Patient-centered communication, disparities, and patient portals in the US, 2017-2022.

OBJECTIVES: To identify the relationship between patient-centered communication and portal offers and use among insured adult patients and to understand the role of patient-centered communication in equitable access to portals. STUDY DESIGN: Using data from 4 cycles of the Health Information National Trends Survey across 2017-2022, we determined how patient-centered communication and sociodemographic characteristics of adult insured patients in the US are associated with offers of and access to online patient portals. METHODS: We conducted multivariable logistic regression analysis to examine associations of patient-centered communication and sociodemographic characteristics of adult insured patients in the US with offers of and access to online patient portals. RESULTS: Across the period of 2017-2022, approximately two-thirds of insured adult patients on average reported being offered a patient portal, and approximately half reported accessing a portal. Patients with lower-than-average patient-centered communication and those who are men, are Hispanic, have less than a college degree, and have no internet are less likely than their counterparts to report being offered or accessing a portal. CONCLUSIONS: Although patient-centered communication is an important factor in facilitating patient portal offers and access, it does not appear to be a driver of demographic divides in portal use.

Provision of Social Care Services by US Hospitals.

Policy Points Hospitals address population health needs and patients' social determinants of health by offering social care services. Tax-exempt hospitals are required to invest in community benefits, including social care services programs, though most community benefits spending is toward unreimbursed health care services. Tax-exempt hospitals offer about 36% more social care services than for-profit hospitals. Among tax-exempt hospitals, those that allocate more resources to community benefits spending offer more types of social care services, but those in states with minimum community benefits spending requirements offer fewer social care services. Policymakers may consider specifically incentivizing community benefits expenditures toward particular social care services, including linking tax exemptions to implementation, utilization, and outcome targets, to more directly help patients. CONTEXT: Despite growing interest in identifying patients' social needs, little is known about hospitals' provision of services to address them. We identify social care services offered by US hospitals and determine whether hospital spending or state policies toward community benefits are associated with the provision of these services by tax-exempt hospitals. METHODS: National secondary data about hospitals were collected from the American Hospital Association Annual Survey, with additional Internal Revenue Service (IRS) Form 990 data on community benefits spending from CommunityBenefitInsight.org and state-level community benefits policies from HilltopInstitute.org. Descriptive statistics for types of social care services and hospital characteristics were calculated, with bivariate chi-square and t-tests comparing for-profit and tax-exempt hospitals. Multivariable Poisson regression was used to estimate associations between hospital characteristics and types of services offered and among tax-exempt hospitals to estimate associations between social care services and community benefits spending and policies. Multivariable logistic regressions modeled associations between community benefits spending/policies and each type of social care services. FINDINGS: Private US hospitals offered an average of 5.7 types of social care services in 2018. Tax-exempt hospitals offered about 36% more social care services than for-profit hospitals. Larger number of beds, health system affiliation, and having community partnerships are associated with more social care services, whereas rural hospitals and those managed under contract offered fewer social care services. Among tax-exempt hospitals, greater community benefits spending is associated with offering more total (incidence rate ratio [IRR] = 1.10, p < 0.01) and patient-focused social care services (IRR = 1.16, p < 0.01). Hospitals in states with minimum community benefits spending requirements offered significantly fewer social care services. CONCLUSIONS: Although tax-exempt status and increased community benefits spending were associated with increased social care services provision, the observation that certain hospital characteristics and state minimum community benefits spending requirements were associated with fewer social care services suggests opportunities for policy reform to increase social care services implementation.

Resident Willingness to Participate in Digital Contact Tracing in a COVID-19 Hotspot: Findings From a Detroit Panel Study.

