How do opt-in versus opt-out settings nudge patients toward electronic health record adoption? An exploratory study of facilitators and barriers in Austria and France.

BACKGROUND: Electronic health records (EHR) are becoming an integral part of the health system in many developed countries, though implementations and settings vary across countries. Some countries have adopted an opt-out policy, in which patients are enrolled in the EHR system following a default nudge, while others have applied an opt-in policy, where patients have to take action to opt into the system. While opt-in systems may exhibit lower levels of active user requests for access, this contrasts with opt-out systems where a notable percentage of users may passively retain access. Thus, our research endeavor aims to explore facilitators and barriers that contribute to explaining EHR usage (i.e., actively accessing the EHR system) in two countries with either an opt-in or opt-out setting, exemplified by France and Austria. METHODS: A qualitative exploratory approach using a semi-structured interview guideline was undertaken in both countries: 1) In Austria, with four homogenously composed group discussions, and 2) in France, with 19 single patient interviews. The data were collected from October 2020 to January 2021. RESULTS: Influencing factors were categorized into twelve subcategories. Patients have similar experiences in both countries with regard to all facilitating categories, for instance, the role of health providers, awareness of EHR and social norms. However, we highlighted important differences between the two systems regarding hurdles impeding EHR usage, namely, a lack of communication as well as transparency or information security about EHR. CONCLUSION: Implementing additional safeguards to enhance privacy protection and supporting patients to improve their digital ability may help to diminish the perception of EHR-induced barriers and improve patients' health and commitment in the long term. PRACTICAL IMPLICATIONS: Understanding the differences and similarities will help to develop practical implications to tackle the problem of low EHR usage rates in the long run. This problem is prevalent in countries with both types of EHR default settings.

A holistic view of facilitators and barriers of electronic health records usage from different perspectives: A qualitative content analysis approach.

BACKGROUND: Electronic health records (EHR) are seen as a promising endeavour, in spite of policies, designs, user rights and types of health data varying across countries. In many European countries, including Austria, EHR usage has fallen short when compared to the deployment plans. OBJECTIVE: By adopting a qualitative approach, this research aimed to explore facilitators and barriers experienced by patients and physicians across the entire EHR usage process in Austria. METHOD: Two studies were conducted: In Study 1, discussions were held with four homogeneously composed groups of patients (N = 30). In Study 2, eight expert semi-structured interviews were conducted with physicians to gain insights into potential facilitators and barriers Austrian physicians face when utilising personal EHR. RESULTS: A wide range of barriers and facilitators were identified along the entire EHR usage spectrum, emerging on three different levels: the micro-level (individual level), the meso-level (level of the EHR system) and the macro-level (level of the health system). EHR literacy was identified as a booster to support EHR adherence. Health providers were identified as crucial gatekeepers with regard to EHR usage. CONCLUSION: The implications for mutual benefits arising out of EHR usage among the triad of health policymakers, providers and patients for both theory and practice are discussed.

The Credibility of Physician Rating Websites: A Systematic Literature Review.

OBJECTIVES: Increasingly, the credibility of online reviews is drawing critical attention due to the lack of control mechanisms, the constant debate about fake reviews and, last but not least, current developments in the field of artificial intelligence. For this reason, the aim of this study was to examine the extent to which assessments recorded on physician rating websites (PRWs) are credible, based on a comparison to other evaluation criteria. METHODS: Referring to the PRISMA guidelines, a comprehensive literature search was conducted across different scientific databases. Data were synthesized by comparing individual statistical outcomes, objectives and conclusions. RESULTS: The chosen search strategy led to a database of 36,755 studies of which 28 were ultimately included in the systematic review. The literature review yielded mixed results regarding the credibility of PRWs. While seven publications supported the credibility of PRWs, six publications found no correlation between PRWs and alternative datasets. 15 studies reported mixed results. CONCLUSIONS: This study has shown that ratings on PRWs seem to be credible when relying primarily on patients' perception. However, these portals seem inadequate to represent alternative comparative values such as the medical quality of physicians. For health policy makers our results show that decisions based on patients' perceptions may be well supported by data from PRWs. For all other decisions, however, PRWs do not seem to contain sufficiently useful data.

A Process Related View on the Usage of Electronic Health Records from the Patients' Perspective: A Systematic Review.

