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Erlingsdóttir, G., Petersson, L. & Jonnergård, K. (2019). A Theoretical Twist on the Transparency of Open Notes: Qualitative Analysis of Health Care Professionals’ Free-Text Answers. Journal of Medical Internet Research, 21(9), Article ID e14347.
Open this publication in new window or tab >>A Theoretical Twist on the Transparency of Open Notes: Qualitative Analysis of Health Care Professionals’ Free-Text Answers
2019 (English)In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 21, no 9, article id e14347Article in journal (Refereed) Published
Abstract [en]

Background: The New Public Management movement strove for transparency so that policy makers and citizens could gain insight into the work and performance of health care. As the use of the electronic health record (EHR) started to diffuse, a foundation was laid for enhanced transparency within and between health care organizations. Now we appear to be experiencing a new kind of transparency in the health care sector. Many health care providers offer their patients online access to their EHRs (here referred to as Open Notes). The Open Notes system enables and strives for transparency between the health care organization and the patient. Hence, this study investigates health care professional (HCP) perceptions of Open Notes and deepens the understanding of the transparency that Open Notes implies.

Objective: Based on two survey studies of HCP perceptions of Open Notes, this paper aims to deepen the academic writing on the type of transparency that is connected to Open Notes.

Methods: HCPs in adult psychiatry in Region Skåne, Sweden, were surveyed before and after implementation of Open Notes. The empirical material presented consists of 1554 free-text answers from two Web surveys. A qualitative content analysis was performed.

Results: The theoretically informed analysis pivots around the following factors connected to transparency: effectiveness; trust; accountability; autonomy and control; confidentiality, privacy, and anonymity; fairness; and legitimacy. The results show that free-text answers can be sorted under these factors as trade-offs with transparency. According to HCPs, trade-offs affect their work, their relationship with patients, and not least, their work tool, the EHR. However, since many HCPs also state that they have not met many patients, and in some cases none, who have read their EHRs, these effects seem to be more connected to the possibility (or threat) of transparency than to the actual effectuated transparency.

Conclusions: The implementation (or reform) of Open Notes is policy driven while demanding real-time transparency on behalf of citizens/patients and not the authorities, which makes this particular form of transparency quite unique and interesting. We have chosen to call it governed individual real-time transparency. The effects of Open Notes may vary between different medical specialties relative to their sensitivity to both total and real-time transparency. When HCPs react by changing their ways of writing notes, Open Notes can affect the efficiency of the work of HCPs and the service itself in a negative manner. HCP reactions are aimed primarily at protecting patients and their relatives as well as their own relationship with the patients and secondly at protecting themselves. Thus, governed individual real-time transparency that provides full transparency of an actual practice in health care may have the intended positive effects but can also result in negative trade-offs between transparency and efficiency of the actual practice. This may imply that full transparency is not always most desirable but that other options can be considered on a scale between none and full transparency.

© Gudbjörg Erlingsdóttir, Lena Petersson, Karin Jonnergård. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 25.09.2019.