BACKGROUND: Digital surveillance tools and health informatics show promise in counteracting diseases but have limited uptake. A notable illustration of the limits of such tools is the general failure of digital contact tracing in the United States in response to COVID-19. OBJECTIVE: We investigated the associations between individual characteristics and the willingness to use app-based contact tracing in Detroit, a majority-minority city that experienced multiple waves of COVID-19 outbreaks and deaths since the start of the pandemic. The aim of this study was to examine variations among residents in the willingness to download a contact tracing app on their phones to provide public health officials with information about close COVID-19 contact during summer 2020. METHODS: To examine residents' willingness to participate in digital contact tracing, we analyzed data from 2 waves of the Detroit Metro Area Communities Study, a population-based survey of Detroit, Michigan residents. The data captured 1873 responses from 991 Detroit residents collected in June and July 2020. We estimated a series of multilevel logit models to gain insights into differences in the willingness to participate in digital contact tracing across a variety of individual attributes, including race/ethnicity, degree of trust in the government, and level of education, as well as interactions among these variables. RESULTS: Our results reflected widespread reluctance to participate in digital contact tracing in response to COVID-19, as less than half (826/1873, 44.1%) of the respondents said they would be willing to participate in app-based contact tracing. Compared to White respondents, Black (odds ratio [OR] 0.45, 95% CI 0.23-0.86) and Latino (OR 0.32, 95% CI 0.11-0.99) respondents were significantly less willing to participate in digital contact tracing. Trust in the government was positively associated with the willingness to participate in digital contact tracing (OR 1.17, 95% CI 1.07-1.27), but this effect was the strongest for White residents (OR 2.14, 95% CI 1.55-2.93). We found similarly divergent patterns of the effects of education by race. While there were no significant differences among noncollege-educated residents, White college-educated residents showed greater willingness to use app-based contact tracing (OR 6.12, 95% CI 1.86-20.15) and Black college-educated residents showed less willingness (OR 0.46, 95% CI 0.26-0.81). CONCLUSIONS: Trust in the government and education contribute to Detroit residents' wariness of digital contact tracing, reflecting concerns about surveillance that cut across race but likely arise from different sources. These findings point to the importance of a culturally informed understanding of health hesitancy for future efforts hoping to leverage digital contact tracing. Though contact tracing technologies have the potential to advance public health, unequal uptake may exacerbate disparate impacts of health crises.

Disparities in patient portal access by US adults before and during the COVID-19 pandemic.

Objective: Online patient portals become important during disruptions to in-person health care, like when cases of coronavirus disease 2019 (COVID-19) and other respiratory viruses rise, yet underlying structural inequalities associated with race, socio-economic status, and other socio-demographic characteristics may affect their use. We analyzed a population-based survey to identify disparities within the United States in access to online portals during the early period of COVID-19 in 2020. Materials and Methods: The National Cancer Institute fielded the 2020 Health and Information National Trends Survey from February to June 2020. We conducted multivariable analysis to identify socio-demographic characteristics of US patients who were offered and accessed online portals, and reasons for nonuse. Results: Less than half of insured adult patients reported accessing an online portal in the prior 12 months, and this was less common among patients who are male, are Hispanic, have less than a college degree, have Medicaid insurance, have no regular provider, or have no internet. Reasons for nonuse include: wanting to speak directly to a provider, not having an online record, concerns about privacy, and discomfort with technology. Discussion: Despite the rapid expansion of digital health technologies due to COVID-19, we found persistent socio-demographic disparities in access to patient portals. Ensuring that digital health tools are secure, private, and trustworthy would address some patient concerns that are barriers to portal access. Conclusion: Expanding the use of online portals requires explicitly addressing fundamental inequities to prevent exacerbating existing disparities, particularly during surges in cases of COVID-19 and other respiratory viruses that tax health care resources.

Discrimination, trust, and withholding information from providers: Implications for missing data and inequity.

Quality care requires collaborative communication, information exchange, and decision-making between patients and providers. Complete and accurate data about patients and from patients are especially important as high volumes of data are used to build clinical decision support tools and inform precision medicine initiatives. However, systematically missing data can bias these tools and threaten their effectiveness. Data completeness relies in many ways on patients being comfortable disclosing information to their providers without prohibitive concerns about security or privacy. Patients are likely to withhold information in the context of low trust relationships with providers, but it is unknown how experiences of discrimination in the healthcare system also relate to non-disclosure. In this study, we assess the relationship between withholding information from providers, experiences of discrimination, and multiple types of patient trust. Using a nationally representative sample of US adults (n = 2,029), weighted logistic regression modeling indicated a statistically significant relationship between experiences of discrimination and withholding information from providers (OR 3.7; CI [2.6-5.2], p < .001). Low trust in provider disclosure of conflicts of interest and low trust in providers' responsible use of health information were also positively associated with non-disclosure. We further analyzed the relationship between non-disclosure and the five most common types of discrimination (e.g., discrimination based on race, education/income, weight, gender, and age). We observed that all five types were statistically significantly associated with non-disclosure (p < .05). These results suggest that experiences of discrimination and specific types of low trust have a meaningful association with a patient's willingness to share information with their provider, with important implications for the quality of data available for medical decision-making and care. Because incomplete information can contribute to lower quality care, especially in the context of data-driven decision-making, patients experiencing discrimination may be further disadvantaged and harmed by systematic data missingness in their records.

