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Personal health records (PHRs) offer patients a portal to view lab results, communicate with their doctors, and refill medications. Expanding PHR access to mobile devices could increase patients' engagement with their PHRs. We examined whether access to a mobile-optimized PHR changed the frequency and timeliness of PHR use among adult patients with diabetes in an integrated delivery system. Among patients originally using the PHR only by computer, PHR use frequency increased with mobile access. Non-White patients were more likely to view their lab results within 7 days if they had computer and mobile access compared with computer only; however, there were no statistically significant differences among White patients. More frequent and timely mobile access to PHR data and tools may lead to convenient and effective PHR engagement to support patient self-management. Future studies should evaluate whether PHR use with a mobile device is associated with changes in self-management and outcomes. [ABSTRACT FROM AUTHOR]

Since 2014, average premiums for health plans available in the Affordable Care Act marketplaces have increased. We examine how premium price changes affected the amount consumers pay after subsidies for the lowest-cost bronze and silver plans available by age in the federally facilitated exchanges. Between 2015 and 2016, benchmark plan premiums increased in 83.3% of counties. Overall, rising benchmark premiums were associated with lower average after-subsidy premiums for the lowest-cost bronze and silver plans for older subsidy-eligible adults, but with higher after-subsidy premiums for younger adults purchasing the same plans, regardless of income. With recent discussions to replace or overhaul the Affordable Care Act, it is critical that we learn from the successes and failures of the current policy. Our findings suggest that the subsidy design, which makes rising premiums costlier for younger adults looking to purchase an entry-level plan, may be contributing to adverse selection and instability in the marketplace. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The COVID-19 pandemic exacerbated risk for poor mental health (MH) outcomes among youth from low-income families and propelled a shift to telemental health. Yet, little is known about barriers to and facilitators of MH care access when services are delivered via synchronous telehealth to Medicaid-enrolled youth. STUDY DESIGN: Between December 2020 and March 2021, we conducted in-depth interviews with 19 therapists from a large safety-net organization who served Medicaid-enrolled youth (< 18 years of age) to elucidate their perspectives on barriers to and facilitators of access to telemental health services among this population. METHODS: We conducted a thematic content analysis, guided by the 5 dimensions of health care access identified by Fortney and colleagues: geographical, temporal, digital, cultural (including acceptability of services), and financial access. RESULTS: Therapists noted that when components of digital access are met (ie, access to hardware and software, connectivity, and technological literacy), then telehealth could facilitate temporal access and eliminate geographic barriers; elimination of these barriers was particularly beneficial for youth in rural and hard-to-reach communities. Notably, many families depended on smartphones for telemental health access, and many youth depended on their caregiver's smartphone. When considering acceptability of services, some youth preferred in-person services, whereas other youth (especially some teenagers with high technological literacy) had a preference for telemental health. CONCLUSIONS: Our results highlight the need for flexibility in reimbursement policies that allows providers to optimize MH care access by offering telehealth delivered via telephone and video as well as in-person services, depending on the needs and preferences of youth and families. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Telemedicine use expanded greatly during the COVID-19 pandemic, and broad use of telemedicine is expected to persist beyond the pandemic. More evidence on the efficiency and safety of different telemedicine modalities is needed to inform clinical and policy decisions around telemedicine use. To evaluate the efficiency and safety of telemedicine, we compared treatment and follow-up care between video and telephone visits during the COVID-19 pandemic. STUDY DESIGN: Observational study of patient-scheduled telemedicine visits for primary care. METHODS: We used multivariate logistic regression to compare treatment (medication prescribing, laboratory/ imaging orders) and 7-day follow-up care (in-person office visits, emergency department visits, and hospitalizations) between video and telephone visits, adjusted for patient characteristics. RESULTS: Among 734,442 telemedicine visits, 58.4% were telephone visits. Adjusted rates of medication prescribing and laboratory/imaging orders were higher in video visits than telephone visits, with differences of 3.5% (95% CI, 3.3%- 3.8%) and 3.9% (95% CI, 3.6%-4.1%), respectively. Adjusted rates of 7-day follow-up in-person office visits, emergency department visits, and hospitalizations were lower after video than telephone visits, with differences of 0.7% (95% CI, 0.5%-0.9%), 0.3% (95% CI, 0.2%-0.3%), and 0.04% (95% CI, 0.02%-0.06%), respectively. CONCLUSIONS: Among telemedicine visits with primary care clinicians, return visits were not common and downstream emergency events were rare. Adjusted rates of treatment measures were higher and adjusted rates of follow-up care were lower for video visits than telephone visits. Although video visits were marginally more efficient than telephone visits, telephone visits may offer an accessible option to address patient primary care needs without raising safety concerns. [ABSTRACT FROM AUTHOR]

