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The American Journal of Managed Care April 2013
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Health Plan Innovations in Delivery System Reforms
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Nathaniel P. Katz, MD, MS; Howard Birnbaum, PhD; Michael J. Brennan, MD; John D. Freedman, MD; Gary P. Gilmore, RPh; Dennis Jay, BS; George A. Kenna, PhD, RPh; Bertha K. Madras, PhD; Lisa McElhaney, B
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Use of Web-Based Shared Medical Records Among Patients With HIV
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

Use of Web-Based Shared Medical Records Among Patients With HIV

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
Use of online shared records was higher among HIV patients who had indicators of recent increases in healthcare needs and lower among several vulnerable populations.
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 ( or 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.

Data Sources

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.

Statistical Methods

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.

We also examined which of these factors were correlated with more frequent use of the SMR among those who used the SMR at least once. We used negative binomial regression to compare rates of SMR use following initial use. To account for overdispersion typical of count data, we used robust standard errors. We fit 2 negative binomial regression models for each variable, first adjusting only for site and then for site, age, sex, and the non-HIV Charlson Comorbidity Index score.


The study population consisted of 6644 KPNC and 754 GH patients (Table 1). Compared with GH patients, KPNC patients were more likely to be black (KPNC 17.7% vs 10.9% GH),Hispanic (KPNC 14.7% vs GH 5.4%), older (mean age KPNC 45.9 years vs GH 42.8 years), living in a low-SES neighborhood (KPNC 26.6% vs GH 18.1%), and HIV positive for longer (KPNC 9.3 years vs GH 3.5 years). Race/ethnicity was missing for 455 (6.6%) patients at KPNC and 67 (8.9%) patients at GH.

Overall Use of the Shared Medical Record by Health Plan

Over the 36-month study period, 3411 (51.3%) KPNC participants and 477 (63.6%) GH participants (P = .01 between sites) used the SMR. Among the SMR’s 7 available functions, the highest proportion of enrollees requested medication refills (27.9% KPNC, 58.9% GH); used secure messaging (41.1% KPNC, 57.6% GH); viewed medical test results (47.4% KPNC, 62.1% GH); and requested appointments (30.3% KPNC, 39.6% GH) (Table 2).

The Figure shows rates of use for SMR functions over the study period. In the final month of the study, the most frequently used features were viewing medical test results (16 unique users per 100 KPNC enrollees; 28 unique users per 100 GH enrollees), requesting medication refills (12 unique users per 100 KPNC enrollees; 34 unique  users per 100 GH enrollees), and using secure messaging (14 unique users per 100 KPNC enrollees; 23 unique users per 100 GH enrollees).

Initial Shared Medical Record Use

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