Motivating, Influencing, and Persuading Patients through Personal Health Records: A Scoping Review

Abstract

The manuscript is an evaluative review of the literature pertaining to personal health records (PHRs). The primary focus was on revealing their potential to function as persuasive tools and their efficiency in this role.

We demonstrated the ways in which PHRs could motivate, influence, and persuade patients in their adoption of target health behaviors associated with disease and medication management. We based this review on the theoretical framework of captology by B. J. Fogg and colleagues (1998) and the York methodological framework by Arksey and O’Malley (2005). The final sample of studies for review included 22 articles that met eligibility criteria and were retrieved from the SciVerse Scopus database (1999–present). Findings of this review were mixed. Some studies provided evidence that patients found PHRs easy to use and useful. The patients’ self-efficacy and motivation in managing health conditions increased as a result of receiving personalized recommendations, guidance, and decision support generated in PHRs. Other studies, however, demonstrated the PHRs’ lack of efficiency associated with the target behavior change. We explain the mixed findings by access to an unbalanced pool of study designs as well as the breadth of the applied theoretical framework of captology. We suggest future research in a more targeted direction, for example, focusing on the evidence of the efficiency of reminders as means for motivation, influence, and persuasion.

Key words: personal health records (PHRs), health information technology, persuasive technology, behavior change

在troduction

The concept of computers as persuasive technologies (called “captology”) was first introduced as a new area of inquiry at the CHI ’97 Conference on Human Factors in Computing Systems. It included the view of computers as technologies that could motivate, influence, and persuade users toward adoption of target behaviors.1The trend of applying the framework of computers as persuasive technologies, although relatively young, has been popular in various domains, including commerce, safety, environmental conservation, preventative healthcare, fitness, disease management, personal finance, and many more.2Persuasive technologies have been found to be efficient in helping users set, achieve, and maintain their goals. These findings, although promising, have not been consistent; therefore, more research is needed to understand their full potential.

One recent definition of personal health records (PHRs) addresses them as “a set of computer-based tools that allow people to access and coordinate their lifelong health information and make appropriate parts of it available to those who need it.”3The design of modern PHRs allows for their interoperability with electronic health records/electronic medical records (EHRs/EMRs), web applications, and external devices.4This interoperability makes computer technology an integral characteristic of PHRs. Drawing on associations between computers as persuasive technologies and PHRs as computer-based tools, we suggest the possibility of considering PHRs as persuasive technologies as well.

According to the Functional Triad framework proposed by Fogg, computers, when functioning as persuasive technologies, can take on the roles of persuasive tools, media, and social actors.5在each case, various strategies and techniques could be employed to make computers persuade, for example, by providing simulations, providing social support, or modeling attitudes and behaviors. Although a holistic view of PHRs as persuasive tools, media, and social actors could be a valuable research direction to pursue, due to the time constraints and the amount of effort required, in this review we looked for the evidence of PHRs as persuasive tools only. Accordingly, we focused on the literature that discussed how PHRs could provide tailored or personalized information, guidance, and decision support for disease and medication management.

This analysis includes studies describing electronic PHRs that are both standalone and interoperable with web applications and external devices. For conciseness, we refer to them simply as PHRs. Since the analysis focused on PHRs in the medical domain, we refer to PHR users as “patients.”

Methods

这篇审查是根据Arksey和O’Malley提出的范围范围的范围范围进行审查进行的。6我们包括以下阶段:识别研究问题;相关研究的识别;选择研究;包括在纳入研究中的信息图表;并整理,总结和报告审查结果。我们没有包括可选的第六阶段,因为本次评论不需要与利益相关者进行咨询。

Research Questions

The main goals of this review were to demonstrate the scope of current research on (1) whether or not existing PHRs were capable of functioning as persuasive tools by delivering to their users tailored and personalized health information, guidance for disease and/or medication management, and health-related decision support; and (2) whether or not the presence of such features had a positive effect on patients’ sense of empowerment and adoption of target health behaviors associated with disease and medication management.

Identification of Relevant Studies

SciVerse Scopus (1999–present) became the database of choice. It offered access to research from several fields, including engineering, consumer health informatics, human-computer interaction, psychology, and other areas. Such variety of disciplines was important for offering diverse perspectives on the topic of PHRs as persuasive tools. Articles, conference papers, reports, business articles, and news media reports were included in searches. To obtain more precise search results, we excluded the “Physical Sciences” category from the available titles since we saw no potential overlap in themes between this subject and the current review. Combinations of the following search terms were used: (1) PHRs or personal health records and (2) monitoring or tracking devices,7personalized or tailored information, and decision-making or decision support.