Purpose: Oral adjuvant endocrine therapy (AET) reduces the risk of cancer recurrence and death for women with hormone receptor-positive (HR+) breast cancer. Because of adverse symptoms and socioecologic barriers, AET adherence rates are low. We conducted post hoc analyses of a randomized trial of a remote symptom and adherence monitoring app to evaluate characteristics associated with higher app use, satisfaction, and how app use was associated with AET adherence., Methods: Patients prescribed AET were randomly assigned to receive one of three intervention conditions: app, app + feedback, or enhanced usual care. Baseline and 6-month follow-up surveys, app use, and pillbox-monitored AET adherence data for app and app + feedback participants were used. Logistic regression evaluated the association between sociodemographic/clinical characteristics and app utilization and satisfaction, and how app use was associated with AET adherence (>80%)., Results: Overall, 163 women with early-stage HR+ breast cancer were included; 35.0% had high app use (≥75% of weeks enrolled). No sociodemographic characteristics were associated with app use. Satisfaction with the app was higher among those who were younger (88.9% for age 31-49 years v 54.9% for age 65+ years, P < .001), identified as White (76.8% v 60.1% for Black, P = .045), had lower health literacy (85.4% v 68.2% with higher health literacy, P = .017), or were nonurban residents (85.7% v 68.6% for urban, P = .021). Most participants (90.3%) with high app use were AET-adherent compared with 66.8% for those with lower app use ( P < .001)., Conclusion: Use of a remote monitoring app was similar across sociodemographic characteristics, and more frequent app use was associated with a higher likelihood of 6-month AET adherence. Encouraging women to monitor medication adherence and communicate adverse symptoms could improve AET adherence.

An ontology is a structured framework that categorizes entities, concepts, and relationships within a domain to facilitate shared understanding, and it is important in computational linguistics and knowledge representation. In this paper, we propose a novel framework to automatically extend an existing ontology from streaming data in a zero-shot manner. Specifically, the zero-shot ontology extension framework uses online and hierarchical clustering to integrate new knowledge into existing ontologies without substantial annotated data or domain-specific expertise. Focusing on the medical field, this approach leverages Large Language Models (LLMs) for two key tasks: Symptom Typing and Symptom Taxonomy among breast and bladder cancer survivors. Symptom Typing involves identifying and classifying medical symptoms from unstructured online patient forum data, while Symptom Taxonomy organizes and integrates these symptoms into an existing ontology. The combined use of online and hierarchical clustering enables real-time and structured categorization and integration of symptoms. The dual-phase model employs multiple LLMs to ensure accurate classification and seamless integration of new symptoms with minimal human oversight. The paper details the framework's development, experiments, quantitative analyses, and data visualizations, demonstrating its effectiveness in enhancing medical ontologies and advancing knowledge-based systems in healthcare., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Wu, Ling, Graetz and Zhao.)

