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Patient-perceived usefulness of an emergency medical card and a continuity-of-care report in enhancing the quality of care

C.H.O. Olola, S. Narus, M. Poynton, J. Nebeker, J. Hales, B. Rowan, M. Smith, R.S. Evans
DOI: http://dx.doi.org/10.1093/intqhc/mzq073 60-67 First published online: 15 December 2010

Abstract

Objective To evaluate the patients' opinion on the usefulness of the electronic medical card (EMC) and continuity-of-care report in enhancing quality of care, and to assess the effects of the patient-entered data on the quality of data in the electronic medical record (EMR).

Design A structured survey assessed patients' opinion on the usefulness of the EMC and continuity-of-care report. The accuracy of EMR data involved comparing the patient-entered data in the continuity-of-care report with the healthcare-provider-entered data in the EMR. The analysis assessed whether the EMR information was consistent with the patient-entered data. A data completeness evaluation compared data entries in the EMR collected before and after the use of continuity-of-care record application.

Results One hundred and thirty-three patients used the application, of which 76% who had actually used the EMC and continuity-of-care report to seek medical care and/or update EMR information were surveyed. Age was associated with the reported usefulness of the documents. Few users (16%) printed the continuity-of-care reports to take to their healthcare providers for data updates and fewer (9%) to correct errors in the EMR. Overall, 68% of patients found the documents to be useful.

Conclusions Patients reported that the EMC and continuity-of-care report were useful in enhancing quality of care. They were able to identify missing or erroneous data in the EMR data, making them an important source of quality control for their information in the healthcare-provider-maintained EMR.

  • data quality
  • patient satisfaction
  • continuity of patient care
  • emergency medical card
  • emergency medical services
  • evaluation studies

Introduction

Real-time clinical data acquisition is one of the most challenging goals for clinical information systems [1]. Computerization reduces human errors while offering wide access to, and sharing of, patient care information [2, 3], improves efficiencies and security, and enables patients to monitor and review the quality of their records [4]. To improve the quality of care at the point of care, such data need to be of high quality and should be immediately accessible and reliable [58]. Patients can be useful in auditing the quality and efficiency of care they receive from their healthcare providers [9]. Therefore, the opinion of patients is vital and should supplement the usual indicators of quality of healthcare [10, 11]. In addition, free flow of information and making patients the source of control of their data are key features of patient-centered care [12]. Patient feedback can help in identifying areas of care for meaningful improvement [1315].

To foster the delivery of efficient and effective patient care, we implemented a continuity-of-care record (CCR) standard [16] compliant application (‘CCR application’), whose design and implementation details were described in a previous study [17]. The CCR application was integrated in an already implemented patient portal, My Health—a web-based application. The CCR application enabled patients to view, add and modify their health information in a personal health information database and to create and print a continuity-of-care report and a pocket-sized emergency medical card (EMC). The continuity-of-care report is a detailed snapshot report of the current and previous 3 months of patient-entered and healthcare-provider-entered data (in two distinct columns) in compliance with the data elements mandated by the CCR standard. Patients may use the CCR application to enter new data on the continuity-of-care report. The data can be used by healthcare providers to correct possible errors or to complete missing patient information in the healthcare-provider-entered data in the electronic medical record (EMR). The EMC, however, contains only a portion of the continuity-of-care report information. It contains the most current core patient-entered data and healthcare-provider-entered data in the EMR. The EMC was designed to provide the core patient information to healthcare providers for appropriate medical decision-making during medical emergencies.

Objectives

The objectives of this study were to evaluate the patients' opinion on the usefulness of the EMC and continuity-of-care report to enhance quality of care and to assess the effects of the patient-entered data through the use of the CCR application on the quality (i.e. accuracy and completeness) of the healthcare-provider-entered data in the EMR.