Selection of Studies

During the review of titles and abstracts of the identified citations, the author applied a screening algorithm that comprised the following inclusion criteria. Studies identified as relevant for a full-text review were those describing (1) either existing PHRs or their working prototypes; (2) the ways in which PHRs provided tailored information or recommendations about patients’ health conditions, guidance for disease or medication management, and decision support; (3) any PHR types, whether standalone, integrated, or tethered. Additionally, we included studies that were published in the English language only, but the studies could have been conducted in or outside of the United States.

Despite the fact that the quality of the studies was not among the inclusion criteria, we still assessed the main characteristics of each study to understand the nature of the research methods used and the quality of the findings reported. We excluded studies that described only frameworks or concepts of PHRs, studies that talked about patient portals even if referred to as PHRs, and studies in languages other than English.

Through multiple iterations of applying the inclusion criteria to the review of titles and abstracts, we identified the most relevant studies, obtained their full-text versions, and reviewed the studies in full. To finalize the sample, the same inclusion and exclusion criteria that were applied at the title and abstract review stage were used at the full-text review stage.

Charting the Information

A spreadsheet was used to create a tabular presentation of the information extracted from each full-text article. General citation information (e.g., country of research origin, disciplines, publication date and type, and study design); characteristics of PHRs (e.g., PHR types, support of a special health condition, examples of devices or applications interoperable with PHRs, and the ability to send alerts, reminders, and/or notifications); examples of information personalization, guidance, or decision support; findings on PHRs’ efficiency including patients’ opinions; and overall findings were recorded as information that could be useful for answering research questions.

Collating, Summarizing, and Reporting Results

To provide a description of the scope of the literature on the topic, the following information relevant to this review was extracted: (1) examples of PHRs as persuasive tools; and (2) evidence of PHRs’ efficiency as tools for persuasion and motivation, including user attitudes about PHRs’ usefulness and ease of use. Such categorization allowed for the presentation of review findings in a structured way.

Results

Overview of Results

最初的文献搜索产生了147个记录。由于Sciverse Scopus允许访问文章的参考列表,而不必首先获得文章的全文,因此我们筛选了潜在相关文章的参考列表,并确定了11个记录。从列表中删除重复后,读取了154个记录的标题和摘要,并应用了预定的纳入标准后,将45篇文章确定为潜在的相关性。在获得45篇全文文章并阅读后,由于不符合纳入标准而排除了23篇文章,而定性分析中包括22篇文章(见参见Figure 1)。

General Citation Information

Most studies were conducted in the United States. Three studies represented collaboration of researchers from various countries, including Greece, Germany, Turkey, Austria, Spain, France, Italy, and Sweden;8–10one study was conducted in the Netherlands;11one was conducted in China;12one was conducted in Germany;13and one was conducted in Canada.14审查中包括的一系列来源导致了许多学科的观点,例如人类计算机互动,卫生专业,计算机研究,生物信息学和医学信息学。尽管有指定的搜索时间,但1999年至今,本综述中包括的所有研究均在过去八年(2005年至前词)中进行,这可能表明对此事的研究兴趣增加。十八项研究作为期刊文章发表,在会议上提出了三项研究,并在一本书中发表了一项研究。15

During the selection of studies, we did not give any special preference to research of particular designs. As a result, the final sample of studies for review represented both qualitative and quantitative works. Specifically, it included four randomized control, clinical, and cluster trials16–19and nineteen qualitative articles, five of which were purely descriptive. Randomized control trials are a popular study design for testing health technologies. The key principle of this type of study—random selection of study participants—helps to reduce bias in the obtained results. Observational studies, on the other hand, provide access to larger and more diverse samples of participants, which allows for the collection of multiple perspectives. Considering benefits and drawbacks of each methodological approach, we particularly pursued the benefits of including observational studies to complement the clinical trials. Due to the applied search strategies, the final sample did not contain any quantitative studies without control groups.

Characteristics of PHRs

The PHRs described in the studies were represented by the following naming conventions: PHRs,20–27电子PHR,28–31web/Internet-based PHRs,32–37personal medical records,38, 39a teen-oriented PHR,40and Internet-based personally controlled health records.41,42大多数phr被成年人和指定使用only two by children and teenagers.43, 44Some PHRs were designed to assist during the management of certain health conditions, for example, cardiovascular conditions,45–47chronic obstructive pulmonary disease (COPD),48special healthcare needs,49,50癌症,51, 52和糖尿病,53–55while others were not associated with support or guidance for any health condition.56–60

在almost all of the reviewed studies, PHRs were interoperable with EHRs/EMRs. Other examples of interoperability included integration with mobile phones,61–65patient portals,66–68and sensor and monitoring devices.69–73The functionality of most PHRs allowed them to send reminders or alerts to patients or their physicians and bring health-related situations to their attention. Seven PHRs sent reminders about medication intake and drug interactions,74–76alerts based on the readings from monitoring devices,77, 78提醒有关适当筛查和疫苗接种的提醒,79, 80或通过个人电子邮件或短信给手机的消息,告知患者需要登录他们的PHR并访问重要的时间敏感信息。81, 82Eight studies discussed reminders and alerts for due screenings and vaccinations83–86and personal recommendations87–90sent to patients within PHRs. Seven PHRs also sent alerts to patients’ providers calling for their involvement in patient care.91–97在六项审查的研究中,PHR没有这种功能,或者研究没有提及。98–103