Place, publisher, year, edition, pages
Toronto: J M I R Publications, Inc., 2019
Keywords
electronic health record, eHealth, transparency, mental health, Open Notes, psychiatry, health care professionals, Web survey, free-text answers
National Category
Work Sciences
Identifiers
urn:nbn:se:hh:diva-40973 (URN)10.2196/14347 (DOI)000487967600001 ()31573905 (PubMedID)2-s2.0-85072848287 (Scopus ID)
Projects
eHealth Services’ Impact on the Working Environment of Health Professionals
Funder
AFA Insurance
Available from: 2019-11-18 Created: 2019-11-18 Last updated: 2019-11-27Bibliographically approved
Petersson, L. (2019). Nya gränser i hälsolandskapet (1ed.). In: Gudbjörg Erlingsdóttir & Helena Sandberg (Ed.), På tal om e-hälsa: (pp. 107-131). Lund: Studentlitteratur AB
Open this publication in new window or tab >>Nya gränser i hälsolandskapet
2019 (English)In: På tal om e-hälsa / [ed] Gudbjörg Erlingsdóttir & Helena Sandberg, Lund: Studentlitteratur AB, 2019, 1, p. 107-131Chapter in book (Other academic)
Place, publisher, year, edition, pages
Lund: Studentlitteratur AB, 2019 Edition: 1
National Category
Work Sciences
Identifiers
urn:nbn:se:hh:diva-40974 (URN)9789144120768 (ISBN)
Available from: 2019-11-18 Created: 2019-11-18 Last updated: 2019-11-26Bibliographically approved
Petersson, L. & Erlingsdóttir, G. (2018). Open Notes in Swedish Psychiatric Care (Part 1): Survey Among Psychiatric Care Professionals. JMIR Mental Health, 5(1), Article ID e11.
Open this publication in new window or tab >>Open Notes in Swedish Psychiatric Care (Part 1): Survey Among Psychiatric Care Professionals
2018 (English)In: JMIR Mental Health, E-ISSN 2368-7959, Vol. 5, no 1, article id e11Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: When the Swedish version of Open Notes, an electronic health record (EHR) service that allows patients online access, was introduced in hospitals, primary care, and specialized care in 2012, psychiatric care was exempt. This was because psychiatric notes were considered too sensitive for patient access. However, as the first region in Sweden, Region Skåne added adult psychiatry to its Open Notes service in 2015. This made it possible to carry out a unique baseline study to investigate how different health care professionals (HCPs) in adult psychiatric care in the region expect Open Notes to impact their patients and their practice. This is the first of two papers about the implementation of Open Notes in adult psychiatric care in Region Skåne.

OBJECTIVE: The objective of this study was to describe, compare, and discuss how different HCPs in adult psychiatric care in Region Skåne expect Open Notes to impact their patients and their own practice.

METHODS: A full population Web-based questionnaire was distributed to psychiatric care professionals in Region Skåne in late 2015. The response rate was 28.86% (871/3017). Analyses show that the respondents were representative of the staff as a whole. A statistical analysis examined the relationships between different professionals and attitudes to the Open Notes service.

RESULTS: The results show that the psychiatric HCPs are generally of the opinion that the service would affect their own practice and their patients negatively. The most striking result was that more than 60% of both doctors (80/132, 60.6%) and psychologists (55/90, 61%) were concerned that they would be less candid in their documentation in the future.

CONCLUSIONS: Open Notes can increase the transparency between patients and psychiatric HCPs because patients are able to access their EHRs online without delay and thus, can read notes that have not yet been approved by the responsible HCP. This may be one explanation as to why HCPs are concerned that the service will affect both their own work and their patients. © Lena Petersson, Gudbjörg Erlingsdóttir.

Place, publisher, year, edition, pages
Toronto, ON: J M I R Publications, 2018
Keywords
baseline survey, eHealth, electronic health record, health professionals, mental health, open notes, psychiatry
National Category
Other Social Sciences Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:hh:diva-38458 (URN)10.2196/mental.9140 (DOI)000425255400009 ()29396386 (PubMedID)2-s2.0-85042098885 (Scopus ID)
Funder
AFA Insurance
Available from: 2018-11-30 Created: 2018-11-30 Last updated: 2018-12-03Bibliographically approved
Petersson, L. & Erlingsdóttir, G. (2018). Open Notes in Swedish Psychiatric Care (Part 2): Survey Among Psychiatric Care Professionals. JMIR mental health, 5(2), Article ID e10521.
Open this publication in new window or tab >>Open Notes in Swedish Psychiatric Care (Part 2): Survey Among Psychiatric Care Professionals
2018 (English)In: JMIR mental health, ISSN 2368-7959, Vol. 5, no 2, article id e10521Article in journal (Refereed) Published
Abstract [en]

Background: This is the second of two papers presenting the results from a study of the implementation of patient online access to their electronic health records (here referred to as Open Notes) in adult psychiatric care in Sweden. The study contributes an important understanding of both the expectations and concerns that existed among health care professionals before the introduction of the Open Notes Service in psychiatry and the perceived impact of the technology on their own work and patient behavior after the implementation. The results from the previously published baseline survey showed that psychiatric health care professionals generally thought that Open Notes would influence both the patients and their own practice negatively.