Methods

Setting and study participants

The study included 36 Intermountain Healthcare (‘Intermountain’) outpatient clinics that offered My Health web portal services. At the end of 6 months of the CCR application use (between October 2008 and June 2009) (Fig. 1), we surveyed patients (aged between 18 and 90 years) who had used the application to create their EMCs and continuity-of-care reports. An email was sent to all patients who had used the application (n = 133), requesting them to participate in the survey. They were provided with a description of the study and an Internet link to the online survey. The survey was used to assess patients' opinion on the usefulness of the EMC and continuity-of-care report in enhancing quality of care (after using them with healthcare providers). The survey required that patients had to use their printed EMC and/or continuity-of-care report during a healthcare encounter in order to participate.

Figure 1

Cumulative monthly use of the CCR application.

Patients' opinion on the usefulness of the EMC and continuity-of-care report

A structured web-based survey was used to assess patients' opinion on the usefulness of the EMC and continuity-of-care report. The question was developed through brainstorm sessions with medical doctors, nurses, administrators, software developers/systems analysts and biomedical informaticians from the Intermountain healthcare, and the research committee members from the University of Utah, Department of Biomedical Informatics. The questionnaire was divided into three main sections: (i) general measures (e.g. user-friendliness of the documents and the impact on user privacy/confidentiality), (ii) data quality measures (e.g. correction of errors and completion of missing information in the EMR, accuracy of patient information in the EMC and continuity-of-care report), (iii) quality of care (e.g. effect of the documents on the overall knowledge of patients on their health condition, patient–healthcare-provider relationship/trust and patient–healthcare provider encounter time). A 5-point Likert scale (1, strongly disagree; 2, disagree; 3, undecided; 4, agree; 5, strongly agree) was provided in the questionnaire for patients to rate their opinion on the usefulness of EMC and continuity-of-care report in each of the continuity-of-care measures/indicators provided above. There was also a provision of a ‘not applicable’ option for patients to select if they had not used their EMC and/or continuity-of-care report to seek care from healthcare providers or for EMR data updates.

Quality of healthcare-provider-entered data in the EMR

To evaluate the quality of EMR data, we assessed the accuracy and completeness of the healthcare-provider-entered data in the EMR. Data accuracy analysis assessed whether the patient records in the EMR correctly represented the patient-entered data in the continuity-of-care report. Only the patient-entered data that had corresponding entries in the healthcare-provider-entered data were compared. Data entries for some attributes could not be compared because either they existed in an unstructured, free-text format or they were not integrated into the EMR's clinical data repository. The data fields included the emergency contact (name and relationship), power of attorney (name, relationship and phone), social and family history, immunization and procedures/imaging. We could not make any assumptions about the EMR data if the patient did not enter new data using the CCR application—i.e. data from visits to non-Intermountain healthcare providers or for error correction. In situations where patients entered new data into the application's database, we used patient identifiers, date of data entry and the data entry values to query the EMR for any matching data. Where the data in the EMR matched the patient-entered data and the EMR data were entered after the date of the patient-entered data, we recorded that data as a complete match. For those cases, we assumed that the patient-entered data was used to update the record in the EMR.

A data completeness evaluation, for the CCR application users, quantified the number of healthcare-provider entries in the EMR that had data (i.e. entries that had no blank or missing data). To perform the evaluation, we compared all the data that were collected 8 months before (‘before’ database) and 8 months after (‘after’ database) the use of the CCR application. We tallied the entries with data for each data field in the ‘before’ database and presented it as a percentage of the total number of all the (expected) entries, i.e. entries with data and those with missing data. The same process was followed for the ‘after’ database. For the overall summary, we presented the total number of complete entries in the ‘before’ and ‘after’ databases as a percentage of the total number of all the (expected) entries in both databases. Any improvement on the data completeness in the ‘after’ database was assumed to be attributable to the use of CCR application.

The data accuracy and completeness analyses were stratified by four major data categories—clinical, demographic, laboratory/diagnostic and prescription data. The clinical data included the patient vital signs, current and past health-problems, appointments and allergies. The demographic data included the patient address, phone number, date of birth, gender, blood group, ethnicity, organ donor status, advance directives, contact lens, dentures, pacemaker, religion preference, primary healthcare provider and primary insurance provider. The laboratory/diagnostic data included the laboratory procedures (procedure name, procedure status and name of hospital/clinic where the procedure was done) and test results (creatinine, potassium, sodium, glucose/blood sugar, urine protein, hemoglobin, hematocrit and WBC). Prescriptions data consisted of the drug name, dose, schedule and the healthcare provider who prescribed the medication.