Background: Women with hormone receptor-positive, early-stage breast cancer who adhere to adjuvant endocrine therapy (AET) reduce the risk of cancer recurrence and mortality. AET, however, is associated with adverse symptoms that often result in poor adherence. We applied participatory action research (PAR) principles to conduct focus groups and interviews to refine and enhance a web-enabled app intervention that facilitates patient-provider communication about AET-related symptoms and other barriers to adherence., Methods: We conducted four focus groups with women with early-stage breast cancer on AET (N=28), stratified by race (Black and White) and length of time on AET (<6 months and >6 months), to determine preferences and refine the app-based intervention. A fifth mixed-race focus group was convened (N=6) to refine THRIVE app content using high-fidelity mock-ups and to develop new, tailored feedback messages. We also conducted interviews with oncology nurses (N=5) who participated in the THRIVE randomized controlled trial., Results: Participants reported preferences for weekly reminder messages to use the THRIVE app, a free-text option to write in AET-related symptoms, and app aesthetics. Other requested app features included: a body map for identifying pain, sleep and dental problems on the symptom list, a dashboard, tailored feedback messages, and information about social support resources. Participants also developed new intervention messages, decided which messages to keep, and edited language for appropriateness and sensitivity. They also discussed the type of electronic pill monitor and incentive plan to be used in the intervention. Nurses reported THRIVE alerts integrated seamlessly into their clinical workflow and increased patient-provider communication, facilitating quicker response to patients' reported symptoms. Nurses reported no negative feedback or usability concerns with the app., Conclusions: THRIVE app content reflects researchers' partnership with a racially diverse sample of breast cancer survivors and healthcare providers and adherence to participatory design by incorporating patient-requested app features, app aesthetics, and message content. The app has the potential to improve AET adherence and quality of life among breast cancer survivors and reduce disparities in mortality rates for Black women by facilitating communication with healthcare providers., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jhmhp-20-103). The series “Innovations and Practices that Influence Patient-Centered Health Care Delivery” was commissioned by the editorial office without any funding or sponsorship. Dr. GAV reports receiving personal fees from Roche/Genetech, Novartis, Eli Lilly, Immunomedics, Puma, Pfizer, AstraZeneca, Biotheranautics, Daiichi Sankyo, Vector Oncology and research funding from Roche/Genetech, Puma, Celcuity, Merck, BMS, Eli Lilly, GTx inc, Astrazeneca, Pfizer, Immunomedics, Tesaro, Halozyme, and ownership of Oncodisc, outside the submitted work. Dr. LS reports receiving personal fees from Amgen, Pfizer, Helsinn, Genentech, Genomic Health, BMS, Myriad, AstraZeneca, Bayer, Spectrum, Napo and research support from Amgen, Pfizer, outside the submitted work. Dr. IG reports receiving research support from Pfizer, outside the submitted work. Dr. RAK reports a speaking fee from General Mills, Inc, outside the submitted work. The authors have no other conflicts of interest to declare.

Objectives: Continuity of patient information across settings can improve transitions after hospital discharge, but outpatient clinicians often have limited access to complete information from recent hospitalizations. We examined whether providers' timely access to clinical information through shared inpatient-outpatient electronic health records (EHRs) was associated with follow-up visits, return emergency department (ED) visits, or readmissions after hospital discharge in patients with diabetes., Study Design: Stepped-wedge observational study., Methods: As an integrated delivery system staggered implementation of a shared inpatient-outpatient EHR, we studied 241,510 hospital discharges in patients with diabetes (2005-2011), examining rates of outpatient follow-up office visits, telemedicine (phone visits and asynchronous secure messages), laboratory tests, and return ED visits or readmissions (as adverse events). We used multivariate logistic regression adjusting for time trends, patient characteristics, and medical center and accounting for patient clustering to calculate adjusted follow-up rates., Results: For patients with diabetes, provider use of a shared inpatient-outpatient EHR was associated with a statistically significant shift toward follow-up delivered through a combination of telemedicine and outpatient laboratory tests, without a traditional in-person visit (from 22.9% with an outpatient-only EHR to 27.0% with a shared inpatient-outpatient EHR; P < .05). We found no statistically significant differences in 30-day return ED visits (odds ratio, 1.02; 95% CI, 0.96-1.09) or readmissions (odds ratio, 0.98; 95% CI, 0.91-1.06) with the shared EHR compared with the outpatient-only EHR., Conclusions: Real-time clinical information availability during transitions between health care settings, along with robust telemedicine access, may shift the method of care delivery without adversely affecting patient health outcomes. Efforts to expand interoperability and information exchange may support follow-up care efficiency.

Objectives: To examine whether mental health conditions, opioid use, and medication nonadherence are associated with inpatient and emergency department (ED) use among Medicare super-utilizers from medically underserved areas., Study Design: Retrospective panel study., Methods: The study included Medicare super-utilizers (≥3 hospitalizations or ≥2 hospitalizations with ≥2 ED visits in 6 months) served by a health system in a medically underserved area in the South from February 2013 to December 2014 with at least 1 filled prescription for hypertension, type 2 diabetes, cardiovascular, and/or chronic obstructive pulmonary disease/asthma medications. We used random effects negative binomial models to assess whether mental health diagnosis, opioid use, and medication nonadherence were associated with preventable and overall hospitalizations and ED visits stratified by age (18-64 vs ≥65 years)., Results: Overall chronic disease medication nonadherence was associated with more frequent hospitalizations and ED visits for both younger (hospitalizations: incidence rate ratio [IRR], 1.31; 95% CI, 1.16-1.47; ED visits: IRR, 1.33; 95% CI, 1.14-1.55) and older (hospitalizations: IRR, 1.34; 95% CI, 1.20-1.49; ED visits: IRR, 1.18; 95% CI, 1.02-1.38) beneficiaries. Mental health diagnosis was significantly associated with higher hospitalizations and ED visits among both age groups. Although associations between opioid medication use and inpatient and ED use were inconsistent and not significant in most cases, we found that 7 or more days' supply of opioids was associated with lower preventable hospitalizations in Medicare beneficiaries 65 years or older., Conclusions: The study findings highlight the importance of improving medication adherence and addressing behavioral health needs in Medicare super-utilizers.

