1. ” Experiences of Healthcare Professionals to the Introduction in Sweden of a Public eHealth Service: Patients’ Online Access to their Electronic Health Records.”
Ture Ålandera, Isabella Scandurrab
a Department of Public Health and Caring Sciences, Uppsala University, Sweden
b School of Business, eHealth, Örebro University, Sweden

2. Patients’ online access to EHR, progress in Sweden
History
1997 Uppsala county pilot
2002 Uppsala GP ´s patients
2008 Changed legislation
2012 Uppsala county all EHR
2014 Other counties, Skåne
2015 Six regions connected to the platform, different content
Action plan
All citizens have access to the entire health record online by 2017
Political issue
A change of the Swedish legislation in 2008 , which permitted the healthcare providers right to have a cohesive EHR-system and give patients right to have direct access to their EHRs, including laboratory values, diagnoses and the doctor’s notes.
In March 2015 there were 80 000 users who have had an average of 4 accesses to their health record and 800 patients accessed their health records from Uppsala county council, every day.
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3. Deployment of Online Medical Records and E-Health Services
Uppsala University
Lund University
University
of Skövde
Örebro University
Ture
Ålander GP
Swedish
Association of
Health
Professionals
DOME is a collaborative project between the University of Lund, University of Skövde, Örebro University and Uppsala University.
VINNOVA is Sweden’s innovation agency with the mission to promote sustainable growth by improving the conditions for innovation, as well as funding needs-driven research.
The study presented in this article is part of a larger research project, DOME, Deployment of Online Medical Records and eHealth services in Sweden [15] with the aim to highlight experiences and effects related to the introduction of public eHealth services. The project was created in July 2012 in order to connect the first European deployment project, Sustains [8], to a purposive research group consisting of 16 nationally spread researchers from various scientific fields
Purpose of the multidisciplinary research project
To produce and disseminate knowledge about the adoption and use of online health records online (eHealth records)
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4. Patient portal ”My health record”
Access through
Citizens in Sweden with a medical record in the connected regions
18 years of age and e-identification
See notes (also unsigned), diagnoses, lab values, referrals, log file, personal data, make comment, block access, give access
Exceptions: Records from Psychiatrist, psychologist, pediatric, genetics, women abuse, youth health
All hospitals and primary healthcare centers, except community nurses and some private doctors, in Uppsala County Council used the same EHR-system from a Swedish healthcare IT company Cambio Healthcare Systems, called Cosmic. This facilitated the initial integration work between the region-wide EHR and the public eHealth services.
In November 11th 2012 the e-service was offered to all registered inhabitants in Uppsala County Council and soon later, in December 3rd, to all Swedish inhabitants with EHRs in the Uppsala County. As the first region-wide trial, the patients were given access to their health records through a secure log in to the national eHealth patient portal “My Healthcare Contacts” ( People log in to the portal using the same general electronic ID as they use for banking and government e-services.
Services successively introduced in the pilot county through the national patient portal were to:
book, re-book/re-schedule or cancel an appointment,
request certificates,
extend sick leave,
safe messaging with nurse or doctor,
update of personal data,
change of house physician/family doctor,
renewal of medical prescriptions and assistive tools,
and to order a written copy of the proper medical health record [10].
Apart from reading the medical text, the patient also has access to the audit log, can order blocking of access to their records, give access to a friend or relative, order, get a SMS reminder of appointments, get a written list of prescriptions and laboratory values, can fill in a health declaration form saved in their records, and see the status and entire flow of their referrals to specialists or hospital.
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5. Professional worries
A common fear among the professionals is that the autonomy of the medical profession is expected to change and decrease.
Computerization transforms the accountability of professionals in relation to different actor groups, patients as well as managers, politicians and auditors [Freidson, 1985].
The autonomy of particularly the medical profession in relation to organizational governing and control systems has been discussed [Kurunmäki, 2004].
Although the eHealth service is popular among patients, it is controversial among many professionals, especially physicians [13]. It is evident that increased knowledge of how the e-service influence users, both patients and clinicians, is essential for successful deployment of public eHealth [14] and that such services in general are challenging to put into practice.
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6. Objective of this study
This study focuses on the impact on care professionals due to patients’ new EHR transparency.
Stämmer detta, och meningen är lite konstig..? Även fast jag tog bort: we want to with this study..
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7. Study groups and Research question
Which attitude do nurses and physicians have after they have been working some time in a region that provide online access to patients’ health records, compared to professionals that are not yet experienced with this eHealth service?
Study groups and Research question
Har försökt förtydliga frågan.