Data analysis

STATA software (Intercooled STATA software, Release 9, StataCorp. 2007; College Station, TX, USA) was used for data analysis. A significant difference between study groups was assessed at the 0.05 level of significance. The Student's t-test was used to test for differences in mean ratings between study groups in the continuous data where normality of samples was established. The non-parametric median test for equality of medians was used where there was no normality of data samples. Fisher's exact test was used to test associations between categorical data.

Characteristics of the study subjects

We tabulated the purpose, as reported by the patients, for which the EMCs and continuity-of-care reports were printed. A profile of the CCR application users by gender and age was presented. We also characterized the distributions of the medians of the clinical measures (i.e. active medical problem, active mediations, appointments and allergies) of the application users, by age. The non-parametric median test was used to assess the differences in the number of active components of the clinical measures between users of various ages. A number of record types were excluded from the analysis sample because they were no longer of a significant concern to the patient at the time of study evaluation. These records included resolved, inactive or wrong/erroneous medical problems. Other records included prescriptions with inactive status and appointments with arrived, bumped (i.e. appointments that had been called earlier than the scheduled time, due to urgency), rescheduled, modified, no show and cancelled status. Records on allergies with no known status were also excluded from the analysis.

Patients' opinion on the usefulness of the EMC and continuity-of-care report

The Fisher's exact test was used to assess associations between gender and age, and the usefulness of the EMC. The same test was performed to assess associations between gender and age, and the usefulness of the continuity-of-care report. Using the Student's t-test, we analyzed the difference between the mean rating of the usefulness of the EMC and that of the continuity-of-care report for each study measure.

Quality of healthcare-provider-entered data in the EMR

Analysis of the accuracy of the healthcare-provider-entered data in the EMR was performed by assessing the proportion of patients whose data was updated in the EMR. This analysis was stratified by the four major data categories. The evaluation of the completeness of the EMR data was accomplished by counting the number of non-blank (or non-missing) data entries in the EMR and graphing the fraction of the entries as a percentage of the total expected number of entries in the EMR. We then used the non-parametric median test to assess the differences in the medians of complete data entries in the EMR, before and after the use of the CCR application.

Results

Characteristics of the study subjects

One hundred and thirty-three patients used the CCR application to create an EMC and a continuity-of-care report. Totally 133 users were surveyed and all of them responded to the survey. However, 32 users were excluded from the analysis because they had not used their EMCs or continuity-of-care reports to seek care from healthcare providers or for update of records in the EMR. The remaining 76% (n = 101) of the users were included in the data analysis (Table 1). Of these users, the majority (75%) was female and the largest subgroup of users consisted of those aged 51–60 years (35%). Thirty-nine percent (39/101) of the users visited healthcare providers outside the Intermountain network. Overall, the median age of the application was 56 years (25th quartile, 75th quartile: 47, 62). Most of the users printed the documents to store for use during emergencies (95%) and many for personal use (46%). Sixteen of the users (16%) printed a continuity-of-care report to take to their healthcare providers to update records in the EMR (i.e. with new information from visits to non-Intermountain healthcare providers or information to complete missing data). However, 9% of the patients printed a continuity-of-care report to use to correct errors in the EMR.

View this table:
Table 1

Characteristics of the CCR application users

MeasurePercentage (n = 101)
Sex
 Female75.3
 Male24.7
Age years56 (47,62)a
 18–3011.9
 31–4013.9
 41–5021.8
 51–6034.7
 >6017.8
Usage of EMC and continuity-of-care reportb
 To update records15.8
 To correct data errors8.9
 For personal use45.6
 Stored for emergency use95.0
 Reviewed and discarded2.0
 Others3.0
  • aMedian (25th quartile, 75th quartile) age of patients.