BACKGROUND: In recent years, there has been an increasing interest in electronic health record (EHR) systems and various approaches of encouraging acceptance. Multiple methods of EHR acceptance have been proposed. However, a systematic review of patient's perspectives of their role and challenges in processing EHR remains lacking. Moreover, so far, there has been little discussion about barriers and facilitators of EHR system acceptance and usage from the patients' perspective. METHODS: The study was reported according to the PRISMA statement. Six databases were systematically searched using keywords for articles from 2002-2020. We reviewed these data and used an inductive approach to analyse findings. RESULTS: A total of 36 studies met the inclusion criteria. Our systematic literature review results reveal a wide range of barriers and facilitators assigned to four distinct stages of EHR system usage: awareness, adoption, behaviour and perception, and consequences. Results were described in a narrative synthesis of the included empirical studies. DISCUSSION: Results underline the necessity to put a particular emphasis - but not exclusively - on the initial stage of awareness in the future. Further research in the field is therefore strongly recommended in order to develop tailored mediated communication to foster EHR system usage in the long run.

Awareness of and interaction with physician rating websites: A cross-sectional study in Austria.

To date, the digital assessment of service experiences represents a decisive process step of a feedback culture in numerous economic areas. In view of this digitalization of service assessments, the importance of Physician Rating Websites (PRWs) has also increased steadily in recent years. Even though these websites could be perceived as a powerful communication tool for the exchange of health specific information, the knowledge about whether and how different population segments use these portals has been limited so far. For this reason, our aim was to investigate the level of awareness regarding PRWs among the study population and to discover how users interact with this specific type of online portals. We performed an online survey including 558 participants. To ensure the attention and integrity of participants, attention checks were included in the questionnaire. Study participants who did not exceed the mentioned security levels were excluded from the study. Statistical analyses were carried out, using IBM SPSS Statistics 27. To illustrate the relationship between demographic variables and dependent variables, two tailed chi square tests were performed. Comparison of means and t-testing was used to investigate the relationship between psychographic variables and the dependent variables. In addition to that, the awareness levels regarding different rating portals were evaluated using descriptive methods. Our results suggest that the general awareness regarding PRWs is relatively high (75.6%, 423/558), especially among female (x21 = 9.880, P = .002), middle-aged (x29 = 26.810, P = .002), more highly educated (x24 = 19.038, P = .001), urban (x21 = 6.274, P = .012), digitally literate (t203 = 2.63, P = .009) individuals and particularly among respondents with a higher eHealth literacy (t203 = 2.37, P = .019). Even though more than three quarters of the respondents know that PRWs exist, compared to other rating platforms, they are only in the lower midfield. The upper ranks are taken by websites on which restaurant visits (98.9%, 552/558), hotel stays (97.7%, 545/558) or movies (95.5%, 533/558) can be rated. The most popular PRWs in Austria include Docfinder.at (31.3%, 175/558; 77.8%, 434/558) followed by the evaluation tools provided by Google.at (8.24%, 46/558; 70.3%, 392/558) and Herold.at (1.61%, 9/558; 44.8%, 250/558). In Austria, PRWs seem to be characterized by a high degree of interaction (89.2%, 498/558) with a wide variety of different types of interactions. While many respondents use PRWs to retrieve general information (83.2%, 464/558), there are significantly fewer who read physicians' reviews (60.9%, 340/558) and use this portal to select a physician (60.6%, 338/558). Respondents who have already rated a doctor themselves belong to the smallest group accounting for just 14.7% (82/558). Significant effects regarding the interaction with PRWs exist between different genders, ages, education levels, marital statuses, occupations and areas of living. In addition to that, respondents with better feelings towards the internet, greater digital literacy as well as a higher eHealth literacy were also characterized with a higher interaction rate regarding PRWs. According to the high level of awareness of and interaction with PRWs within our study population, PRWs appear to be a successful medium for health-related communication. Especially for female, middle-aged, more highly educated, urban and more technology savvy population segments, PRWs seem to represent an effective tool to support the health-specific decision-making process.

The Impact of Social Influence on the Intention to Use Physician Rating Websites: Moderated Mediation Analysis Using a Mixed Methods Approach.