PHR作为有说服力的工具的示例

审查的文章报道了多个示例,说明了PHR如何充当有说服力的工具。八项研究描述了PHR,这些PHR以监视和传感器设备的读数产生的健康风险评估的形式传递了个性化信息104–106or from the patient’s answers to health risk assessment surveys.107–111Six studies talked about PHRs that provided recommendations, guidelines, and advice on disease management.112–117Examples of support and guidance for medication management was described in eight studies118–125and included drug intake directions and tracking, such as dosage and scheduling. Eight of the described PHRs provided the patients with links to educational resources on health and disease management.126–133七篇文章谈到了PHR,提供了与健康风险评估调查结果相关的决策支持,134–136readings from monitoring devices,137–139and analysis of patient information stored in a PHR.140Most of the PHRs provided personalized information in a combination of ways, for example, health risk assessment and appropriate decision support,141personalized health risk assessment and guidelines for disease management,142or decision support and advice on disease management accompanied by links to educational resources.143

Efficiency of PHRs as Persuasive Tools

从审查问题研究的发现cy of PHRs as persuasive tools were mixed. Qualitative studies reported positive patient feedback about the ease of use and usefulness of PHRs. Through focus groups and questionnaires, patients expressed their preferences for access to personalized over general health information,144, 145and the need for timely feedback about their health conditions accompanied by guidance on what to do.146Patients reported that PHRs were making them act on the coming information, which increased their sense of empowerment,147–149increased their motivation,150–152and promoted positive behavior change.153在cases where the primary users of PHRs were children and teenagers, their feedback about PHRs functioning as persuasive tools was also positive. Slagle et al. reported that children took more responsibility for medication administration upon receiving a call to action in the form of a message.154Chira et al. reported that teenagers were interested in better understanding their overall health state by referring to information generated in a PHR and delivered via mobile phones.155患者强烈称赞与外部设备和系统的PHR互操作性。PHR与监视设备集成的价值被视为有助于挽救生命并大力帮助院前分类的功能。156Patients were supportive of the fact that providers could obtain timely access to patients’ health information thanks to reminders and notifications and could engage in different levels of care delivery.157

只有少数定性研究报告了缺乏PHR的效率。在Wiljer等人的研究中,尽管患者发现PHR易于使用,但他们并未证明其自我效能得分的变化。158Hess et al. found that despite the fact that a PHR provided patients with the sense of empowerment by offering access to health self-management tools, the actual number of patient visits to the clinic or the number of phone calls did not change.159Additionally, user testing of PHRs revealed the need for usability improvements regarding some of the PHRs’ features and functionality.160

Studies in which PHRs were evaluated through randomized controlled trials revealed their low efficiency as persuasive tools. Sequist et al. found that electronic outreach via a PHR produced an initial increase in colorectal cancer screening rates among patients but that the increase was not sustained.161 Bourgeois et al. found that the use of a PHR did not have a statistically significant effect on patients’ knowledge, beliefs, and behaviors associated with influenza prevention.162 Grant et al. found that the use of a PHR specific to diabetes mellitus might have improved the process of diabetes mellitus care; however, low rates of account registration limited the effect of the intervention.163 Wright et al. found that efficiency of reminders sent via a PHR was fragmented but potentially helpful to improve patient self-efficacy.164 The summary of findings is included inTable 1.

Discussion

A scoping review of research on PHRs’ efficiency as persuasive tools was conducted in accordance with the theoretical framework of captology and the York framework methodology and identified a diversity of studies and research approaches. Through the charting process, we created a detailed description of the literature that could be useful for future research on studying the motivational and design characteristics of PHRs. This review also contributes to the methodology of scoping reviews by offering a description of our approach to critically appraising the relevant literature.

结果从evide提供的综述文章nce that PHRs, as computer-based tools, are capable of motivating and persuading patients to adopt target health behaviors associated with disease and medication management. Motivation and persuasion was achieved through tailored health-related information and personalized recommendations, guidance, and decision support delivered within or with the assistance of PHRs. Effects of such influence, however, were not consistent throughout the reviewed studies. Findings from almost all qualitative studies demonstrated patients’ overall positive attitudes related to the efficiency and usefulness of PHRs. Randomized controlled trial studies, on the other hand, provided evidence that PHRs did not have a significant impact on patients’ health behaviors or did not result in increases in patients’ self-efficacy. Despite their inconsistency, we consider findings from each methodological approach equally valuable to the research questions as they provide different perspectives on the phenomena under investigation. If anything, this review demonstrated that a more balanced sample of studies for review is needed to provide a full scope of the existing evidence of PHRs’ efficiency as persuasive tools.

