Data for this study was collected years ago, but we just never had the time to sit down and analyze it properly until last year. But we somehow managed to squeeze it into the pandemic schedule at last, and now it’s published!
The data was collected through an oline survey which was accessible to everyone who logged into the Swedish patient accessible electronic health record (PAEHR) Journalen. The survey had lots of questions, and part of it was the 10 System Usability Scale (SUS) items. We had 2587 unique users complete the survey.
Questions in Swedish
I think that I would like to use this system frequently.
I think that I would like to use Journalen regularly
Jag tror att jag vill använda ”Journalen” regelbundet
I found the system unnecessarily complex.
I found Journalen unnecessarily complex
Jag anser att ”Journalen” är mer komplicerad än vad den behöver vara
I thought the system was easy to use.
I thought Journalen was easy to use
Jag anser att ”Journalen” är lätt att använda
I think that I would need the support of a technical person to be able to use this system.
I think that I would need the support of a technical person to be able to use Journalen
Jag tror att jag skulle behöva personlig teknisk support för att kunna använda ”Journalen”
I found the various functions in this system were well integrated.
I found the various functions in the system were well integrated
Jag anser att de olika funktionerna i ”Journalen” fungerar väl tillsammans
I thought there was too much inconsistency in this system.
I thought there was too much inconsistency in this system
Jag anser att det finns många delar i ”Journalen” som inte är konsekventa
I would imagine that most people would learn to use this system very quickly.
I would imagine that most people would learn to use Journalen very quickly
Jag tror att de flesta skulle kunna lära sig att använda ”Journalen” ganska snabbt
I found the system very cumbersome to use.
I found Journalen very cumbersome to use
Jag anser att ”Journalen” är besvärlig att använda
I felt very confident using the system.
I felt very confident using Journalen
Jag känner mig väldigt säker och trygg (på vad jag gör) när jag använder ”Journalen”
I needed to learn a lot of things before I could get going with this system.
I needed to learn a lot things before I could get going with Journalen
Jag behöver lära mig ganska mycket innan jag kan börja använda ”Journalen”
The SUS questions and our modifications
The total mean score for all respondents to the SUS items was 79.81 (SD 14.25), which corresponds to a system with good usability. According to Bangor and colleagues’ thorough evaluation of the SUS, a system needs to score above 70 to be considered at least passable. Better systems will score in the high 70s to high 80s, and scores over 90 indicate a truly superior system.
Now, the SUS scale will give you an indication of how good or bad a system is, but it will not tell you much about what usability problems your users are actually struggling with. Therefore, we also asked the study participants to comment on the usability in a free-text answer. We are currently working on finalizing the analysis of these answers, and they are VERY interesting!
If it’s one thing I’m struggling with that has been even more difficult during the pandemic, it’s finding the balance between work and rest. As I’ve been working exclusively from home for the past year, this has been increasingly challenging. When there’s not much else to do – work has taken over most of my time. Even now, in the middle of summer, last week of my vacation – I can’t help but planning for activities starting up in August…
It doesn’t help of course when that long overdue paper finally gets accepted and you need to do proof reading within two days… and then again a week or so later. Or funding applications with deadlines. Or a thesis arriving in the mail that have agreed to review. But I’m also blessed with work that feels really rewarding and fun – I just don’t want it to take over EVERYTHING.
As of April 5th 2021, a new US policy is requiring immediate release of records to patients. The rule require US healthcare providers to give patients access to all the health information in their electronic medical records without charge.
In Sweden, we can access most of the information from our electronic health records through the national patient portal 1177.se – and there are national recommendations stating that all citizens should have immediate online access to all the information documented about them in healthcare, but the recommendations are not enforced and it’s up to each healthcare provider to decide what patients have access to and not. Still, Swedish patients probably have access to a lot more than many others, but it is at the goodwill of healthcare providers.
The new US rule will make it possible to fine healthcare providers or EHR vendors that block patients from access information. This of course sharpens the rule and hopefully will speed up the implementation.
Another major difference between the Swedish context and the US is that the new legislation also stipulates that people should be able to download their data to third party digital applications (apps) and aggregate all their health records into their digital platform of choice. This should be implemented by October 2022, allowing people to share health information with anyone involved in their care. In Sweden, this is out of the question. Similar solutions have be proposed, but have consistently been deemed not secure enough by the Swedish Authority for Privacy Protection. In fact, a function that would allow patients to add a person of their own choosing to have access to parts or all of their EHR was implemented in the Swedish “Journalen”, but removed after the Swedish Authority for Privacy Protection found it illegal. It will be interesting to follow the evolution in Sweden and internationally as patients are increasingly demanding and gaining access to their health information.