BACKGROUND: Physician rating websites (PRWs) have become increasingly important in the cross-section between health and digitalization. Social influence plays a crucial role in human behavior in many domains of life, as can be demonstrated by the increase in high-profile influential individuals such as social media influencers (SMIs). Particularly in the health-specific environment, the opinion of family and friends has a significant influence on health-related decisions. However, so far, there has been little discussion about the role of social influence as an antecedent of behavioral intention to use PRWs. OBJECTIVE: On the basis of theories of social psychology and technology acceptance and theories from the economic perspective, this study aimed to evaluate the impact of social influence on the behavioral intention to use PRWs. METHODS: We conducted 2 studies by applying a mixed methods approach including a total of 712 participants from the Austrian population. The impact of social influence on the behavioral intention to use PRWs was investigated through linear regression and mediation and moderated mediation analysis using the PROCESS macro 4.0 in SPSS 27 (IBM Corp). RESULTS: The 2 studies show similar results. In study 1, an experiment, no direct effect of social influence on the behavioral intention to use PRWs could be detected. However, an indirect effect of social influence on the behavioral intention to use PRWs via credibility (b=0.572; P=.005) and performance expectancy (b=0.340; P<.001) could be confirmed. The results of study 2, a cross-sectional study, demonstrate that social influence seems to have a direct impact on the behavioral intention to use PRWs (b=0.410; P<.001). However, when calculating the proposed mediation model, it becomes clear that this impact may partly be explained through the 2 mediator variables-credibility (b=0.208; P<.001) and performance expectancy (b=0.312; P<.001). In contrast to the observed direct and indirect effect, neither demographic nor psychographic variables have a significant moderating impact on the influencing chain in study 2. CONCLUSIONS: This study provides an indication that social influence has at least an indirect impact on the behavioral intention to use PRWs. It was observed that this impact is exerted through credibility and performance expectancy. According to the findings of both studies, social influence has the potential to boost the use of PRWs. As a result, these web-based networks might be a promising future interface between health care and digitalization, allowing health care practitioners to gain a beneficial external impact while also learning from feedback. Social influence nowadays is not just limited to friends and family but can also be exerted by SMIs in the domain of PRW use. Thus, from a marketing perspective, PRW providers could think of collaborating with SMIs, and our results could contribute to stimulating discussion in this vein.

Promoting advance care planning via mediated health resources: A systematic mixed studies review.

OBJECTIVE: This systematic review aims (a) to analyze the message design of mediated advance care planning (ACP) interventions targeted at adults from a social marketing and health communication perspective, (b) to identify associations between message design and ACP outcomes, and (c) to illuminate gaps in the literature and highlight needs for future research. METHODS: A systematic mixed studies review was conducted. Empirical articles on mediated ACP interventions were systematically searched by using nine scientific databases with keywords related to ACP and mediated health communication. Data were synthesized using a sequential explanatory approach. RESULTS: A total of 11,824 titles were identified, of which 36 studies were included. Interventions disseminated ACP messages via video (36%), digital channels (22%), print (19%), a combination of channels (19%), and mass media (3%). The interventions used generic (42%), targeted (33%), and tailored (25%) communication. Overall, the evidence suggests that mediated ACP resources positively impact ACP Process and Action outcomes. CONCLUSION: This study has shown that mediated ACP interventions use various contents, formats, and structures to influence patient-centered ACP outcomes. Most message design techniques were associated with positive ACP outcomes. PRACTICE IMPLICATIONS: Mediated ACP resources are a promising approach to encourage ACP among adults.

What Patients Value in Physicians: Analyzing Drivers of Patient Satisfaction Using Physician-Rating Website Data.

