eHealth is a model of care for augmenting efficient, safe, high-quality, continuous, coordinated delivery of evidence-based services to Veterans and their families. eHealth technologies include those that are intended for use by Veterans and/or their caregivers as well as those that are intended for joint use by Veterans/caregivers and members of their clinical teams. VA has invested in various eHealth technologies, including the My HealtheVet (MHV) patient portal and its suite of features, that hold great potential for positive effects on Veterans' health care. However, despite this positive potential, the unintended adverse consequences that can accompany the implementation of eHealth technologies must also be carefully considered to ensure patient safety and the delivery of high quality services. In the context of this study, we use the term unintended adverse consequences (UACs) to refer to events whereby the implementation and/or use of eHealth technologies is associated with an unplanned negative outcome. Through a combination of primary data collection, synthesis of existing secondary data, and reviewing of published literature, we examined the UACs associated with the adoption and use of VA's My HealtheVet patient portal.
Guided by the Socio-Technical Model for studying Health Information Technology, our work was organized around three Specific Aims: Aim 1: Review existing literature and data available from previous projects evaluating use of My HealtheVet features in VA; Aim 2: Gather data around experienced or postulated UACs; and Aim 3: Synthesize UACs into products to guide implementation planning and monitoring for UACs.
This was a mixed-methods study. Our approach included a review of published literature on the consequences of patient portal implementation and use, secondary analysis of excerpts from prior qualitative interviews about My HealtheVet feature use where participants discussed actual or potential consequences associated with portal use, and 30 semi-structured key informant interviews with key stakeholders (patient volunteers, providers, My HealtheVet coordinators, and operational staff) engaged in My HealtheVet implementation and use. A card sort technique was used to sort unintended consequences into themed groupings and create a code list which was used to code data from all three sources and generate our final analytic summary.
We identified multiple UACs associated with patient portal use which we broadly categorized into five domains: (1)Clinical team/staff impacts, (2)Patient/caregiver impacts, (3)Impacts on communication and relationships, (4)Usability problems, and (5)Other adverse impacts. Clinical team/staff impacts include those that influence processes such as clinical workflow (e.g., how clinical team structures their time), health care utilization (e.g., changes in visit types or frequency), and documentation practices (e.g., how clinicians document in the EHR). They also include impacts on the clinical team or other clinic/hospital staff (e.g., stress/burnout, uncertainty, concerns about liability) and their attitudes towards technology. Patient/caregiver impacts include impacts on health outcomes, patient/caregiver understanding of health information (e.g., incorrect interpretation of clinical results), patient/caregiver emotional response (e.g., anxiety, worry, upset, offense, uncertainty), or increase in disparities (i.e., impacts on vulnerable subsets of the patient population). Impacts on communication include changes in communication-related practices, satisfaction, and impacts on the patient-provider relationship or within-team relationships. All stakeholders reported usability/human-computer interface issues, especially when first accessing portal features. Other UACs include data security and privacy issues of portal use. All stakeholders reported that in addition to usability issues, lack of adequate training and conflicts or inconsistencies with policies led to UACs in one or more of the above categories. Important to note, for almost every category in which we uncovered unintended adverse consequences, there was also evidence of positive consequences of patient portal use. Consistent with prior research, positive consequences are far more common than unintended adverse consequences to patient portal adoption. Nonetheless, it remains important to pay attention to the UACs of portal use so that they can be addressed.
Recommendations published in 2013 by the American Medical Informatics Association encourage researchers to develop a core set of measures for adverse events related to health IT use. This pilot is a critical first step towards measuring, monitoring, intervening in and preventing eHealth UACs, specifically unintended consequences related to patient portals such as My HealtheVet. The study has identified important concepts that help elucidate the impacts of portals on different stakeholder groups. Next steps involve the development of a taxonomy of potential UACs and a guide for considering UACs in the context of implementation. Such tools can be used directly by VHA operations when designing and rolling out patient-facing eHealth technologies, and by researchers and program evaluators conducting post-market surveillance of these tools.
None at this time.
Health Systems, Other Conditions
Treatment - Implementation, TRL - Applied/Translational
Adverse Event Monitoring, Best Practices, Guideline Development and Implementation, Knowledge Integration, Personal Health Record