Objective: The objective of this study was to describe and discuss how health care professionals in adult psychiatric care in Region Skåne in southern Sweden experienced the influence of Open Notes on their patients and their own practice, and to compare the results with those of the baseline study.

Methods: We distributed a full population Web-based questionnaire to psychiatric care professionals in Region Skåne in the spring of 2017, which was one and a half years after the implementation of the service. The response rate was 27.73% (699/2521). Analyses showed that the respondents were representative of the staff as a whole. A statistical analysis examined the relationships between health professional groups and attitudes to the Open Notes Service.

Results: A total of 41.5% (285/687) of the health care professionals reported that none of their patients stated that they had read their Open Notes. Few health care professionals agreed with the statements about the potential benefits for patients from Open Notes. Slightly more of the health care professionals agreed with the statements about the potential risks. In addition, the results indicate that there was little impact on practice in terms of longer appointments or health care professionals having to address patients' questions outside of appointments. However, the results also indicate that changes had taken place in clinical documentation. Psychologists (39/63, 62%) and doctors (36/94, 38%) in particular stated that they were less candid in their documentation after the implementation of Open Notes. Nearly 40% of the health care professionals (239/650, 36.8%) reported that the Open Notes Service in psychiatry was a good idea.

Conclusions: Most health care professionals who responded to the postimplementation survey did not experience that patients in adult psychiatric care had become more involved in their care after the implementation of Open Notes. The results also indicate that the clinical documentation had changed after the implementation of Open Notes. Finally, the results indicate that it is important to prepare health care professionals before an implementation of Open Notes, especially in medical areas where the service is considered sensitive. ©Lena Petersson, Gudbjörg Erlingsdóttir. Originally published in JMIR Mental Health (http://mental.jmir.org), 21.06.2018.

Place, publisher, year, edition, pages
Toronto: J M I R Publications, Inc., 2018
Keywords
Open Notes, eHealth, electronic health records, health care surveys, health professionals, mental health, postimplementation survey, psychiatry, telemedicine
National Category
Work Sciences
Identifiers
urn:nbn:se:hh:diva-38459 (URN)10.2196/10521 (DOI)000449366300001 ()29929946 (PubMedID)2-s2.0-85048892949 (Scopus ID)
Funder
AFA Insurance
Available from: 2019-11-18 Created: 2019-11-18 Last updated: 2019-11-28Bibliographically approved
Erlingsdottir, G. & Petersson, L. (2017). E-hälsotjänsters Påverkan på Sjukvårdspersonalens Arbetsmiljö (EPSA): Slutrapport till AFA Försäkring Juni 2017. Stockholm: AFA Försäkring
Open this publication in new window or tab >>E-hälsotjänsters Påverkan på Sjukvårdspersonalens Arbetsmiljö (EPSA): Slutrapport till AFA Försäkring Juni 2017
2017 (Swedish)Report (Other academic)
Abstract [sv]

Allt fler så kallade e-tjänster, exempelvis journaler på nätet, införs i vården. De kan dock leda till nya problem för personalen, inte minst när det gäller arbetsbelastning och yrkesroller. Projektet har tagit fram kunskap som förebygger arbetsmiljöproblem vid införandet av e-hälsotjänster.

Place, publisher, year, edition, pages
Stockholm: AFA Försäkring, 2017. p. 27
Keywords
e-tjänsten Journalen, Journal via nätet, arbetsmiljö, invånartjänst, professioner, ehälsa, digitalisering av hälso- och sjukvården, digital arbetsmiljö
National Category
Work Sciences
Identifiers
urn:nbn:se:hh:diva-40977 (URN)
Note

Finansiär: EPSA-projektet

Available from: 2019-11-18 Created: 2019-11-18 Last updated: 2019-12-06Bibliographically approved
Petersson, L. & Erlingsdottir, G. (2017). Factors to consider when implementing patient online access to their electronic health record. In: : . Paper presented at Annual Conference of Nordic Ergonomics and Human Factors Society, Joy at Work, (NES2017), Lund, Sweden, August 20-23, 2017. Lund
Open this publication in new window or tab >>Factors to consider when implementing patient online access to their electronic health record
2017 (English)Conference paper, Oral presentation with published abstract (Refereed)
Abstract [en]