BACKGROUND: Customer-oriented health care management and patient satisfaction have become important for physicians to attract patients in an increasingly competitive environment. Satisfaction influences patients' choice of physician and leads to higher patient retention and higher willingness to engage in positive word of mouth. In addition, higher satisfaction has positive effects on patients' willingness to follow the advice given by the physician. In recent years, physician-rating websites (PRWs) have emerged in the health care sector and are increasingly used by patients. Patients' usage includes either posting an evaluation to provide feedback to others about their own experience with a physician or reading evaluations of other patients before choosing a physician. The emergence of PRWs offers new avenues to analyze patient satisfaction and its key drivers. PRW data enable both satisfaction analyses and implications on the level of the individual physician as well as satisfaction analyses and implications on an overall level. OBJECTIVE: This study aimed to identify linear and nonlinear effects of patients' perceived quality of physician appointment service attributes on the overall evaluation measures that are published on PRWs. METHODS: We analyzed large-scale survey data from a German PRW containing 84,680 surveys of patients rating a total of 7038 physicians on 24 service attributes and 4 overall evaluation measures. Elasticities are estimated from regression models with perceived attribute quality as explanatory variables and overall evaluation measures as dependent variables. Depending on the magnitude of the elasticity, service attributes are classified into 3 categories: attributes with diminishing, constant, or increasing returns to overall evaluation. RESULTS: The proposed approach revealed new insights into what patients value when visiting physicians and what they take for granted. Improvements in the physicians' pleasantness and friendliness have increasing returns to the publicly available overall evaluation (b=1.26). The practices' cleanliness (b=1.05) and the communication behavior of a physician during a visit (b level between .97 and 1.03) have constant returns. Indiscretion in the waiting rooms, extended waiting times, and a lack of modernity of the medical equipment (b level between .46 and .59) have the strongest diminishing returns to overall evaluation. CONCLUSIONS: The categorization of the service attributes supports physicians in identifying potential for improvements and prioritizing resource allocation to improve the publicly available overall evaluation ratings on PRWs. Thus, the study contributes to patient-centered health care management and, furthermore, promotes the utility of PRWs through large-scale data analysis.

Advance directives in Austrian intensive care units: An analysis of prevalence and barriers.

PURPOSE: To investigate the prevalence of advance directives, healthcare proxies, and legal representatives in Austrian intensive care units (ICUs), and to explore barriers faced by adults engaged in the contemplation and documentation phase of the advance care planning process. METHODS: Two studies were conducted: (1) A 4-week multicenter study covering seven Austrian ICUs. A retrospective chart review of 475 patients who presented to the ICUs between 1 January 2019 and 31 January 2019 was conducted. (2) An interview and focus group study with 12 semi-structured expert interviews and three focus groups with 21 adults was performed to gain insights into potential barriers faced by Austrian adults planning medical decisions in advance. RESULTS: Of the 475 ICU patients, 3 (0.6%) had an advance directive, 4 (0.8%) had a healthcare proxy, and 7 (1.5%) had a legal guardian. Despite the low prevalence rates, patients and relatives reacted positively to the question of whether they had an advance directive. Patients older than 55 years and patients with children reacted significantly more positively than younger patients and patients without children. The interviews and focus groups revealed important barriers that prevent adults in Austria from considering planning in advance for potentially critical health states. CONCLUSION: The studies show low prevalence rates of healthcare documents in Austrian ICUs. However, when patients were asked about an advance directive, reactions indicated positive attitudes. The gap between positive attitudes and actual document completion can be explained by multiple barriers that exist for adults in Austria when it comes to planning for potential future incapacity.

What Predicts Patients' Willingness to Undergo Online Treatment and Pay for Online Treatment? Results from a Web-Based Survey to Investigate the Changing Patient-Physician Relationship.

BACKGROUND: Substantial research has focused on patients' health information-seeking behavior on the Internet, but little is known about the variables that may predict patients' willingness to undergo online treatment and willingness to pay additionally for online treatment. OBJECTIVE: This study analyzed sociodemographic variables, psychosocial variables, and variables of Internet usage to predict willingness to undergo online treatment and willingness to pay additionally for online treatment offered by the general practitioner (GP). METHODS: An online survey of 1006 randomly selected German patients was conducted. The sample was drawn from an e-panel maintained by GfK HealthCare. Missing values were imputed; 958 usable questionnaires were analyzed. Variables with multi-item measurement were factor analyzed. Willingness to undergo online treatment and willingness to pay additionally for online treatment offered by the GP were predicted using 2 multiple regression models. RESULTS: Exploratory factor analyses revealed that the disposition of patients' personality to engage in information-searching behavior on the Internet was unidimensional. Exploratory factor analysis with the variables measuring the motives for Internet usage led to 2 separate factors: perceived usefulness (PU) of the Internet for health-related information searching and social motives for information searching on the Internet. Sociodemographic variables did not serve as significant predictors for willingness to undergo online treatment offered by the GP, whereas PU (B=.092, P=.08), willingness to communicate with the GP more often in the future (B=.495, P<.001), health-related information-seeking personality (B=.369, P<.001), actual use of online communication with the GP (B=.198, P<.001), and social motive (B=.178, P=.002) were significant predictors. Age, gender, satisfaction with the GP, social motive, and trust in the GP had no significant impact on the willingness to pay additionally for online treatment, but it was predicted by health-related information-seeking personality (B=.127, P=.07), PU (B=-.098, P=.09), willingness to undergo online treatment (B=.391, P<.001), actual use of online communication with the GP (B=.192, P=.001), highest education level (B=.178, P<.001), monthly household net income (B=.115, P=.01), and willingness to communicate with the GP online more often in the future (B=.076, P=.03). CONCLUSIONS: Age, gender, and trust in the GP were not significant predictors for either willingness to undergo online treatment or to pay additionally for online treatment. Willingness to undergo online treatment was partly determined by the actual use of online communication with the GP, willingness to communicate online with the GP, health information-seeking personality, and social motivation for such behavior. Willingness to pay extra for online treatment was influenced by the monthly household net income category and education level. The results of this study are useful for online health care providers and physicians who are considering offering online treatments as a viable number of patients would appreciate the possibility of undergoing an online treatment offered by their GP.

