity pain, but the effect of tDCS could not be separated from placebo effects for medium and low pain.

[Transcranial direct current stimulation for chronic pain]. / Transkranial likestrømsstimulering ved kroniske smerter.

BACKGROUND: Transcranial Direct Current Stimulation (tDCS) is a non-invasive method for neuromodulation. By changing the neurons' resting membrane potential, the method can alter the activity in areas of the brain. We therefore wished to review randomised controlled trials (RCTs) that investigate the treatment effect of tDCS on chronic pain. EVIDENCE: We undertook a search in PubMed with the search terms «transcranial direct current stimulation¼ and «pain¼, with «randomized controlled trial¼ as a filter. RESULTS: Five randomised, controlled trials that used quantitative outcome measures for pain were identified. The studies focused on strongly varying groups of patients suffering from pain. The results from some of the studies showed that stimulation with the aid of tDCS led to a significantly lower level of pain, but seen as a whole, the results were not conclusive. INTERPRETATION: The method should be further investigated in studies that include clearly defined groups of patients suffering from pain, as well as a larger number of participants, before implementation of the method is considered as a treatment option for chronic pain.