Abstract
Personal health records designed for shared decision making (SDM) have the potential to engage patients and provide opportunities for positive health outcomes. Given the limited number of published interventions that become normal practice, this preimplementation evaluation of an integrated SDM personal health record system (e-PHR) was underpinned by Normalization Process Theory (NPT). The theory provides a framework to analyze cognitive and behavioral mechanisms known to influence implementation success. A mixed-methods investigation was utilized to explain the work required to implement e-PHR and its potential to integrate into practice. Patients, care providers, and electronic health record (EHR) and clinical leaders (n = 27) offered a rich explanation of the implementation work. Reliability tests of the NPT-based instrument negated the use of scores for two of the four mechanisms. Participants indicated that e-PHR made sense as explained by two qualitative themes: game-changing technology and sensibility of change. Participants appraised e-PHR as explained by two themes: reflecting on value and monitoring and adapting. The combined qualitative and quantitative results for the other two NPT mechanisms corroborated. Participants strongly agreed (score = 4.6/5) with processes requiring an investment in commitment, explained by two themes: sharing ownership of the work and enabling involvement. Weak agreement (score = 3.6/5) was observed with processes requiring an investment in effort, explained by one theme: uncovering the challenge of building collective action, and three subthemes: assessing fit, adapting to change together, and investing in the change. Finally, participants strongly agreed (score = 4.5/5) that e-PHR would positively affect engagement in self-management decision-making in two themes: care is efficient, and care is patient-centered. Overall, successful integration of e-PHR will only be attained when systemic effort is invested to enact it. Additional investigation is needed to explore the collective action gaps to inform priorities and approaches for future implementation success. This research has implications for patients, care providers, EHR vendors, and the healthcare system for improving the effectiveness and efficiency of patient-centric services. Findings confirm the usefulness of NPT for planning and understanding implementation success of PHRs.
Highlights
Healthcare systems and clinician practices are actively seeking health information technologies (HITs) that engage patients in decision-making as part of health self-management [1]
personal health record (PHR) offer patients: (a) access to their health information, such as results, clinical notes, and self-management information such as standard forms, educational materials, and protocol information in a linked or embedded knowledge base; (b) the ability to contribute patient-generated data to their health record, such as subjective experience data and objective data related to their condition over time; (c) health management and decision support tools, such as disease-tracking tools, goal setting, decision aids, and evidence-based reminders and alerts; and (d) the means to communicate with their care providers and community support groups using mechanisms such as secure messaging and video tools [3]
The discussion section examines (a) the psychometric tests of the Normalization MeAsure Development (NoMAD) instrument in this study, (b) the implementation work of e-PHR and its potential to integrate into clinical practice in terms of the four Normalization Process Theory (NPT) mechanisms, and (c) the potential practice-related outcomes
Summary
Healthcare systems and clinician practices are actively seeking health information technologies (HITs) that engage patients in decision-making as part of health self-management [1]. (c) health management and decision support tools, such as disease-tracking tools, goal setting, decision aids, and evidence-based reminders and alerts; and (d) the means to communicate with their care providers and community support groups using mechanisms such as secure messaging and video tools [3]. These PHR characteristics were identified as components leading to improved health outcomes for patients in a systematic review (n = 23), which examined conditions potentially sensitive to the PHR [4]. Designed for function and cohesive with the broader digital health ecosystem, PHRs present an opportunity for improvement in patient engagement in self-management and decision-making
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