Family Caregivers' Experiences With Telehealth During COVID-19: Insights From Michigan.

Telehealth can benefit older adults during COVID-19. The purpose of this study was to understand benefits and barriers to telemedicine visits for older adults from the perspectives of family caregivers. A cross-sectional, online survey was conducted across the state of Michigan with family caregivers (n = 90) who responded to open- and closed-ended questions. Perceived benefits of telemedicine included access and rapport; barriers included the appropriateness of telemedicine for certain health care needs. Telemedicine is a likely to remain beyond COVID-19 and can facilitate access to and continuity of care. There are barriers, however, that must be addressed, especially among older patients.

What Does "Patient-Centered" Mean? Qualitative Perspectives from Older Adults and Family Caregivers.

This study aimed to (1) examine what patient-centeredness means for older adults and family caregivers, and (2) assess circumstances underlying their preference for geriatric care. We conducted separate focus groups with older adults and family caregivers of older adults about health care experiences and expectations and conducted a vignette-based experiment to assess preference for geriatric care. Participants expressed a need for greater skill and empathy and integration of caregivers. They preferred geriatric care to usual primary care with increasing social, health, and healthcare complexity. Distinct needs of older adults should be considered in referral practices to geriatric medicine.

Racial and ethnic differences in self-reported telehealth use during the COVID-19 pandemic: a secondary analysis of a US survey of internet users from late March.

OBJECTIVE: Widespread technological changes, like the rapid uptake of telehealth in the US during the COVID-19 pandemic, risk creating or widening racial/ethnic disparities. We conducted a secondary analysis of a cross-sectional, nationally representative survey of internet users to evaluate whether there were racial/ethnic disparities in self-reported telehealth use early in the pandemic. MATERIALS AND METHODS: The Pew Research Center fielded the survey March 19-24, 2020. Telehealth use because of the pandemic was measured by asking whether respondents (N = 10 624) "used the internet or e-mail to connect with doctors or other medical professionals as a result of the coronavirus outbreak." We conducted survey-weighted logistic regressions, adjusting for respondents' socioeconomic characteristics and perceived threat of the pandemic to their own health (eg, no threat, minor, major). RESULTS: Approximately 17% of respondents reported using telehealth because of the pandemic, with significantly higher unadjusted odds among Blacks, Latinos, and those identified with other race compared to White respondents. The multivariable logistic regressions and sensitivity analyses show Black respondents were more likely than Whites to report using telehealth because of the pandemic, particularly when perceiving the pandemic as a minor threat to their own health. DISCUSSION: Black respondents are most likely to report using telehealth because of the COVID-19 pandemic, particularly when they perceive the pandemic as a minor health threat. CONCLUSION: The systemic racism creating health and health care disparities has likely raised the need for telehealth among Black patients during the pandemic. Findings suggest opportunities to leverage a broadly defined set of telehealth tools to reduce health care disparities postpandemic.

Exploring How Personal, Social, and Institutional Characteristics Contribute to Geriatric Medicine Subspecialty Decisions: A Qualitative Study of Trainees' Perceptions.

PURPOSE: To explore internal medicine residents' and geriatrics fellows' perceptions of how personal, social, and institutional characteristics contribute to their professional identity and subspecialty decisions related to geriatric medicine. METHOD: The authors conducted 23 in-depth, semistructured interviews with internal medicine residents, with and without an interest in geriatrics, and geriatrics fellows across 3 academic medical centers in the United States from October 2018 through June 2019. They then used a qualitative narrative approach to analyze the interview data. RESULTS: Trainees related personal experiences, such as exposure to physicians and experiences with grandparents, to their interest in medicine. Trainees with an interest in geriatrics at 2 institutions did not feel supported, or understood, by peers and mentors in their respective institutions but maintained their interest in the field. The following variations between institutions that are supportive and those that are not were noted: the number of geriatricians, the proximity of the institution to geriatrics clinics, and the ways in which institutional leaders portrayed the prestige of geriatric medicine. Institutional characteristics influenced trainees' understanding of what it meant to be a doctor, what meaning they garnered from work as a physician, and their comfort with different types of complexity, such as those presented when providing care to older adults. CONCLUSIONS: Institutional characteristics may be particularly important in shaping trainee interest in geriatric medicine. Institutions should encourage leadership training and opportunities for geriatricians so they can serve as role models and as hands-on mentors for trainees beginning in medical school. Increasing the number of geriatricians requires institutions to increase the value they place on geriatrics to generate a positive interest in this field among trainees. Institutions facilitating formation of professional identity and sense of purpose in work may consider engaging geriatricians in leadership and mentoring roles as well as curriculum development.

