Published Online: April 16, 2013
James D. Ralston, MD, MPH; Michael J. Silverberg, PhD, MPH; Louis Grothaus, MA; Wendy A. Leyden, MPH; Tyler Ross, MA; Christine Stewart, PhD; Steven Carzasty, MSW; Michael Horberg, MD, MAS; and Sheryl L. Catz, PhD
Objectives: To compare use of 7 shared electronic medical record (SMR) features by adult HIV patients.
Study Design: Observational cohort study of adult HIV-positive patients in the first 36 months following implementation of the SMR at Group Health and Kaiser Permanente Northern California.
Methods: Automated data from the 36 months following SMR implementation were assessed in 2 integrated delivery systems. Cox proportional hazards analysis identified factors associated with any SMR use.
Results: Most (3888/7398) patients used the SMR at least once. Users were most likely to view medical test results (49%), use secure messaging (43%), or request appointments (31%) or medication refills (30%). Initial use was associated with new prescription for antiretroviral therapy (rate ratio [RR] 1.65, P <.001), recent change to a CD4+ count of fewer than 200 cells per microliter (RR = 1.34, P <.02), new HIV RNA of 75 or more copies per milliliter (RR = 1.63, P <.001), or recent increase in non-HIV comorbidity score (RR = 1.49, P = .0001). Users were less likely to be women (RR = 0.49, P = .0001), injection drug users (RR = 0.59, P = .0001), or from lower–socioeconomic status neighborhoods (RR = 0.68, P = .0001), and were less likely to be black (RR = 0.38, P = .0001), Hispanic (RR = 0.52, P = .0001) or Asian/Pacific Islander (RR = 0.59, P = .001).
Conclusions: SMR use was higher among HIVpatients who had indicators of recent increases in healthcare needs and lower among several vulnerable populations.
Am J Manag Care. 2013;19(4):e114-e124
This observational cohort study compared use of 7 features of an online shared medical record by adult patients with HIV.
Use was higher among those with HIV who had indicators of recent increases in healthcare needs and lower among several vulnerable populations.
Healthcare providers and systems should support use of online shared medical records among patients with HIV as part of broader efforts to improve overall access to care.
Ongoing collaboration with providers is essential for care of patients with HIV. To reduce HIV-related morbidity and mortality, patients and providers monitor CD4+ T-cell counts and HIV viral loads, and initiate and adjust antiretroviral therapy. Patients on antiretroviral therapy must adhere tightly to the regimen for benefits, while managing the medications’ frequent side effects.1 Healthcare systems that enable good communication with providers and access to services such as laboratory monitoring and medication refills are critical for patients to manage HIV infection successfully.
Patient websites providing secure access to electronic medical records that are shared between patients and healthcare providers may help meet the ongoing care needs of many patients with HIV. Also known as integrated personal health records, these web-based shared electronic medical records (SMRs) can provide a constellation of services for patients, typically including exchanging secure electronic messages and scheduling appointments with healthcare providers, ordering medication refills, and viewing care plans, medical test results, and other portions of the electronic medical record.2-4 Proposed federal meaningful use criteria for electronic health records support patients’ use of the SMR, including secure messaging with providers.5 Many of these services may help patients with HIV, particularly during times of heightened need (eg, when starting new antiretroviral medications or when there is a significant CD4+ count decrease).
Despite the SMR’s potential, some groups of patients disproportionately affected by HIV may be less likely to use it. HIV is estimated to be 9 times more common in blacks and nearly 3 times more common in Hispanics6 than in whites; black and Hispanic populations are also less likely to receive highly active antiretroviral therapy7 and experimental treatments. Individuals with low socioeconomic status (SES) are twice as likely to have HIV8 and are more likely to die of HIV,9 and less likely to receive highly active antiretroviral therapy. Older patients with HIV have faster progression of disease, with treatment often complicated by coexisting chronic health conditions.10 All these sociodemographic groups are also less likely to use the Internet11 and patient websites.12-15 An initial study of personal health record use among patients with HIV receiving care at San Francisco General Hospital also found that users were more likely to be Caucasian and non-Hispanic.16 Further understanding of potential differences in SMR use by patients with HIV who belong to vulnerable populations is essential to ensure that healthcare is designed to meet the needs of all patients with HIV. These potential differences are particularly important if the SMR is being used to support care at critical times, such as initiation of antiretroviral medications or a drop in CD4+ cell count.
Study Design, Setting, and Participants
We performed a cohort study of adult HIV-positive patients in the first 36 months following implementation of the SMR at Group Health (GH) (August 1, 2003, to July 31, 2006) and Kaiser Permanente Northern California (KPNC) (November 1, 2005, to October 31, 2008). Group Health and KPNC are large, integrated healthcare delivery organizations providing multidisciplinary care, including HIV specialty care. The study population included enrollees 18 years or older in either institution’s HIV registry. Patients were followed from the date they met eligibility criteria (>18 years of age, HIV positive, enrolled in health plan) until the earliest of disenrollment, death, or the end of the study period.