  • bData collected in an Exit survey [17] where patients indicated their anticipated use of the printed EMC and continuity-of-care report.

On average, each patient user had approximately five active medical problems, active medications, appointments and two allergies. Patients aged 60 years and older had the highest number of medical problems and medications. The number of allergies was similar across various ages. However, patients over 50 years had a significantly higher number of appointments than those aged 30 years and older.

Patients' opinion on the usefulness of the EMC and continuity-of-care report

The user's age was found to be significantly associated with the way the user rated the usefulness of the EMC and continuity-of-care report in enhancing quality of care (P = 0.019 and P = 0.009, respectively) (Table 2). Although more female users rated the two documents, the way users rated the usefulness of either of the documents did not differ significantly. Overall, the majority of patients (68%) found the EMC and continuity-of-care report to be useful (Table 3). Although a higher proportion of patients found the EMC to be more useful than the continuity-of-care report (71 and 64%, respectively), the difference was not statistically significant (P = 0.196). The users perceive the documents more useful in specific continuity-of-care measures: easy to understand and use (84%), secure—i.e. do not compromise confidentiality (83%), useful to complete missing information in the EMR (78%) and useful to increase knowledge about their health condition (72%).

View this table:
Table 2

Comparison of the usefulness of the EMC and continuity-of-care report by patient gender and age

MeasurenUsefulness ratingaPa
EMC, n (%)PbContinuity-of-care report, n (%)
Sex
 Female7641 (54.0)1.0048 (63.2)0.232
 Male2513 (52.0)12 (48.0)
Age (years)
 18–30127 (58.3)9 (75.0)
 31–401410 (71.4)11 (78.6)
 41–502211 (50.0)0.01910 (45.5)0.009
 51–603512 (34.3)15 (42.9)
 >601814 (77.8)15 (83.3)
  • aQuestion: use the 5-point Likert scale response (1, strongly disagree; 2, disagree; 3, undecided; 4, agree; 5, strong agree) to rate your opinion on the usefulness of EMC and continuity-of-care report:

  • The data were accurate; the data were useful to correct errors in my electronic medical data; the data were useful to complete missing data in my electronic medical data; the document were user-friendly (i.e. to store and understand); the document did not compromise the confidentiality and security of my data; the data in the document increased my knowledge about my health condition; the document enhanced the quality of healthcare given to me; the document increased my trust with the healthcare provider; the document improved my relationship with the healthcare provider; the document shortened my encounter time with the healthcare provider; the document lengthened my encounter time with the healthcare provider. bTwo-sided P-value from Fisher's exact test for the association between patient demographics and the usefulness of the EMC and continuity-of-care report.

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Table 3

Categorization of the usefulness of the EMC and of the continuity-of-care report by quality of care measurements

MeasureEMCContinuity-of-care report
nAgree, n (%)Mean rating (mean ± SDa)nAgree, n (%)Mean rating (mean ± SDa)P*
Question: use the 5-point Likert scale response (1, strongly disagree; 2, disagree; 3, undecided; 4, agree; 5, strong agree) to rate your opinion on the usefulness of EMC and continuity-of-care report
 The data were accurate9974 (74.8)3.9 ± 1.010075 (75.0)3.8 ± 0.90.251
 The data were useful to correct errors in my electronic medical data9061 (67.8)3.9 ± 0.89264 (69.6)3.8 ± 0.90.540
 The data were useful to complete missing data in my electronic medical data9172 (79.1)4.1 ± 0.89472 (76.6)3.9 ± 0.90.037
 The document were user-friendly (i.e. to store and understand)10183 (82.2)4.1 ± 0.810187 (86.1)4.1 ± 0.80.580
 The document did not compromise the confidentiality and security of my data10184 (83.2)4.1 ± 0.710184 (83.2)4.1 ± 0.70.829
 The data in the document increased my knowledge about my health condition10173 (72.3)3.9 ± 1.010071 (71.0)3.9 ± 1.00.372
 The document enhanced the quality of healthcare given to me9657 (59.4)3.8 ± 1.09561 (64.2)3.8 ± 0.90.567
 The document increased my trust with the healthcare provider9657 (59.4)3.7 ± 0.99557 (60.0)3.7 ± 0.90.726
 The document improved my relationship with the healthcare provider9555 (57.9)3.7 ± 0.99554 (56.8)3.7 ± 0.90.276
 The document shortened my encounter time with the healthcare provider9447 (50.0)3.6 ± 0.99545 (47.9)3.6 ± 0.90.453
 The document lengthened my encounter time with the healthcare provider9425 (26.6)3.2 ± 1.09330 (32.3)3.2 ± 1.00.365
 Overall (all quality of care measurements)10172 (71.3)3.8 ± 0.910165 (64.4)3.6 ± 0.90.196
  • aMean rate/score and standard deviation (SD) for each measure. *Two-sided P-value from the t-test of the difference between the mean rating of the usefulness of the EMC and continuity-of-care report.

