Expectations and experiences of eHealth in primary care: A qualitative practice-based investigation

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Abstract

Objectives

(1) To assess expectations and experiences of a new eHealth service by patients and staff in three primary care settings; (2) to ascertain attitudes to a range of future, primary care-oriented eHealth services.

Design

Qualitative case study.

Setting

Three UK general practices introducing an eHealth service for booking patient appointments.

Participants

Ninety patients purposively selected from users and non-users of the new service and 28 staff (clinicians, management and administrative staff).

Results

Actual patient use of the service was lower than stated intention. Patients and staff felt that more active promotion of the service would have resulted in more use. Low usage did not result in a negative assessment of the service by most staff. Different patient groupings were identified with characteristics that may be used as predictors of eHealth service use and indicators of training needs. GPs and patients expressed opposing viewpoints on a range of future eHealth services.

Conclusions

Take-up of eHealth services may be lower than expected. To overcome patient barriers, factors that may narrow the intention–behaviour gap such as level of service promotion, GP endorsement, and usage by different patient groups, should be investigated. For clinician barriers, the eHealth evidence base needs strengthening, while for primary care practices, a learning process including staff training needs to be instituted. The differing views of patients and GPs about components of eHealth means that policymakers need to plan for a lengthy political process to obtain agreement on contentious issues if they are to achieve successful eHealth services.

Introduction

Public access to eHealth applications is growing but eHealth services will not be used unless both patients’ and clinicians’ expectations and experiences are taken into account during their design and adoption [1], [2]. Recent IT developments in the National Health Service (NHS) in the UK have largely been aimed at improving information for clinicians and administrative staff. The next step in eHealth is to develop applications and services for use by patients. While evidence shows that health can be improved by engaging patients in eHealth initiatives [3], [4], other studies suggest that success is by no means guaranteed [5]. eHealth services represent a significant shift in culture and practice from the traditional model [6], and patients may be required to move from being primarily passive recipients of information and services to a more active role where they are expected to exercise more initiative.

There have been very few studies of patient experiences of non-clinical eHealth services. In the UK, a survey [7] was undertaken of patients’ perception of choice when using Choose and Book, which allows secondary care (hospital and specialist clinic) outpatient appointments to be booked by GPs in consultation with patients. However, this service is not patient-initiated as its use is always mediated by someone else (usually the GP). In the US, web-based services have been surveyed [8], [9] that allow patients to book appointments and order repeat prescriptions amongst other features. High patient satisfaction was found [8] and users were generally younger, white, more affluent and healthier than the average patient [9]. Prescription requests were used slightly more frequently than appointment booking, but neither service was used as often as others such as viewing lab results or emailing clinicians.

Patient opinions concerning future eHealth services have been sought in a number of studies. In studies based on existing eHealth services, the utility of using grounded theory to ascertain patient views on electronic medical records systems has been highlighted [10], while Ross et al. [11] concluded that while a majority of patients are interested in using Internet-accessible records a substantial minority are not. Andreassen et al. [12] found that patient use of eHealth services was to supplement other services rather than to replace them. In scenario-based studies in the UK, it was found [13] that patients (and GPs) broadly welcomed future services, Greenhalgh et al. [14] estimated that health literacy influenced patient attitudes towards future use of both their Electronic Health Record (EHR) and Personal Health Record (PHR), while it was found [15] that patients were interested in future use of PHRs and email and also wanted more information on clinicians, particularly surgeons. For clinician views, a survey of NHS primary healthcare professionals’ views on future eHealth services [16] found that they recognized general benefits; however some physicians have expressed concerns that shared medical records may increase workload or disrupt the doctor–patient relationship [11], [17].

In this study we investigate the experiences of patients using an eHealth service in three primary care general practices in the UK, discussing factors influencing use as well as non-use; we also study staff expectations and experiences [1]. Additionally we explore patient and GP attitudes to a range of future, primary care-oriented eHealth features planned as extensions to the service. Much research into patient use of eHealth services, for example on electronic access to medical records [18], [19], [20] and support for patients with conditions such as diabetes or chronic heart disease [21], [22], has been conducted under experimental or trial, rather than naturalistic, conditions. In contrast, our research investigates an eHealth service in everyday settings.

Section snippets

Context

Our research was conducted at three different general practices that were introducing a new eHealth service (Access, from the UK IT provider EMIS) between 2002 and 2004. North 1 was a city centre practice with a patient population of 16,000, with two-thirds of its patients being students. North 2 was in a town with a patient population of 3500, almost half of whom were elderly, and in an area rated as deprived in terms of government investment, while London was a suburban practice where the

Patient use of Access

At all three practices, usage log files indicated that the number of appointments made during the study, shown in Table 2, was low. The London practice, after 6 months, achieved much greater use than the other two practices had after almost 2 years. Our measure of usage, constructed from the percentage of appointments made using Access as a ratio of the average number of appointments patients normally make [29], highlights the differences between the three practices as it takes into account the

Mixed patient perceptions of Access

There was a big gap between expressed intention to use Access and actual usage, which was low. The extent of the gap depends upon the context of intended technology use [30], [22], and our interpretation was that “intention to use” meant intention to use for every appointment.

A functionally similar service is Choose and Book, a central part of the NHS £12.7 billion National Programme for IT (NPfIT). This service has been fully implemented in the NHS since 2006, and allows secondary care

Limitations

A feature of this study was that it evaluated the use of Access by patients in a naturalistic, as opposed to experimental environment, where patients and staff integrated Access with their everyday health-related behaviour. In this type of investigative research the researcher is part of the social world being studied and may therefore introduce bias. We attempted to minimise this by open questioning and discussion of emerging results with fellow researchers. The study was limited to three

EMIS Access

Access has undergone considerable development and expansion since the study was completed. The features of Access now include appointment booking, prescription management, secure messaging, demographic updates, pre-registration and medical record viewing. It is now (figures for December 2008) used by at least 1650 practices in the UK, and 189,973 individuals logged in to the service during the course of the month.

The most popular feature with patients, based on usage, is prescription

Acknowledgements

Access to the three research sites, to the web-based survey and to usage figures was facilitated by Rob Murgatroyd at EMIS. Thanks to him, the staff and patients of the three participating practices. Financial assistance is gratefully acknowledged from the Mersey Primary Care R&D Consortium and the Barnsley Primary Care Trust.

Contributors: DF, MG and HM planned and designed the study; HM carried out the data collection with assistance from DF; HM, DF, MG and PG carried out data analysis; DF and

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