NYC Consumer Attitudes towards Electronic Health

RecordsA Qualitative Analysis

Edward Wu, MD, MBA, MS1

Kathryn LaSorsa, MS2

Farzad Mostashari, MD, MSc2

Research support:NYC Department of Health and Mental Hygiene & CDC T01 CD000146

1NYU School of Medicine; 2NYC Department of Health and Mental Hygiene

Aims

• Characterize health consumer attitudes (risks and benefits) toward electronic health records

• Understand the impact of increased awareness on consumer attitudes

• Inform policy recommendations

Why study the health consumer?

Rationale for Studying Consumers

• Consumers can increase demand for EHR– Influence physician decision to

implement– Prefer physicians who use EHRs

• Consumers can decrease demand for EHR– Privacy concerns may impede adoptionConsumer values and concerns are key to maximizing EHR adoption

Background

• Little is known about how consumers perceive the risks and benefits of EHRs

• Low public awareness of EHR– Patients: 57% report their physicians use

a computerized record– Physicians: 24% of physicians use EHRs

Kaiser Permanente Poll 2007; National Ambulatory Medical Care Survey 2006

Research Question:

How does increased consumer awareness impact perceived risks and benefits?

Conceptual Model

Consumer Support forProvider Adoption of EHR

PerceivedBenefit

PerceivedRisk

+-

IncreasedAwareness

Methods: Population

• Study population– Respondents from the random-digit

dialed 2005 NYC DOHMH Community Health Survey

– Willing to be contacted for further studies

• Screening criteria– Seen by a physician in the past 12

months

Methods: Interview

• 40 Semi-structured telephone interviews conducted by DOHMH– 33 Interviews Analyzed– 90 Open and closed ended questions– Duration of interview: 60 mins

• Qualitative study– Grounded theory approach– Content analysis

Rationale for Qualitative Methods

• Exploratory, not explanatory• Rich, detailed responses can

communicate more accurate concerns • Traditional surveys limited by low

awareness - subject to wording bias• Semi-structured interview process

raises awareness - informs research question

Methods: Interview topics

• Paper-based health records• Electronic health records• Privacy issues • Patient-provider communication• Public health surveillance

Demographics: Age & Internet Use

Demographics: Race/Ethnicity

Demographics: Education

Demographics: Health Status

Themes: Perceived Benefits and Risks

• Convenience• Quality• Access Rights• Privacy

Convenience

Convenience for the

Consumer• Flexibility• Time• Continuity of Care• Legibility

Convenience for the

Provider• Flexibility• Efficiency• Continuity of Care• Sharing records

Convenience for the Consumer

• Flexibility• Time• Continuity of Care• Legibility

“… patient files go from the floor to the ceiling. EHR might be a time saver… you don’t have to wait 2 hours for the doc.”

“I was in the ER, and had to visit my doctor the next day. My doctor had all the information, and I didn’t have to repeat it all.”

“Electronic records would be great – it would help me legibly decipher what he’s saying about me.”

Convenience for the Provider

• Flexibility• Efficiency• Continuity of Care• Sharing Records

“My doctors would be able to access information easier, and perhaps I could cut down on visits.”

“Being able to transfer my records with the click of a button must be much more convenient and efficient for my doctor.”

“Using computerized records would be great if a doctor – any doctor – needed to see me in the ER.”

Themes: Perceived Benefits and Risks

• Convenience• Quality• Access Rights• Privacy

Quality

Accuracy & Errors

• Verification• Fixing errors• Typos• Entry effort

• Interaction quality• Satisfaction

Durability Communication

• Longevity• Backups

Quality

Accuracy & Errors

• Verification• Fixing errors• Typos• Entry effort

“The computer would have more complete information which could prevent a misdiagnosis – it’s a better record for the doctor.”

“…entering something into a computer introduces another source of error.”

“Viewing my record electronically would allow me to verify what my doctor is saying and bring any errors to him.”

Quality

Quality

Durability

• Longevity of information• Backups

“I think you must have a paper backup somewhere… if you just rely on electronics, we’re gonna be in deep shit someday -- absolutely.”

“If there’s a fire, an electronic record would last, since it’s probably backed up somewhere else. Paper can be more fragile.”

Quality

Communication

• Information Quality• Satisfaction

“If the doctor had all the facts straight with a electronic record, we would have a better conversation.”

“The computer might make the doctor more impersonal, since they would always be typing.”

“If I communicate with the doctor electronically, I don’t feel like I’m always interrupting. He can get back to me whenever.”

Themes: Perceived Benefits and Risks

• Convenience• Quality• Access Rights• Privacy

Access Rights

Consumer Others

• Ability to access• Legal right to access

• Timeliness of access• Continuity of care• Public health • Research entities

“You must have access to your medical records. You paid for it – you should have it when you want.”

“Definitely, my family needs access to my records, in case I can’t communicate. Maybe computers would help.”

“The only people I mind looking at my records are my employer and the insurance company.”

“I think my records can help the DOH. I would want them to notify anyone, including me, if anything was wrong.”

Themes: Perceived Benefits and Risks

• Convenience• Quality• Access Rights• Privacy

Privacy concerns of EHR

• More worry with increased adoption

• Fear of prosecution• Identity theft• Ease of access• Volume of accessible

information

Privacy

Privacy

Privacy

“My biggest concern would be the availability of my records to all those out there who shouldn’t be looking.”

“Privacy is my number one concern.”“I like electronic records, but I don’t

want people harmed by privacy breaches.”

“If we want electronic records, we definitely have to deal with privacy issues.”

Privacy: Sharing Information

% Would Share

Another Treating Physician 100

A member of your family 94

Employer 34

“How would you feel if information from your doctor visit or emergency room was shared with…”

Privacy: Sharing Information

% Would Share

Department of Health to keep track of the health of New Yorkers?

94

Scientific community for medical research?

64

A federal or national data warehouse?

61

“If this information was shared without revealing anything about your personal identity to…”

Results:Overall Opinions of Consumers

EHR Benefits outweigh concerns 61%

EHR adoption should be a high priority for the Department of Health

61%

Conceptual Model

Consumer Support forProvider Adoption of EHR

PerceivedBenefit

PerceivedRisk

+-

IncreasedAwareness +

-+

Policy Recommendations

• Increase patient awareness of EHRs – Emphasize perceived benefits

• Convenience, Access, Continuity of Care

– Address perceived risks• Distractions to patient encounter• Privacy concerns

• Address privacy concerns– Patient and provider education– Industry standards– Vendor product development– Formal practice guidelines

Study Limitations

• Qualitative – biases of investigators

• Sample size • Generalizability

Next Steps

• Quantitative surveys informed by this study

• Post-EHR Adoption Studies– Perceived benefits and risks after

experience– Impact of EHRs on physician-patient

encounter