Quality of healthcare-provider-entered data in the EMR

Sixty-nine percent of the patients (70/101) entered new data in the personal database (1994 entries), using the CCR application (Table 4). Out of the 1994 entries, only the 1505 entries that had data attributes both in patient-entered and HCP-entered databases were compared. The majority of the updates were observed in the demographic data category (address, biodata, insurance- and primary healthcare-provider attributes). The records of allergies that were not updated in the EMR by the healthcare providers were mostly moderate food and resolved drug allergies. The inactive, resolved, past medical problems and prescriptions were also usually not updated in the EMR.

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Table 4

Effect of the patient-entered data on the accuracy of the healthcare-provider-entered data in the EMRfor CCR application users only

Data categoryData attributesNumber of patients who entered new data in the CCR application (n = 70)Percentage of patients whose data were updated in the EMR (%)Data entries (n), n = 1505a; 43.8%Percentage of updated entries (%)
DemographicAddress6995.727188.9
Biodatab70100.055543.2
Insurance6665.211563.5
Primary healthcare provider6580.012163.6
ClinicalAllergies1346.21060.0
Active problems137.7690.0
Vital signs128.36328.6
Laboratory/diagnosticObservations and results250.0580.0
Active prescriptionsPrescription drugs156.72092.9
  • aNumber of patient-entered records for EMR updatealthough 1994 data values were entered by the patients, only the 1505 data values of the data attributes that existed both in patient-entered and HCP-entered databases could be and were compared. bBiodata included ethnicity, sex, date of birth, religion, blood group, advance directive, pacemaker, contact lens, dentures, organ donor and emergency phone.

A significant increase in the completeness of healthcare-provider-entered data in the EMR, for the CCR application users, was observed in the demographic and laboratory data categories (P < 0.001 and P = 0.004, respectively) (Table 5). Overall, the EMR data had a lower completeness percentage after the use of the CCR application, although the difference was not statistically significant (P = 0.446).

View this table:
Table 5

Completeness of the healthcare-provider-entered data in the EMR, before and after the use of the CCR application

Data categoryPeriodPatients (n)aMedian (interquartile range)bP*
ClinicalBefore202.59 (0.25–43.73)0.752
After202.06 (0.27–45.63)
DemographicsBefore150.46 (0.36–0.71)<0.001
After151.21 (1.12–1.22)
LaboratoryBefore15138.09 (138.091–138.091)0.004
After15145.68 (61.57–145.68)
MedicationsBefore52.37 (2.19–2.56)0.206
After53.04 (2.77–3.25)
OverallBefore552.56 (0.36–138.09)0.446
After553.04 (1.12–61.57)
  • aThe number of patients who used the CCR application and had records before and after the use of the application, out of the patients who entered new data (n = 70). bThe median number and interquartile range (in millions, rounded off to two decimal places) of the complete data entries in the EMR, before and after the use of the application. For each data field in the EMR, we queried the before and after databases and counted the number of healthcare-provider entries that had data, i.e. entries that had no blank or missing data. *Two-sided Fisher's exact P-value for testing equality of medians of complete data entries in the before and after databases.