Government and public agencies in Sweden have promoted the expansion of eHealth. The strategy behind this effort is to increase quality of care, efficiency, patient empowerment and patient safety, and one of the most important civic eHealth services is patient online access to electronic health records (EHR). By 2017, all of Sweden's inhabitants will be able to access their EHR from somatic care through the Internet and thus read clinical notes. In 2015 Region Skåne was the first county council in Sweden to implement patient online access to their EHR as a civic service, for adult psychiatric care patients. Earlier research shows that initial implementation of the service in somatic care raised both questions and resistance among involved healthcare professionals. Thus, for an implementer, there are many factors to consider and it may be difficult to choose and prioritize among them; on the other hand, there is little knowledge about what healthcare professionals think is important when implementing a civic service in healthcare. The aim of this study is to present and discuss what healthcare professionals think is important to consider when Region Skåne implements patient online access to EHR in psychiatric care.

The material presented derives from a full-population web survey, distributed to employees in adult psychiatry in Region Skåne just before the introduction of the service. The response rate was 29% (n = 871). In one of the question in the survey, respondents were asked to choose five out of eleven factors that they thought might affect the implementation of the service. Thereafter they were asked to rank these five factors and assign the most important factor five points, the second most important factor four points and so on.

Overall, the results show that the most frequently chosen factor was Evaluation of patient online access to their EHR, but Patient safety was the factor with the highest total score and also the highest mean value. Furthermore, it is interesting to note that the factor receiving the lowest score was a support line for the employees; this factor has the lowest total score and lowest mean value. The results also show that different professional groups consider different factors to be important in the implementation process.

The conclusions are firstly; that healthcare professionals care about the implementation of civic services even though the technology does not change towards them. Secondly; that the healthcare professionals consider not only factors that affect their own work to be important but also factors that are related to patient's interests. Thirdly; it is important for implementers to be aware of that civic services can affect the healthcare professionals work even if the service is only aimed at patients. It is thus important to consider factors related to both patients and professionals when implementing a civic eHealth service, even if the service is aimed at only one of these groups.

Place, publisher, year, edition, pages
Lund: , 2017
Keywords
Implementation, Healthcare professionals, eHealth, Psychiatry, EHR
National Category
Work Sciences
Identifiers
urn:nbn:se:hh:diva-40976 (URN)
Conference
Annual Conference of Nordic Ergonomics and Human Factors Society, Joy at Work, (NES2017), Lund, Sweden, August 20-23, 2017
Available from: 2019-11-19 Created: 2019-11-19 Last updated: 2020-02-19Bibliographically approved
Petersson, L. & Erlingsdottir, G. (2016). Communicating to Employees the Implementation of Patient Online Access to Their EHR. The Case of Adult Psychiatry in Southern Sweden. In: Proceedings from The 14th Scandinavian Conference on Health Informatics 2016, Gothenburg, Sweden, April 6-7, 2016: . Paper presented at The 14th Scandinavian Conference on Health Informatics 2016, Gothenburg, Sweden, April 6-7, 2016 (pp. 7-11). Linköping: Linköping University Electronic Press
Open this publication in new window or tab >>Communicating to Employees the Implementation of Patient Online Access to Their EHR. The Case of Adult Psychiatry in Southern Sweden
2016 (English)In: Proceedings from The 14th Scandinavian Conference on Health Informatics 2016, Gothenburg, Sweden, April 6-7, 2016, Linköping: Linköping University Electronic Press, 2016, p. 7-11Conference paper, Published paper (Refereed)
Abstract [en]

