Impact of Patient Access to Online VA Notes on Healthcare Utilization and Clinician Documentation: a Retrospective Cohort Study

BackgroundIn an effort to foster patient engagement, some healthcare systems provide their patients with open notes, enabling them to access their clinical notes online. In January 2013, the Veterans Health Administration (VA) implemented online access to clinical notes (“VA Notes”) through the Blue Button feature of its patient portal.ObjectiveTo measure the association of online patient access to clinical notes with changes in healthcare utilization and clinician documentation behaviors.DesignA retrospective cohort study.PatientsPatients accessing My HealtheVet (MHV), the VA’s online patient portal, between July 2011 and January 2015.Main MeasuresUse of healthcare services (primary care clinic visits and online electronic secure messaging), and characteristics of physician clinical documentation (readability of notes).Key ResultsAmong 882,575 unique portal users, those who accessed clinical notes (16.2%; N = 122,972) were younger, more racially homogenous (white), and less likely to be financially vulnerable. Compared with non-users, Notes users more frequently used the secure messaging feature on the portal (mean of 2.6 messages (SD 7.0) v. 0.87 messages (SD 3.3) in January–July 2013), but their higher use of secure messaging began prior to VA Notes implementation, and thus was not temporally related to the implementation. When comparing clinic visit rates pre- and post-implementation, Notes users had a small but significant increase in rate of 0.36 primary care clinic visits (2012 v. 2013) compared to portal users who did not view their Notes (p = 0.01). At baseline, the mean reading ease of primary care clinical notes was 53.8 (SD 10.1) and did not improve after implementation of VA Notes.ConclusionsVA Notes users were different than patients with portal access who did not view their notes online, and they had higher rates of healthcare service use prior to and after VA Notes implementation. Opportunities exist to improve clinical note access and readability.     

Platelet count response to H. pylori treatment in patients with immune thrombocytopenic purpura with and without H. pylori infection: a systematic review

Eradication of H. pylori improves thrombocytopenia in some patients with immune thrombocytopenic purpura by mechanisms that remain obscure. Platelet count responses may occur independently of H. pylori infection as a result of the immune modulating effects of macrolide antimicrobials or the removal of other commensal bacteria. We performed a systematic review of the literature to determine the effect of H. pylori eradication therapy in patients with immune thrombocytopenic purpura by comparing the platelet response in patients who were, and who were not infected with H. pylori. MEDLINE, EMBASE, Cochrane central registry and abstracts from the American Society of Hematology (from 2003) were searched in duplicate and independently without language or age restrictions. Eleven studies, 8 from Japan, were included enrolling 282 patients with immune thrombocytopenic purpura who received eradication therapy; 205 were H. pylori-positive and 77 were H. pylori-negative. The odds of achieving a platelet count response following eradication therapy were 14.5 higher (95% confidence interval 4.2 to 83.0) in patients with H. pylori infection (51.2% vs. 8.8%). No study reported bleeding or quality of life. Adverse events were reported in 12 patients. H. pylori eradication therapy was of little benefit for H. pylori-negative patients. These findings strengthen the causal association between H. pylori infection and immune thrombocytopenia in some patients. Randomized trials are needed to determine the applicability of H. pylori eradication therapy across diverse geographical regions.     

Potential of personal health record portals in the care of individuals with spinal cord injuries and disorders: Provider perspectives

Context/Objective: Although personal health record (PHR) portals are designed for patients, healthcare providers are a key influence in how patients use their features and realize benefits from them. A few studies have examined provider attitudes toward PHR portals, but none have focused on those who care for individuals with spinal cord injuries and disorders (SCI/D). We characterize SCI/D provider perspectives of PHR portals, including perceived advantages and disadvantages of PHR portal use in SCI/D care.

Design: Cross-sectional; semi-structured interviews.

Setting: Spinal Cord Injury (SCI) Centers in the Veterans Health Administration.

Participants: Twenty-six SCI/D healthcare providers.

Interventions: None.

Outcome Measures: Perceived advantages and disadvantages of PHR portals.

Results: The complex situations of individuals with SCI/D shaped provider perspectives of PHR portals and their potential role in practice. Perceived advantages of PHR portal use in SCI/D care included the ability to coordinate information and care, monitor and respond to outpatient requests, support patient self-management activities, and provide reliable health information to patients. Perceived disadvantages of PHR portal use in SCI/D care included concerns about the quality of patient-generated health data, other potential liabilities for providers and workload burden, and the ability of individuals with SCI/D to understand clinical information accessed through a portal.

Conclusion: Our study highlights advantages and disadvantages that should be considered when promoting engagement of SCI/D healthcare providers in use of PHR portals, and portal features that may have the most utility in SCI/D care.     