Gender Differences in Searching for Health Information on the Internet and the Virtual Patient-Physician Relationship in Germany: Exploratory Results on How Men and Women Differ and Why.

BACKGROUND: Many studies have shown that women use the Internet more often for health-related information searches than men, but we have limited knowledge about the underlying reasons. We also do not know whether and how women and men differ in their current use of the Internet for communicating with their general practitioner (GP) and in their future intention to do so (virtual patient-physician relationship). OBJECTIVE: This study investigates (1) gender differences in health-related information search behavior by exploring underlying emotional, motivational, attitudinal as well as cognitive variables, situational involvement, and normative influences, and different personal involvement regarding health-related information searching and (2) gender differences in the virtual patient-physician relationship. METHODS: Gender differences were analyzed based on an empirical online survey of 1006 randomly selected German patients. The sample was drawn from an e-panel maintained by GfK HealthCare. A total of 958 usable questionnaires were analyzed. Principal component analyses were carried out for some variables. Differences between men (517/958) and women (441/958) were analyzed using t tests and Kendall's tau-b tests. The survey instrument was guided by several research questions and was based on existing literature. RESULTS: Women were more engaged in using the Internet for health-related information searching. Gender differences were found for the frequency of usage of various Internet channels for health-related information searches. Women used the Internet for health-related information searches to a higher degree for social motives and enjoyment and they judged the usability of the Internet medium and of the information gained by health information searches higher than men did. Women had a more positive attitude toward Web 2.0 than men did, but perceived themselves as less digitally competent. Women had a higher health and nutrition awareness and a greater reluctance to make use of medical support, as well as a higher personal disposition of being well-informed as a patient. Men may be more open toward the virtual patient-physician relationship. CONCLUSIONS: Women have a stronger social motive for and experience greater enjoyment in health-related information searches, explained by social role interpretations, suggesting these needs should be met when offering health-related information on the Internet. This may be interesting for governmental bodies as well as for the insurance and the pharmaceutical industries. Furthermore, women may be more easily convinced by health awareness campaigns and are, therefore, the primary target group for them. Men are more open to engaging in a virtual relationship with the GP; therefore, they could be the primary target group for additional online services offered by GPs. There were several areas for GPs to reinforce the virtual patient-physician relationship: the fixing of personal appointments, referral to other doctors, writing prescriptions, and discussions of normal test results and doctor's notes/certificates of health.

What explains usage of mobile physician-rating apps? Results from a web-based questionnaire.