Earlier this year, I was one of the co-authors for a BMJ editorial on the new US regulation:
Salmi, L., Blease, C., Hägglund, M., Walker, J., DesRoches, C. (2021). US policy requires immediate release of records to patients. BMJ. British Medical Journal, 372
The book is written in Swedish, and consists of 31 chapters that cover everything from terminologies and interoperability, to ethics and sustainability. Our chapter focuses on person-centered care (PCC) and the relationship with eHealth in general and patients access to the electronic health record specifically. PCC aims optimize the care process and its goals by starting from what is important and important to the patient regarding their health, quality of life and goals, as well as healthcare professionals’ expertise, experience and guidelines / procedures regarding evidence-based care and treatment. Key components in PCC includes that information and knowledge is shared by all stakeholders (including the patient), and that the patient can actively participate in their care, decision-making, and documentation.
We discuss how patients access to their records (including ‘open notes’), has potential to support – or may even be pre-requisits to – PCC, but that the technical tools themselves are not enough. Patients who have access to information often report positive outcomes, but PCC requires that healthcare professionals are also engaged in a dialogue and shared decision making. This requires a change in practice too, and a willingness to collaborate in new ways.
During 2020, I joined forces with researchers all over Sweden with a special interest in digital care, specifically online consultations. We started a research network to exchange experiences, coordinate research and share results, both within the network and to other interested.
It’s really rewarding to bounce ideas, hear what others are working on and get feedback on your own work. The network is very interdisciplinary and with perspectives ranging from patient empowerment, to usability, to reimbursement and financial aspects it’s discussions are always very challenging and exciting. 2021 we will start a series of lunch webinars, where researchers presents interesting studies. Most will be held in Swedish.
19th of February 12.45-13.00 is our first webinar, where professor Åsa Cajander, Uppsala University, will present a study on how a chat function affected the work environment of healthcare professionals at 1177. The webinar will be held in Swedish, and is open for anyone to join. Find out more and sign up here.
Cajander, Å., Larusdottir, M. & Hedström, G., The effects of automation of a patient-centric service in primary care on the work engagement and exhaustion of nurse. Qual User Exp 5, 9 (2020). (open Accesshttps://doi.org/10.1007/s41233-020-00038-x)
2020 was a year like no other. It’s been tough. I’ve managed to stay clear of the virus myself (and my closest family), but the necessary restrictions have been hard on us all. At the same time, it’s been a great year for me professionally and personally. It started off with renting out our house in Sweden and returning to Boston for a second semester in Brookline and at OpenNotes. Little did we know then that just a few months later we’d be confined to our small apartment, homeschooling and going for daily walks around the parks of the Emerald Necklace – pondering whether we would be able to safely return to Sweden as planned in July.
But everything worked out and we have now been back home in Uppsala for 6 months. So, what happened professionally during this 2020?
A lot of hard work writing funding applications paid off and two new international research projects were funded!
Peute, L., Lichtner, V., Baysari, M., Hägglund, M., Homco, J. et al.(2020). Challenges and Best Practices in Ethical Review of Human and Organizational Factors Studies in Health Technology: a Synthesis of Testimonies. IMIA Yearbook of Medical Informatics
We transformed courses to online teaching and I’ve been the course director for two new courses at Uppsala University (and I was awarded the title Excellent Teacher!):
I also recruited two new PhD students (Annika Bärkås and Irene Muli) who will be working with us in our ongoing research projects around patients access to their electronic health records and online consultations in primary care. The latter topic is also the focus in our new research network where researchers from all over Sweden exchange ideas and collaborate.
I’ve now spent almost a whole year with the OpenNotes research group at Beth Israel Deaconess Medical Center in Boston. We had only planned for 6 months, but plans are made to be changed, and we decided to stay until the end of June instead.
Needless to say, the last 3 months were not exactly what we had hoped for… but what a learning experience. The children are now not only fluent in English, they are also fluent in Canvas, google classroom, online meetings and sharing documents online. I have learned that sometimes things cannot be controled, and you have to adapt to uncertainty. And we have learned as a family that yes, we can spend almost 24 hours a day in a small apartment for 3 months without killing each other. Which is a good thing to know I guess.
It has also been a very productive year for me as a researcher. The main goal I had when coming here was to establish a more long-term collaboration with the OpenNotes team and to build a foundation that would enable an international platform for research around patients access to their electronic health records – or open notes. In the past two weeks, we have learned that we have been granted two major funding proposals that will enable us to do just this!
Therefore, although this time next week we will be on the train to Newark airport (an adventure in itself) I am very confident that this is not only the end of my stay here in Boston, but the start of something new and very exhiting!
Maria Hägglund is an Associate Professor in Health Informatics at Uppsala MedTech Science and Innovation, Uppsala University, Sweden. She has a PhD in Medical Informatics and worked at Karolinska Institutet 2009-2019 before returning home to Uppsala.