Why Most of Your Patients Aren't Using an Online Portal, and What You Can Do About It.

Online portals that provide patients with secure access to their medical records and provider communication can improve health care. Yet new technologies can also exacerbate existing health disparities. We analyzed information about 2,325 insured respondents to the nationally representative 2017 Health Information National Trends Survey to examine characteristics of portal nonusers and reasons for nonuse. Sixty-three percent reported not using a portal during the prior year. In multivariable analysis, we found that nonusers were more likely to be male, be on Medicaid, lack a regular provider, and have less than a college education, compared to users. Similar disparities existed in who reported being offered access to a portal, with nonwhites also less likely to report being offered access. Reasons for nonuse included privacy concerns and the desire to speak directly to providers, both of which indicate the important role of the doctor-patient relationship.

Trust and Privacy: How Patient Trust in Providers is Related to Privacy Behaviors and Attitudes.

Healthcare today requires extensive sharing and access to patient health information. The use of health information technology (health IT) exacerbates patients' privacy concerns because it expands the availability of patient data to numerous members of the healthcare team. Patient concerns about the privacy of their data may be associated with nondisclosure of their information to providers. Patient trust in physicians, a multi-dimensional perception influenced by patient, physician, and situational factors, can facilitate disclosure and use of health IT. Previous work has done little to explore how specific dimensions of trust in physicians are related to patient information-sharing concerns or behavior. Using data from a nationally-representative survey, we show that patients with higher trust in provider confidentiality have significantly lower likelihood of reporting having ever withheld important health information and lower likelihood of thinking it is important to find out who has looked at their medical records. Patient trust in physician competence is related to higher likelihood of thinking it is important for health care providers to share information electronically This work sheds light on the importance of considering multiple dimensions of trust for patient behavior and attitudes related to their information sharing with health care providers.

The Catch to Confidentiality: The Use of Electronic Health Records in Adolescent Health Care.

PURPOSE: This study aims to understand pediatric health-care providers' expectations and the practices they employ to protect confidentiality in electronic health records (EHRs) and subsequently how EHRs affect the documentation and dissemination of information in the course of health-care delivery to adolescent minors. METHODS: Twenty-six pediatric health-care providers participated in in-depth interviews about their experiences using EHRs to understand a broad spectrum of expectations and practices guiding the documentation and dissemination of information in the EHR. A thematic analysis of interviews was conducted to draw findings and conclusions. RESULTS: Two themes and several subthemes emerged centering on how EHRs affected confidentiality expectations and practices. Participants expressed confidentiality concerns due to the EHR's longevity as a legacy record, its multidimensional uses, and increased access by users (theme 1). These concerns affected practices for protecting adolescent confidentiality within the EHR (theme 2). Practices included selectively omitting or concealing information and utilizing sets of personal and collective codes designed to alert providers or teams of providers to confidential information within a patient's record. CONCLUSIONS: EHRs create new and unresolved challenges for pediatric health care as they alter expectations of confidentiality and the documentation and dissemination of information within the record. This is particularly relevant in the course of care to adolescent minors as EHRs may compromise the tenuous balance providers maintain between protecting confidentiality and effective documentation within the record.

Who Isn't Using Patient Portals And Why? Evidence And Implications From A National Sample Of US Adults.

Patient portals that provide secure online access to medical record information and provider communication can improve health care. Yet new technologies can exacerbate existing disparities. We analyzed information about 2,325 insured respondents to the nationally representative 2017 Health Information National Trends Survey to examine characteristics of portal nonusers and reasons for nonuse. Sixty-three percent reported not using a portal during the prior year. In multivariable analysis, we found that nonusers were more likely to be male, be on Medicaid, lack a regular provider, and have less than a college education, compared to users. Similar disparities existed in who reported being offered access to a portal, with nonwhites also less likely to report being offered access. Reasons for nonuse included the desire to speak directly to providers and privacy concerns, both of which require recognition of the important role of provider communication and patient-provider relationships.