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8. Methodology Nation-wide web survey
Physicians in Uppsala County Council (the pilot) n=1602 (S1)
Nurses and midwives in Sweden (The Swedish Association of Health professionals) n=8460 (S2)
Methodology
WEB SURVEY 2 similar 5-graded Likert scale web questionnaires S1: JUNE 2013 S2: MARCH 2014
Background questions
5 set of items
Free text fields to each set
Delivered by web survey tools
RESPONDENTS S1: Reached 1602 physicians in pilot county S1 response rate 25% (399)
S2: reached 8460 registered nurses/midwives (Sweden) S2 response rate 35,4% (2867)
ANALYSIS
The Mann-Whitney ranksum and χ2 tests were used.
The data was analyzed by the Stata statistical package 13.1
This study collected data from two similar 5-graded Likert scale web surveys to Swedish healthcare staff and was focused on attitudes and opinions of physicians (S1) and nurses (S2). S1 was sent out in June 2013 to 1602 physicians in the Pilot County with a response rate of 25% (399 respondents). S2 was sent out in March 2014 to 8460 registered nurses and midwifes in Sweden with a response rate of 35,4% (2867 respondents). The questionnaires consisted of background questions and 5 sets of items with free text fields to each set. To deliver the questionnaires web survey tools were used.
Standard data reports were created for each survey with charts showing the most prominent differences in each statement. Currently each statement is being analysed by statistics and healthcare informatics researchers and students. As the questionnaires were jointly developed, this first analysis expected to discover differences.
The two web surveys of this study were distributed to the physicians in Uppsala county 6 months after the deployment of the new e-service and to the nurses 9 months after the deployment. Data were collected from two similar 5-graded Likert scale web surveys (S1 and S2) to Swedish healthcare staff and is focused on attitudes and opinions of physicians (S1) and nurses (S2). To each set of statements, there was also a possibility to give answers in free text.
S1 was sent out in June 2013 to 1602 physicians in the pilot county with a response rate of 25% (399 respondents, 52% women, age years, median worktime 14 years, 78% worked inhospital and 22% in primary care, 85% native in Swedish language).
S2 was sent out in March 2014 to 8460 registered nurses and midwives in Sweden with a response rate of 35,4% (2867 respondents, of whom working as nurses were 84%, midwives 6%, chief position 5%, in projects 2% and other 3%). The questionnaires consisted of background questions and 5 sets of items with free text fields to each set. To deliver the questionnaires the Uppsala County Council’s and the Swedish Association of Health Professionals’ internal web survey tools were used. The accompanying letter stated that responding was voluntary and that the time spent to respond according to the strongly agree (5) - strongly disagree (1)-scale was approx. 10 minutes.
Ethical approval for S1 was made by the Uppsala County Council’s research units as well by the Swedish central ethical committee. S2 was conducted according to the principles of the Declaration of Helsinki.
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9. Studied attitudes
- To which extent do you consider it a benefit for the patients that their relatives have a possibility to take part in their EHR?
- To which extent do you consider the eHealth service “online health records” a good reform?
The two different questionnaires distributed to the nurses and physicians contain more statements to analyze, however the responses handled in this study are consistent between the two surveys.
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10. UCC= pilot county, Mean (SD), p Mann-Whitney
Overall results
5-graded scale. Strongly disagree (1) to strongly agree (5).
UCC= pilot county, Mean (SD), p Mann-Whitney
Benefit for patients
Good reform n
Physicians (UCC)
2,2 (1.1)
1,7 (1.0)
381
Nurses (UCC)
3.1 (1.2)
3.2 (1.3)
234
Nurses (rest of country)
2.9 (1.12)
2.7 (1.2)
2495
Nurses(UCC/rest)
p<0.05
p<0.0001
The two different questionnaires distributed to the nurses and physicians contain more statements to analyze, however the responses handled in this study are consistent between the two surveys. The responses of the physicians to the multiple choice questions are presented in Table based on a 5-graded scale from strongly disagree (1) to strongly agree (5). The responses of the nurses are presented . In general, professionals’ opinions of patients reading their health record online were negative (grade <2.5) among physicians and positive (grade >2.5) among nurses. Both pilot nurses and the ones outside the pilot county were generally more positive than the physicians. , Nurses from the pilot county were far more positive (35% agree and strongly agree) to the importance of this eHealth service for the patients, compared to nurses outside the pilot (25%) as well as physicians (64% disagree or strongly disagree).
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11. Result doctors - additional questions
Physicians using the eHealth service themselves, compared to non-users, regarded the eHealth service:
more important for patients
improve quality in care
contribute to equality in healthcare
experienced less change in their working conditions
found the eHealth service being a good reform
thought their medical noting had improved
found the launch of the reform better
A sub-analysis revealed that the own usage was equal between hospital and primary care physicians, females and males, but that the users were younger (p=0.0004).
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12. Conclusion Many professionals are reluctant to online EHR.
Professionals with personal experience of the eHealth service are more positive.
Real experiences of the professionals should be disseminated to their unexperienced peers!
A gradual implementation is recommended.
An adaptation has been applied to support the introduction of an eHealth system in a Swedish county council, with successful results
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13. ture@tapraktik.se isabella.scandurra@oru.se
Obrigado !
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