In 2015 Region Skåne was the first county council in Sweden to add adult psychiatry patients to the civic service of patient online access to their EHR (electronic health records). The initial implementation of the service in somatic care had previously raised both questions and resistance amongst the healthcare professionals. It was thus considered important to inform the professionals involved about the planned introduction in psychiatry well in advance. This paper presents and discusses how well the management was able to do this. The material presented derives from a survey that was distributed to employees in adult psychiatry in Region Skåne just before the introduction of the service. Overall, the results show that different professions receive information through different channels. This indicates that it is important for an employer to use many information and communication channels to reach employees. It is also important to use both interpersonal and mediated communication channels as they serve different purposes.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2016
Series
Linköping Electronic Conference Proceedings
Keywords
eHealth, EHR, psychiatric care, patient online access, employees, communication channels
National Category
Information Systems, Social aspects
Identifiers
urn:nbn:se:hh:diva-40981 (URN)
Conference
The 14th Scandinavian Conference on Health Informatics 2016, Gothenburg, Sweden, April 6-7, 2016
Funder
AFA Insurance
Available from: 2019-11-18 Created: 2019-11-18 Last updated: 2020-02-19Bibliographically approved
Erlingsdottir, G. & Petersson, L. (2016). Employees’ work environment and patients’ rights, conflicting responsibilities when implementing patient online access to their EHR. In: : . Paper presented at HEPS 2016 - Healthcare systems, Ergonomics and Patient Safety Conference, Toulouse, France, October 5-7, 2016.
Open this publication in new window or tab >>Employees’ work environment and patients’ rights, conflicting responsibilities when implementing patient online access to their EHR
2016 (English)Conference paper, Published paper (Refereed)
Abstract [en]

This paper is based on an interview study examining the implementation of the eHealth service patient online access to electronic health records in two county councils in Sweden. Our aim is to present and discuss the two councils’ implementation processes and the differences between them, with particular focus on the implementers’ consideration of caregivers’ work environment. A theoretical aim is to shed light on the complicated situation that arises when a county council is responsible for both the implementation of an eHealth service and the effects it has on the work environment of the employees (professionals). The results from the total of 16 semi-structured indepth interviews show that the two county councils differ in the following areas: 1) whether the implementation is interpreted as a threat for the work environment; 2) who the interviewees consider as responsible for the work environment; and 3) if it was considered important to build trust between the implementers (the county councils) and the professionals – and how this trustbuilding was accomplished. It is concluded that the differences between the two implementation processes was due in part to the difference in how the service was framed and labelled in the two respective county councils, and that one of the county councils has encountered difficulties in taking dual responsibility towards both patients and the work environment of the employees. This implies, according to Bovens’ (1998) classification, that one of the county councils takes active responsibility for the work environment while the other takes passive responsibility for the work environment. 

Keywords
Electronic health record (EHR), eHealth, responsibility, online access, implementation
National Category
Work Sciences
Identifiers
urn:nbn:se:hh:diva-40980 (URN)
Conference
HEPS 2016 - Healthcare systems, Ergonomics and Patient Safety Conference, Toulouse, France, October 5-7, 2016
Available from: 2019-11-18 Created: 2019-11-18 Last updated: 2020-02-19Bibliographically approved
Erlingsdottir, G. & Petersson, L. (2016). Healthcare personel does not consider the eHealth service "patient online access to their electronic health record" to be beneficial for the work environment and patient safety. In: Sigrún Gunnarsdóttir, Helga Bragadóttir, Kristinn Tómasson (Ed.), 10th NOVO symposium: Sustainable healthcare through professional collaboration across boundaries: Reykjavík 10 – 11 November, 2016: Abstract book. Paper presented at 10th NOVO Symposium, Reykjavík, Iceland, November 10-11, 2016 (pp. 27-27). Reykjavík: Administration for Occupational Health and Safety
Open this publication in new window or tab >>Healthcare personel does not consider the eHealth service "patient online access to their electronic health record" to be beneficial for the work environment and patient safety
2016 (English)In: 10th NOVO symposium: Sustainable healthcare through professional collaboration across boundaries: Reykjavík 10 – 11 November, 2016: Abstract book / [ed] Sigrún Gunnarsdóttir, Helga Bragadóttir, Kristinn Tómasson, Reykjavík: Administration for Occupational Health and Safety , 2016, p. 27-27Conference paper, Oral presentation with published abstract (Refereed)
Abstract [en]

Introduction: Government and public agencies in Sweden have promoted the expansion of eHealth. The strategy behind many of the eHealth services is to increase quality of care, enhance efficiency, patient empowerment and patient safety. Patient online access to their electronic health record (EHR) is one of the most important civic eHealth services. By 2017, all patients in Sweden will be able to access their EHR online. In Mars 2014, Region Skåne (RS) introduced the service in somatic care and in September 2015 RS introduced the service in adult psychiatry. The aim of this presentation is to discuss 1) how the employees in somatic care experience the service in terms of effects on work environment and patient safety. 2) How the employees in psychiatric care anticipated that the service would affect their work environment and patient safety.