Health IT and inappropriate utilization of outpatient imaging: A cross-sectional study of U.S. hospitals.

OBJECTIVE: To determine whether the use of information technology (IT), measured by Meaningful Use capability, is associated with lower rates of inappropriate utilization of imaging services in hospital outpatient settings. RESEARCH DESIGN: A retrospective cross-sectional analysis of 3332 nonfederal U.S. hospitals using data from: Hospital Compare (2011 outpatient imaging efficiency measures), HIMSS Analytics (2009 health IT), and Health Indicator Warehouse (market characteristics). Hospitals were categorized for their health IT infrastructure including EHR Stage-1 capability, and three advanced imaging functionalities/systems including integrated picture archiving and communication system, Web-based image distribution, and clinical decision support (CDS) with physician pathways. Three imaging efficiency measures suggesting inappropriate utilization during 2011 included: percentage of "combined" (with and without contrast) computed tomography (CT) studies out of all CT studies for abdomen and chest respectively, and percentage of magnetic resonance imaging (MRI) studies of lumbar spine without antecedent conservative therapy within 60days. For each measure, three separate regression models (GLM with gamma-log link function, and denominator of imaging measure as exposure) were estimated adjusting for hospital characteristics, market characteristics, and state fixed effects. Additionally, Heckman's Inverse Mills Ratio and propensity for Stage-1 EHR capability were used to account for selection bias. PRINCIPAL FINDINGS: We find support for association of each of the four health IT capabilities with inappropriate utilization rates of one or more imaging modality. Stage-1 EHR capability is associated with lower inappropriate utilization rates for chest CT (incidence rate ratio IRR=0.72, p-value <0.01) and lumbar MRI (IRR=0.87, p-value <0.05). Integrated PACS is associated with lower inappropriate utilization rate of abdomen CT (IRR=0.84, p-value <0.05). Imaging distribution over Web capability is associated with lower inappropriate utilization rates for chest CT (IRR=0.66, p-value <0.05) and lumbar MRI (IRR=0.86, p-value <0.05). CDS with physician pathways is associated with lower inappropriate utilization rates for abdomen CT (IRR=0.87, p-value <0.01) and lumbar MRI (IRR=0.90, p-value <0.05). All other cases showed no association. CONCLUSIONS: The study offers mixed results. Taken together, the results suggest that the use of Stage-1 Meaningful Use capable EHR systems along with advanced imaging related functionalities could have a beneficial impact on reducing some of the inappropriate utilization of outpatient imaging.

In the shade of a forest status, reputation, and ambiguity in an online microcredit market.

Scholars have long recognized status and reputation as pervasive forces reproducing comparative advantage in social and economic systems. Yet, due in part to methodological challenges, relatively few studies have examined how status and reputation interact. We use data from an online market for peer-to-peer lending to study independent and joint effects of status and reputation on borrowers' success at obtaining loans. First, we find a positive main effect of status, even when reputational signals are reliable and abundant. Second, we find that status matters the most for borrowers with moderate (rather than high or low) reputations, suggesting a curvilinear effect of status x reputation on loans. These results support the idea that status matters not only under conditions of too little information that creates information asymmetry, as typically assumed, but also under conditions of abundant information and too many choices that creates ambiguity about how to evaluate candidates.

Privacy in practice: professional discourse about information control in health care.

