Beverley Suzanne Ellis

Patients' online access to their electronic health records and linked online services: a systematic interpretative review

Objectives To investigate the effect of providing patients online access to their electronic health record (EHR) and linked transactional services on the provision, quality and safety of healthcare. The objectives are also to identify and understand: barriers and facilitators for providing online access to their records and services for primary care workers; and their association with organisational/IT system issues. Setting Primary care. Participants A total of 143 studies were included. 17 were experimental in design and subject to risk of bias assessment, which is reported in a separate paper. Detailed inclusion and exclusion criteria have also been published elsewhere in the protocol. Primary and secondary outcome measures Our primary outcome measure was change in quality or safety as a result of implementation or utilisation of online records/transactional services. Results No studies reported changes in health outcomes; though eight detected medication errors and seven reported improved uptake of preventative care. Professional concerns over privacy were reported in 14 studies. 18 studies reported concern over potential increased workload; with some showing an increase workload in email or online messaging; telephone contact remaining unchanged, and face-to face contact staying the same or falling. Owing to heterogeneity in reporting overall workload change was hard to predict. 10 studies reported how online access offered convenience, primarily for more advantaged patients, who were largely highly satisfied with the process when clinician responses were prompt. Conclusions Patient online access and services offer increased convenience and satisfaction. However, professionals were concerned about impact on workload and risk to privacy. Studies correcting medication errors may improve patient safety. There may need to be a redesign of the business process to engage health professionals in online access and of the EHR to make it friendlier and provide equity of access to a wider group of patients. A1. Systematic review registration number PROSPERO CRD42012003091.

Patients' online access to their electronic health records and linked online services: a systematic review in primary care

BACKGROUND Online access to medical records by patients can potentially enhance provision of patient-centred care and improve satisfaction. However, online access and services may also prove to be an additional burden for the healthcare provider. AIM To assess the impact of providing patients with access to their general practice electronic health records (EHR) and other EHR-linked online services on the provision, quality, and safety of health care. DESIGN AND SETTING A systematic review was conducted that focused on all studies about online record access and transactional services in primary care. METHOD Data sources included MEDLINE, Embase, CINAHL, Cochrane Library, EPOC, DARE, Kings Fund, Nuffield Health, PsycINFO, OpenGrey (1999-2012). The literature was independently screened against detailed inclusion and exclusion criteria; independent dual data extraction was conducted, the risk of bias (RoB) assessed, and a narrative synthesis of the evidence conducted. RESULTS A total of 176 studies were identified, 17 of which were randomised controlled trials, cohort, or cluster studies. Patients reported improved satisfaction with online access and services compared with standard provision, improved self-care, and better communication and engagement with clinicians. Safety improvements were patient-led through identifying medication errors and facilitating more use of preventive services. Provision of online record access and services resulted in a moderate increase of e-mail, no change on telephone contact, but there were variable effects on face-to-face contact. However, other tasks were necessary to sustain these services, which impacted on clinician time. There were no reports of harm or breaches in privacy. CONCLUSION While the RoB scores suggest many of the studies were of low quality, patients using online services reported increased convenience and satisfaction. These services positively impacted on patient safety, although there were variations of record access and use by specific ethnic and socioeconomic groups. Professional concerns about privacy were unrealised and those about workload were only partly so.

Clinical governance, education and learning to manage health information

– This paper aims to suggest that the concept of clinical governance goes beyond a bureaucratic accountability structure and can be viewed as a negotiated balance between imperfectly aligned and sometimes conflicting goals within a complex adaptive system. On this view, the information system cannot be separated conceptually from the system of governance it supports or the people whose work it facilitates or hinders., – The study, located within the English National Health Service (NHS) between 1999 and 2005, is case study based using a multi method approach to data collection within two primary care organisations (PCOs). The research strategy is conducted within a social constructionist ontological perspective., – The findings reflect the following broad‐based themes: mutual adjustment of a plurality of stakeholder perceptions, preferences and priorities; the development of information and communication systems, empowered by informatics; an emphasis on education and training to build capacity and capability., – Limitations of case study methodology include a tendency to provide selected accounts. These are potentially biased and risk trivialising findings. Rooted in specific context, their generalisability to other contexts is limited by the extent to which contexts are similar. Reasonable attempts were made to minimise any bias. The diversity of data collection methods used in the study was an attempt to counterbalance the limitations highlighted in one method by strength from alternative techniques., – The paper makes recommendations in two key governance areas: education and learning to manage health information. In practice, the lessons learned provide opportunities to inform future approaches to health informatics educational programmes., – With regard to topicality, it is suggested that many of the developmental issues highlighted during the establishment of quality improvement programmes within primary care organisations (PCGs/PCTs) are relevant in the light of current NHS reforms and move towards commissioning consortia.

An Overview of Complexity Theory: Understanding Primary Care as a Complex Adaptive System

This chapter introduces complexity theories and proposes that primary care can be thought of as a negotiated balance between imperfectly aligned and sometimes conflicting goals within a complex adaptive system (CAS). A CAS approach is interpreted as a framework that assists in thinking about the nature of primary care that allows consideration of its dynamic beyond the practice, the background of trend towards integrated organisations and federated models of practice. To illustrate how the propositions described can be put into daily practice the author brings in the literature on informatics relevant to quality improvement. The chapter concludes and makes recommendations in two key areas: education and learning to manage health information.

The Value of Systems and Complexity Thinking to Enable Change in Adaptive Healthcare Organisations, Supported by Informatics

Background. This paper provides an overview of complex adaptive systems (CAS) theories and value in enabling change in an adaptive organisation. A CAS approach is interpreted here as a framework that assists thinking about the nature of quality improvement programmes with a focus on the people involved.