Discussion

This study has demonstrated that although the majority of the users of an application like CCR are likely to be female, gender has no significant influence on how the users rate or perceive the usefulness of the documents in enhancing the quality of care. This suggests that, for such documents, randomization of evaluators by gender is not necessary. However, age was found to be significantly associated with the way users rated the usefulness of the documents. Patients 51–60 years (median age: 56 years) were the largest group of users (35%), but were evidently less likely than the other users to rate the EMC and continuity-of-care report as useful in enhancing quality of care (ranges: 34–43 and 58–83%, respectively). This may suggest that the lower-use groups had a perceived value in quality management of the continuity-of-care information or they needed assistance in entering information the most. On the other hand, the high-use group (i.e. patients 51–60 years of age) may have had high expectations of the EMC and continuity-of-care report. This result might, therefore, suggest that the middle group of patients is potentially a better group to evaluate the continuity-of-care tools.

A significant proportion of users (39%) visited non-Intermountain healthcare providers. The majority of these users created EMCs compared with continuity-of-care reports. As reported by the users, the documents were created mostly for personal use and for use during medical emergencies, compared with other anticipated uses. This demonstrates that patients are more likely to be concerned about what could assist them during future medical emergencies than to update their records in the EMR. Further research is needed to find out whether this finding may be due to patients finding the current data to be mostly complete and/or accurate. Other potential questions that need further investigation may include: Did patients perceive that there were no errors or missing data, or did they believe that the errors were negligible? Could it be that the patients misunderstood the need to update their records, or was there some sociological effect that discouraged them from questioning the data in the EMR?

Over 68% of the users reported that the EMC (71%) and continuity-of-care report (64%) are useful in enhancing the quality of care. More specifically, these users found the documents to be legible, easy to understand and safe (do not compromise confidentiality/privacy) to use, useful in completing missing data in the EMR, and can significantly increase the overall knowledge about their health condition. These moderate ratings show that these documents are vital for medical decision-making at the point of care.

On average, a user had approximately five medical problems, prescriptions, appointments and two allergies. Although not significantly different, the users over 60 years of age tended to have the highest number of medical problems and medications, than those aged 30 years and younger. However, users over the age of 50 years had a significantly higher number of appointments than those aged 30 years and younger. These findings demonstrate that patients who are older and sicker (i.e. with multiple medical problems and medications) are more likely to use an application such as the CCR application because they are more concerned about their health. Such patients will be able to benefit from a patient proxy feature that was proposed for future implementation in the CCR application [17]. The feature will allow patient proxies to use the CCR application to create EMCs and continuity-of-care reports on behalf of such severely ill patients.

Seventy percent of the users entered (new) data using the CCR application, of which there was a reasonable proportion of patients (72%) whose data were updated in the EMR by the healthcare providers. The proportions of EMR updates were even higher for specific continuity-of-care measures such as biodata and demographic information. These results show that the patient is potentially an important source of quality control for this type of information in the EMR. Although it was not documented, there was the possibility that at the time of the survey some patients may not have taken their continuity-of-care reports to healthcare providers for EMR updates. This update failure may, therefore, have contributed to the overall moderate percentage of EMR updates. The substantial continuity-of-care report data (for EMR updates) observed in the patient demographic information may be attributed to frequent residential location changes, regular changes in contacts and healthcare-provider information and multiple visits to multiple healthcare providers. Overall, each patient visited two healthcare providers and 39% of the patients visited non-Intermountain healthcare providers. Further research is required to investigate why there was minimal continuity-of-care report data for other data types such as prescriptions, allergies and problems. Among many other issues, such future studies should investigate whether the healthcare providers did not update the EMR information with the patient-entered data because the healthcare providers believed that the EMR records were accurate.