PURPOSE: The purpose of this paper is to explore different health care professionals' discourse about privacy - its definition and importance in health care, and its role in their day-to-day work. Professionals' discourse about privacy reveals how new technologies and laws challenge existing practices of information control within and between professional groups in health care, with implications not only for patient privacy, but also for the role of information control in professions more generally. DESIGN/METHODOLOGY/APPROACH: The authors conducted in-depth, semi-structured interviews with n=83 doctors, nurses, and health information professionals in two academic medical centers and one veteran's administration hospital/clinic in the Northeastern USA. Interview responses were qualitatively coded for themes and patterns across groups were identified. FINDINGS: The health care providers and the authors studied actively sought to uphold the protection (and control) of patient information through professional ethics and practices, as well as through the use of technologies and compliance with legal regulations. They used discourses of professionalism, as well as of law and technology, to sometimes accept and sometimes resist changes to practice required in the changing technological and legal context of health care. The authors found differences across professional groups; for some, protection of patient information is part of core professional ethics, while for others it is simply part of their occupational work, aligned with organizational interests. RESEARCH LIMITATIONS/IMPLICATIONS: This qualitative study of physicians, nurses, and health information professionals revealed some differences in views and practices for protecting patient information in the changing technological and legal context of health care that suggest some professional groups (doctors) may be more likely to resist such changes and others (health information professionals) will actively adopt them. PRACTICAL IMPLICATIONS: New technologies and regulations are changing how information is used in health care delivery, challenging professional practices for the control of patient information that may change the value or meaning of medical records for different professional groups. ORIGINALITY/VALUE: Qualitative findings suggest that professional groups in health care vary in the extent of information control they have, as well in how they view such control. Some groups may be more likely to (be able to) resist changes in the professional control of information that stem from new technologies or regulatory policies. Some professionals recognize that new IT systems and regulations challenge existing social control of information in health care, with the potential to undermine (or possibly bolster) professional self-control for some but not necessarily all occupational groups.

Seeking and receiving social support on Facebook for surgery.

Social networking sites such as Facebook provide a new way to seek and receive social support, a factor widely recognized as important for one's health. However, few studies have used actual conversations from social networking sites to study social support for health related matters. We studied 3,899 Facebook users, among a sample of 33,326 monitored adults, who initiated a conversation that referred to surgery on their Facebook Wall during a six-month period. We explored predictors of social support as measured by number of response posts from "friends." Among our sample, we identified 8,343 Facebook conversation threads with the term "surgery" in the initial post with, on average, 5.7 response posts (SD 6.2). We used a variant of latent semantic analysis to explore the relationship between specific words in the posts that allowed us to develop three thematic categories of words related to family, immediacy of the surgery, and prayer. We used generalized linear mixed models to examine the association between characteristics of the Facebook user as well as the thematic categories on the likelihood of receiving response posts following the announcement of a surgery. Words from the three thematic categories were used in 32.5% (family), 39.5 (immediacy), and 50.7% (prayer) of root posts. Few user characteristics were associated with response in multivariate models [rate ratios, RR, 1.08 (95% CI 1.01, 1.15) for married/living with partner; 1.10 (95% CI 1.03, 1.19) for annual income > $75,000]. In multivariate models adjusted for Facebook user characteristics and network size, use of family and prayer words in the root post were associated with significantly higher number of response posts, RR 1.40 (95% CI 1.37, 1.43) and 2.07 (95% CI 2.02, 2.12) respectively. We found some evidence of social support on Facebook for surgery and that the language used in the root post of a conversation thread is predictive of overall response.

The double-edged sword of electronic health records: implications for patient disclosure.

OBJECTIVE: Electronic health record (EHR) systems are linked to improvements in quality of care, yet also privacy and security risks. Results from research studies are mixed about whether patients withhold personal information from their providers to protect against the perceived EHR privacy and security risks. This study seeks to reconcile the mixed findings by focusing on whether accounting for patients' global ratings of care reveals a relationship between EHR provider-use and patient non-disclosure. MATERIALS AND METHODS: A nationally representative sample from the 2012 Health Information National Trends Survey was analyzed using bivariate and multivariable logit regressions to examine whether global ratings of care suppress the relationship between EHR provider-use and patient non-disclosure. RESULTS: 13% of respondents reported having ever withheld information from a provider because of privacy/security concerns. Bivariate analysis showed that withholding information was unrelated to whether respondents' providers used an EHR. Multivariable analysis showed that accounting for respondents' global ratings of care revealed a positive relationship between having a provider who uses an EHR and withholding information. DISCUSSION: After accounting for global ratings of care, findings suggest that patients may non-disclose to providers to protect against the perceived EHR privacy and security risks. Despite evidence that EHRs inhibit patient disclosure, their advantages for promoting quality of care may outweigh the drawbacks. CONCLUSIONS: Clinicians should leverage the EHR's value in quality of care and discuss patients' privacy concerns during clinic visits, while policy makers should consider how to address the real and perceived privacy and security risks of EHRs.