Material and methods: The material presented derives from two surveys: 1) A full population web survey distributed to employees in somatic care in RS approximately two years after the introduction of the service (post implementation). Response rate: 20% (n = 2376). 2) A full population web survey that was distributed to employees in adult psychiatry in RS just before the introduction of the service (ante implementation). Response rate: 29% (n = 871).

Results: The results show that the experience in somatic care and the expectation in adult psychiatric care correspond to a large degree. Respondents in both groups are sceptical to the anticipated positive effects of the service. The comparison between the two surveys further show that the employees with experience of the service (somatic care) are even more negative then the employees without experience (psychiatric care).

Conclusions: The results from the two surveys indicate that there is a large difference between the aimes of the national eHealth strategy and the expectations and experiences of the healthcare personell and that little attention is given to the negative effects that civic eHealth services may have on the work environment of healthcare personell. There is thus a need for more research about how eHealth services affect work environment, patient safety and quality of care.

Place, publisher, year, edition, pages
Reykjavík: Administration for Occupational Health and Safety, 2016
National Category
Work Sciences
Identifiers
urn:nbn:se:hh:diva-40978 (URN)978-9935-9265-5-5 (ISBN)
Conference
10th NOVO Symposium, Reykjavík, Iceland, November 10-11, 2016
Available from: 2019-11-18 Created: 2019-11-18 Last updated: 2020-02-19Bibliographically approved
Petersson, L., Erlingsdottir, G. & Lindholm, C. (2016). Professionernas farhågor om införandet av eJournal inom vuxenpsykiatrin i Region Skåne. In: Book of Abstracts: NORDPRO-konferensen, 27-28 oktober 2016. Paper presented at NORDPRO-konferensen 2016, Lund, Sverige, 27-28 oktober, 2016.
Open this publication in new window or tab >>Professionernas farhågor om införandet av eJournal inom vuxenpsykiatrin i Region Skåne
2016 (English)In: Book of Abstracts: NORDPRO-konferensen, 27-28 oktober 2016, 2016Conference paper, Oral presentation with published abstract (Refereed)
Abstract [sv]

Hösten 2015 var Region Skåne först i Sverige med att lägga till patientjournaler från psykiatrin till invånartjänsten eJournal. Genom tjänsten, har alla patienter i den vuxenpsykiatriska vården i Region Skåne tillgång till sin journal via nätet. Det finns lite kunskap om hur professioner na inom den psykiatriska vården förväntar sig att deras arbete kommer att påverkas av den ökade transparens som patienternas tillgång till sin journal via internet innebär. Syftet med detta paper är att undersöka hur socionomer, läkare, psykologer och sjuksköterskor i vuxenpsykiatrin i Region Skåne förväntar sig att patienternas tillgång till eJournal kommer att förändra villkore n för det egna professionella arbetet. Empirin som presenteras härrör från en webbenkät som skickades till samtliga anställda inom vuxenpsykiatrin i Region Skåne strax före införandet av tjänsten. Svarsfrekvensen på enkäten var 29% och fördelningen mellan de olika personalkategorierna överensstämmer väl med andelen anställda i varje personalgrupp. Analysen visar dels att förväntningarna skiljersigmellan de olika professionerna och dels att professionerna förväntar sig att eJournal kommer att påverka deras legitimitet, makten över journalen som arbetsverktyg samt patienternas förtroende för dem.

Keywords
professioner, psykiatri, styrning utifrån, legitimitet, förtroende
National Category
Work Sciences
Identifiers
urn:nbn:se:hh:diva-40979 (URN)
Conference
NORDPRO-konferensen 2016, Lund, Sverige, 27-28 oktober, 2016
Available from: 2019-11-19 Created: 2019-11-19 Last updated: 2020-02-19Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0001-7874-7970

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