Beginning in 2003 at GH and 2005 at KPNC, all patients could access an SMR (www.ghc.org or www.kp.org) with 7 features common to both sites: secure messaging with healthcare providers; requesting medication refills; requesting inperson appointments; and viewing after-visit summaries, allergies, immunizations, and test results (excluding CD4+ and HIV RNA results at KPNC). Detailed descriptions of the patient websites at GH3,17 and KPNC4 were previously reported. Patients verified their identity to GH or KPNC before using these features.17 We hypothesized that SMR use would be higher among those with a recent heightened need for care but lower among racial and ethnic minorities, older patients, and those from lower-SES groups.
The KPNC HIV registry18,19 includes all known cases since the early 1980s; the GH registry, since 1997. Registry data include sex; birth date; race/ethnicity; dates of known HIV infection and AIDS diagnoses; and at KPNC only, HIV transmission risk factors. There are also historical databases at KPNC and GH on member demographics, prescriptions, hospitalizations, outpatient visits, and laboratory tests, including CD4+ T-cell count and HIV RNA test results, health insurance status, and zip code. Date of death was identified from hospitalizations, membership files, California and Washington state death certificates,
and Social Security Administration data sets.
Use of the Shared Medical Record. The primary outcome of interest was any SMR use defined as using at least 1 of the 7 SMR features during the study period. Secondary outcome was continued SMR use (mean days of SMR use per month). Rates of use were measured as the number of days per month in which patients used any of the SMR features.
Variables Potentially Associated With Shared Medical Record Use. Primary predictors were recent increase in healthcare need, race/ethnicity, neighborhood SES, and age. We defined recent increase in healthcare need as 1 of the following clinical events occurring within the prior 3 months: start or restart of antiretroviral therapy; new CD4+ count of fewer than 200 cells per microliter; newly quantifiable HIV RNA of 75 or more copies per milliliter; or worsening comorbidity unrelated to HIV. Non-HIV morbidity was measured using a modified Charlson Comorbidity Index, excluding HIV/AIDS diagnoses.20 Neighborhood SES was categorized as low for a patient if at least 20% of 2000 Census block residents had an income below $20,000 or at least 25% of residents over age 25 years had not completed high school.14,21,22 Secondary predictors included sex, HIV risk factors, insurance status, time with health plan, and specific comorbid conditions (depression and hepatitis B and C). Predictor selection was based on prior studies of SMR use in other populations13,23,24 and prior studies of access to care in people with HIV.7 Depression was defined by outpatient diagnosis in prior 12 months. HIV transmission risk factors and history of hepatitis B and C were from the HIV and the hepatitis C virus/hepatitis B virus registries at each site.
We used Cox proportional hazards analysis to identify the factors associated with any use of the SMR. Outcome was time to first use; rate ratios (RRs; hazard ratios) compared the rate of initial use (percentage of patients per month who first used SMR) with that of a reference group. Separate Cox models were fit to each variable, first adjusting for site only, and then for site, sex, age, and non–HIV-related morbidity.
Race/ethnicity analyses adjusted for age, sex, and a modified Charlson Comorbidity Index (without HIV/AIDS)25; this allowed potential mediation of SMR use by racial/ethnic group through SES factors26 and is consistent with the Institute of Medicine recommendation for handling potential healthcare disparities (defined as any difference not due to clinical need or preferences) when comparing groups defined by race/ethnicity.25 Fixed and time-varying characteristics potentially associated with SMR use were identified before the analyses. We looked at baseline factors that did not change during follow-up and examined how the following time-varying factors (updated monthly) were related to use: non–HIV-related morbidity, antiretroviral use, CD4+ count, viral load, hepatitis B infection, hepatitis C infection, and depression diagnosis.
We tested for interactions between sites and each potential predictor of SMR use. To minimize the risk of false-positive interactions, interaction tests used a significance level of .01. We also tested for interactions between racial groups and HIV risk factor, sex, and overall HIV healthcare need in past 3 months (any start of antiretroviral therapy, new CD4+ count fewer than 200 cells per microliter, new HIV RNA of 75 or more copies per milliliter, or increase in Charlson Comorbidity Index score).
Cox models assessed the short-term effect of markers of increased healthcare need on the likelihood of initial SMR use. We defined short term as 3 months and assessed whether individuals were more likely to start using the SMR in the 3 months following 1 of these events: worsening non–HIVrelated morbidity, start of antiretroviral therapy, CD4+ count below 200 cells per microliter, or viral load exceeding 75 copies per milliliter.
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