The molecular pathology of beta-thalassemia in Turkey: the Boğaziçi university experience

The thalassemias are a diverse group of hemoglobin (Hb) disorders characterized by a reduced synthesis of the globin chains of Hb. Today, more than 200 mutations, affecting different levels of beta-globin gene expression, by a variety of mechanisms, are known to result in a beta-thalassemia (thal) phenotype. According to recent findings, the multilayered complexity in the phenotype of beta-thal is the result not only of marked molecular heterogeneity at the beta-globin locus, but at the level of several other genes as well. The heterogeneity at the beta-globin locus, which is the most reliable and predictive factor of disease phenotype, is simplified, to a certain extent, by the fact that the mutations are ethnic-group specific. Fifty out of >200 beta-thal mutations account for 90-95% beta-thalassemias worldwide. In the broad group of Mediterranean countries, approximately 35 mutations have been reported thus far; however, allele frequencies vary among countries. beta-Thal is a major public health concern in Turkey; throughout the country the gene frequency is estimated to be 2.1%, but in certain regions, this figure increases to 10%. The estimated number of carriers is 1,300,000 and the number of homozygous beta-thal patients is around 4,000. The number of affected births is higher than expected, since the birthrate is still very high in Turkey, and the number of consanguineous marriages is above 60% in the eastern parts of the country. Unlike many other Mediterranean countries, beta-thal in Turkey is very heterogeneous at the clinical level, transfusion-dependent beta-thal major predominating. Between 1987 and 2006, more than 1,500 patients with homozyous beta-thal, unrelated and not preselected, were investigated by DNA analysis. Our results revealed that by far the most common mutation in Turkey is IVS-I-110 (G-->A), followed by IVS-I-6 (T-->C) and frameshift codon (FSC) 8 (-AA). The six most common mutations add up to approximately 70.3%, and the overall frequency of the first 12 mutations is 83.3%. The ratio of beta (0):beta (+)-thal mutations is 1:1, but the majority of beta (+)-thal cases carry the severe IVS-I-110 lesion; thus, most of these mutations give rise to beta-thal major in homozygous or compound heterozygous combinations. In addition to the 12 common mutations, several rare and four novel beta-thal mutations were reported in the framework of this project, totaling 36 mutations. Turkey's large molecular heterogeneity can be explained by its unique geographical position and rich history, an important crossroad between cultures, civilizations and continents for several centuries. This study shows that despite its great molecular heterogeneity, and with the advent of polymerase chain reaction (PCR)-based techniques and improved methods of early fetal sampling, heterozygote screening and prenatal diagnosis are feasible in Turkey.     

Promoting Access Through Complementary eHealth Technologies: Recommendations for VA’s Home Telehealth and Personal Health Record Programs

BACKGROUND

Many healthcare organizations have embraced eHealth technologies in their efforts to promote patient-centered care, increase access to services, and improve outcomes.

OBJECTIVE

Using the Department of Veterans Affairs (VA) as a case study, this paper presents two specific eHealth technologies, the Care Coordination Home Telehealth (CCHT) Program and the My HealtheVet (MHV) personal health record (PHR) portal with integrated secure messaging, and articulates a vision of how they might be implemented as part of a patient-centric healthcare model and used in a complementary manner to enhance access to care and to support patient-centered care.

METHODS

Based on our experience and ongoing work with both programs, we offer a series of recommendations for pursuing and ultimately achieving this vision.

CONCLUSION

VA’s CCHT and MHV programs are examples of an expanding repertoire of eHealth applications available to patients and healthcare teams. VA’s new patient-centric healthcare model represents a significant shift in the way that services are delivered and a profound opportunity to incorporate eHealth technologies like the CCHT and MHV programs into clinical practice to increase access to care, and to ensure the responsiveness of such technologies to the preferences and circumstances of patients.

     

Defining Core Issues in Utilizing Information Technology to Improve Access: Evaluation and Research Agenda

The Department of Veterans Affairs (VA) has been at the vanguard of information technology (IT) and use of comprehensive electronic health records. Despite the widespread use of health IT in the VA, there are still a variety of key questions that need to be answered in order to maximize the utility of IT to improve patient access to quality services. This paper summarizes the potential of IT to enhance healthcare access, key gaps in current evidence linking IT and access, and methodologic challenges for related research. We also highlight four key issues to be addressed when implementing and evaluating the impact of IT interventions on improving access to quality care: 1) Understanding broader needs/perceptions of the Veteran population and their caregivers regarding use of IT to access healthcare services and related information. 2) Understanding individual provider/clinician needs/perceptions regarding use of IT for patient access to healthcare. 3) System/Organizational issues within the VA and other organizations related to the use of IT to improve access. 4) IT integration and information flow with non-VA entities. While the VA is used as an example, the issues are salient for healthcare systems that are beginning to take advantage of IT solutions.