BACKGROUND: Consumers are increasingly accessing health-related information via mobile devices. Recently, several apps to rate and locate physicians have been released in the United States and Germany. However, knowledge about what kinds of variables explain usage of mobile physician-rating apps is still lacking. OBJECTIVE: This study analyzes factors influencing the adoption of and willingness to pay for mobile physician-rating apps. A structural equation model was developed based on the Technology Acceptance Model and the literature on health-related information searches and usage of mobile apps. Relationships in the model were analyzed for moderating effects of physician-rating website (PRW) usage. METHODS: A total of 1006 randomly selected German patients who had visited a general practitioner at least once in the 3 months before the beginning of the survey were randomly selected and surveyed. A total of 958 usable questionnaires were analyzed by partial least squares path modeling and moderator analyses. RESULTS: The suggested model yielded a high model fit. We found that perceived ease of use (PEOU) of the Internet to gain health-related information, the sociodemographic variables age and gender, and the psychographic variables digital literacy, feelings about the Internet and other Web-based applications in general, patients' value of health-related knowledgeability, as well as the information-seeking behavior variables regarding the amount of daily private Internet use for health-related information, frequency of using apps for health-related information in the past, and attitude toward PRWs significantly affected the adoption of mobile physician-rating apps. The sociodemographic variable age, but not gender, and the psychographic variables feelings about the Internet and other Web-based applications in general and patients' value of health-related knowledgeability, but not digital literacy, were significant predictors of willingness to pay. Frequency of using apps for health-related information in the past and attitude toward PRWs, but not the amount of daily Internet use for health-related information, were significant predictors of willingness to pay. The perceived usefulness of the Internet to gain health-related information and the amount of daily Internet use in general did not have any significant effect on both of the endogenous variables. The moderation analysis with the group comparisons for users and nonusers of PRWs revealed that the attitude toward PRWs had significantly more impact on the adoption and willingness to pay for mobile physician-rating apps in the nonuser group. CONCLUSIONS: Important variables that contribute to the adoption of a mobile physician-rating app and the willingness to pay for it were identified. The results of this study are important for researchers because they can provide important insights about the variables that influence the acceptance of apps that allow for ratings of physicians. They are also useful for creators of mobile physician-rating apps because they can help tailor mobile physician-rating apps to the consumers' characteristics and needs.

Who uses physician-rating websites? Differences in sociodemographic variables, psychographic variables, and health status of users and nonusers of physician-rating websites.

BACKGROUND: The number of physician-rating websites (PRWs) is rising rapidly, but usage is still poor. So far, there has been little discussion about what kind of variables influence usage of PRWs. OBJECTIVE: We focused on sociodemographic variables, psychographic variables, and health status of PRW users and nonusers. METHODS: An online survey of 1006 randomly selected German patients was conducted in September 2012. We analyzed the patients' knowledge and use of online PRWs. We also analyzed the impact of sociodemographic variables (gender, age, and education), psychographic variables (eg, feelings toward the Internet, digital literacy), and health status on use or nonuse as well as the judgment of and behavior intentions toward PRWs. The survey instrument was based on existing literature and was guided by several research questions. RESULTS: A total of 29.3% (289/986) of the sample knew of a PRW and 26.1% (257/986) had already used a PRW. Younger people were more prone than older ones to use PRWs (t967=2.27, P=.02). Women used them more than men (χ(2) 1=9.4, P=.002), the more highly educated more than less educated people (χ(2) 4=19.7, P=.001), and people with chronic diseases more than people without (χ(2) 1=5.6, P=.02). No differences were found between users and nonusers in their daily private Internet use and in their use of the Internet for health-related information. Users had more positive feelings about the Internet and other Web-based applications in general (t489=3.07, P=.002) than nonusers, and they had higher digital literacy (t520=4.20, P<.001). Users ascribed higher usefulness to PRWs than nonusers (t612=11.61, P<.001) and users trusted information on PRWs to a greater degree than nonusers (t559=11.48, P<.001). Users were also more likely to rate a physician on a PRW in the future (t367=7.63, P<.001) and to use a PRW in the future (t619=15.01, P<.001). The results of 2 binary logistic regression analyses demonstrated that sociodemographic variables (gender, age, education) and health status alone did not predict whether persons were prone to use PRWs or not. Adding psychographic variables and information-seeking behavior variables to the binary logistic regression analyses led to a satisfying fit of the model and revealed that higher education, poorer health status, higher digital literacy (at the 10% level of significance), lower importance of family and pharmacist for health-related information, higher trust in information on PRWs, and higher appraisal of usefulness of PRWs served as significant predictors for usage of PRWs. CONCLUSIONS: Sociodemographic variables alone do not sufficiently predict use or nonuse of PRWs; specific psychographic variables and health status need to be taken into account. The results can help designers of PRWs to better tailor their product to specific target groups, which may increase use of PRWs in the future.