In the data categories where patients entered the highest volume of new data (e.g. the demographic data category), there was an improved EMR data completeness. These data fields may not have a direct clinical benefit; however, they might be useful in activities such as demographic surveillance studies. Such surveillance studies could include longitudinal or follow-up studies, where accuracy of patients’ physical location details is vital for tracking patients. The findings showed that the EMR data were complete to a significant level, with an overall mean of 94% before the use of the CCR application and 85% after use of the application (range among the four data categories: 90–99% before the use of the CCR application and 72–91% after the use of the application). Despite the overall decrease in data completeness after the use of CCR application, there was a significant increase in data completeness in the demographic and laboratory data categories (P < 0.001 and P = 0.004, respectively). Due to the lack of a universal trend in data completeness after the use of the application, the findings do not demonstrate conclusive evidence of its effect on data completeness in the EMR.

Study limitations

No patient data were extracted from the EMR for the social and family history, procedures/ imaging, clinical notes, emergency contacts, personal notes and immunization data categories. This was because Intermountain had not integrated these types of data in the EMR or the data still existed in an unstructured, free-text format. Therefore, entries of these data types were not used in the comparison of the patient-entered data using the CCR application and healthcare-provider-entered data in the EMR. Only the patient-entered data were available for these data categories. Another limitation is that the study relied on the patient-reported opinion on the usefulness of the continuity-of-care report (and the EMC)—we have no concrete proof that the continuity-of-care report was used for actual EMR updates. Therefore, the survey results showed only the assumed benefits of the EMCs and continuity-of-care reports, but not necessarily their actual benefits.

In addition, the study population was a select (or special) cohort of patient population at Intermountain. The users included only patients who were enrolled in the My Health project. We, therefore, have no idea how the findings would turn out to be if all the Intermountain patients were allowed to use the application. Therefore, although the application was not dependent on any clinical setting, because of the special group of the users, it might be difficult to know the application's general applicability and generality of the survey results.

The low uptake of the CCR application technology was a limitation in this survey. When My Health web portal users were contacted to inform them of the availability of the CCR application in My Healh, the majority of them indicated that they had not known that the application existed in My Health. Therefore, we believe that the marketing technique used did not have adequate impact in creating the needed awarenessit was the major problem. Email messages (to patients and HCPs), ‘teaser’ icon (implemented in the My Health) and fliers (to HCPs) were used to promote the CCR application. By mid-October 2008, the first promotional email message was sent out to 19 689 patients with active online access accounts in the My Health patient web portal. Eighty-three percent (n = 18 358) of the messages reached their destinations successfully, while others bounced back mainly due to inactive or erroneous email addresses. In addition, by the time of survey, some users of the CCR application had not supposedly used their EMC and/or continuity-of-care report to seek care from healthcare providers or to update their records in the EMR.

Conclusions

Patients found the EMC and continuity-of-care report to be useful tools to enhance the quality of care. Patients with multiple medical problems, prescription, appointments and allergies, and more specifically older patients (older 60 years) with multiple medical problems and prescriptions, were more likely to use the CCR application. Patients also perceived the EMC and continuity-of-care report to be more useful to identify missing patient information in the demographic data than in the other healthcare data categories. It was also shown that the patient is potentially an important source of quality control for their record in the healthcare-provider-maintained EMR, especially for the demographic and laboratory data. Observational studies of patients who use the EMC or continuity-of-care report in clinical care settings, and surveys of healthcare providers who receive the continuity-of-care report and/or use the EMC to deliver care would be helpful in determining the true benefits and uses of these documents.

Author contributions

C.O. conceived, planned, designed, developed and implemented the study, performed all the data analysis and results interpretation, wrote and reviewed the manuscript for publication. M.P., S.N., J.N., J.H., B.W., M.S. and R.S.E. participated in the study plan, design and development and reviewed the manuscript. R.S.E. chaired and supervised this research.

Ethical approval: The University of Utah Institutional Review Board (IRB) and the Intermountain IRB approved the study.

Acknowledgements

The authors thank all the patients for their participation in the user-satisfaction survey. We are grateful to the Intermountain personnel/teams: Lee Pierce, Chuck Lyon, John Hess, Jose Milla, ISSA and Perimeter personnel for their immense help with the database connectivity configurations to the enterprise data warehouse/clinical data repository. Thanks also goes to Babara Gatke and Traci Hastings of Intermountain for their coordination of the connectivity to the EMC databases.

References

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