Electronic health record systems have the potential to significantly improve care coordination and, ultimately, clinical care delivery. Still, it is clear that these systems are not silver bullets that will automatically result in better coordination of care and quality.

Objectives: Some patients lack regular computer access and experience a digital divide that causes them to miss internet-based health innovations. The diffusion of smartphones has increased internet access across the socioeconomic spectrum, and increasing the channels through which patients can access their personal health records (PHRs) could help bridge the divide in PHR use. We examined PHR use through a computer-based Web browser or mobile device., Study Design: Cross-sectional historical cohort analysis., Methods: Among adult patients in the diabetes registry of an integrated healthcare delivery system, we studied the devices used to access their PHR during 2016., Results: Among 267,208 patients with diabetes, 68.1% used the PHR in 2016; 60.6% of all log-ins were via computer and 39.4% were via mobile device. Overall, 63.9% used it from both a computer and mobile device, 29.6% used only a computer, and 6.5% used only a mobile device. After adjustment, patients who were black, Hispanic, or Asian; lived in lower socioeconomic status (SES) neighborhoods; or had lower engagement were all significantly more likely to use the PHR only from a mobile device (P <.05). Patients using the PHR only via mobile device used it less frequently., Conclusions: Mobile-ready PHRs may increase access among patients facing a digital divide in computer use, disproportionately reaching racial/ethnic minorities and lower SES patients. Nonetheless, even with a mobile-optimized and app-accessible PHR, differences in PHR use by race/ethnicity and SES remain. Continued efforts are needed to increase equitable access to PHRs among patients with chronic conditions.

Objectives: To understand when patients use secure e-mail messaging with healthcare providers across several types of questions or concerns, associations between out-of-pocket costs for in-person visits and use of secure messaging, and to examine patient-reported impacts on care-seeking behavior and overall health., Study Design: Cross-sectional survey of patients in an integrated healthcare delivery system, with access to a patient portal to send secure e-mail messages to providers at no out-of-pocket cost., Methods: The study included patients with a chronic condition (N = 1041). We described patient-reported preferences for contacting providers and patient-reported impact of e-mail use on phone calls, in-person visits, and overall health. We used multivariate analyses to examine patient characteristics associated with using e-mail as a first contact method, and effects on care-seeking and health., Results: Overall, 56% of patients sent their provider an e-mail within 1 year, and 46% reported e-mail as their first method of contact for 1 or more types of medical concerns. After adjustment, higher out-of-pocket costs for in-person visits were significantly associated with choosing e-mail as a first method of contact (P < .05). Among patients who had e-mailed their provider, 42% reported that it reduced their phone contacts, 36% reduced in-person office visits and 32% reported e-mailing improved their overall health., Conclusions: Patients reported using e-mail broadly to initiate conversations with their providers, and patients with higher out-of-pocket costs for in-person visits were more likely to choose e-mail as a first contact method. Use of secure e-mails reduced patients' use of other types of healthcare and resulted in improved overall health.

Objective: To examine the association between use of electronic health records (EHR) and care coordination., Study Design: Two surveys, in 2005 and again in 2006, of primary care clinicians working in a prepaid integrated delivery system during the staggered implementation of an EHR system. Using multivariate logistic regression to adjust for clinician characteristics, we examined the association between EHR use and clinicians' perceptions of three dimensions of care coordination: timely access to complete information; treatment goal agreement; and role/responsibility agreement., Results: Compared to clinicians without EHR, clinicians with 6+ months of EHR use more frequently reported timely access to complete information, and being in agreement on treatment goals with other involved clinicians. There was no significant association between EHR use and being in agreement on roles and responsibilities with other clinicians., Conclusions: EHR use is associated with aspects of care coordination involving information transfer and communication of treatment goals.