All but six of the reviewed articles described instances in which alerts, notifications, or reminders were generated with the assistance of or within PHRs and were used as a means of communicating health-related information to patients or their healthcare providers. Some of these alerts were delivered internally via PHRs, and some were delivered externally via mobile phones or personal e-mail. In half of the studies in which PHRs were not found to significantly change patients’ target health behaviors, health-related reminders were delivered within PHRs. We hypothesize that when health-related reminders and alerts are delivered internally within PHRs, they could be easily overlooked by patients, especially if the patients opt not to log into PHRs for a certain amount of time. Therefore, in order to bring patients’ attention to time-sensitive information generated within or with the assistance of PHRs, the information should be delivered outside of the system, for example, in the form of alerts or reminders sent to mobile devices or e-mail accounts.

This finding contributes to the idea that the efficiency of PHRs as a persuasive tool depends on their level of interoperability. When PHRs are interoperable with other systems or devices, they become a powerful tool; when PHRs function as standalone accounts, they have limited value. Interoperability with mobile devices that enables a PHR to send alerts, reminders, or notifications to patients even when they are not using the PHR could trigger necessary actions associated with disease or medication management. Interoperability of PHRs with electronic health systems could allow for easier information exchange between patients and providers, and interoperability with monitoring and tracking devices could significantly improve critical healthcare by allowing patients or healthcare providers to foresee and prevent serious health incidents.

Limitations and Future Research

Findings of this scoping review should be interpreted with a number of limitations taken into account. First, the final sample of the reviewed research was lacking non-control-group quantitative studies that addressed PHRs’ efficiency as persuasive tools. Adding studies of this type would balance the body of available evidence and avoid the possibility of dealing with conflicting findings. Other factors that could have limited the value of the findings were that (1) only one database was searched, and only certain search strategies were applied; (2) this scoping review provided a glimpse of the literature at only a single moment in time; (3) this review did not include follow-up findings from the studies that described PHR prototypes; therefore, information about the efficiency of the final products was not included; and (4) articles published only in the English language were reviewed.

One of the main reasons that could have contributed to the mixed findings is the breadth of the theoretical framework of captology that was used in this study. Even though we applied only one aspect of this framework, namely, computers as persuasive tools, it still was too broad since included multiple characteristics of PHRs. For that reason, focusing on separate, smaller elements of this framework, for example, the role of reminders within PHRs or the role of personalized guidance in conforming to the treatment plan, would be a more appropriate approach to the analysis of PHRs as persuasive tools. In order to evaluate the consistency of the impact of PHRs as persuasive tools on changes in patients’ health, reviews of longitudinal studies are also needed.

Dinara Saparova, MA, is a PhD student at the University of Missouri’s School of Information Science and Learning Technologies in Columbia, MO.

Notes

1.Fogg,B。“捕捉:将计算机作为有说服力的技术的研究。”在Extended Abstracts of CHI’97. New York; ACM Press, 1997, p. 129.

2.Fogg,B.,G。Cuellar和D. Danielson。“Motivating, Influencing, and Persuading Users: An Introduction to Captology.” In A. Sears and J. A. Jacko (Editors),人力计算机互动手册:基础,不断发展的技术和新兴应用. New York: Taylor & Francis, 2009, 133–46.

3.Markle Foundation.Americans Overwhelmingly Believe Electronic Personal Health Records Could Improve Their Health. June 2008. Available athttp://www.markle.org/sites/default/files/ResearchBrief-200806.pdf(2011年11月17日访问)。

4.Kotz, D. “A Threat Taxonomy for mHealth Privacy.” Proceedings of the Third International Conference on Communication Systems and Networks, 2011. Available athttp://www.cs.dartmouth.edu/~dfk/papers/kotz-mHealth-threats.pdf.

5.Fogg, B. “Persuasive Computers: Perspectives and Research Directions.” In CHI ’98: Proceedings of the ACM SIGCHI Conference on Human Factors in Computing Systems, April 18–23, 1998, 225–232. Available athttp://wesrac.usc.edu/wired/bldg-7_file/Persuasive_Computers.pdf.

6.Arksey, H., and L. O’Malley. “Scoping Studies: Towards a Methodological Framework.”国际社会研究方法学杂志8, no. 1 (2005): 19–32.

7.我们使用了搜索查询“监视和跟踪设备”,因为这些设备被发现可以帮助患者更有效地实现其健康目标并提高了自我效能感。Fogg,B.,G。Cuellar和D. Danielson。“激励,影响和说服用户:捕育学简介”,113-114。

8.Chronaki,C。等。“可植入除颤器患者的健康管理中的互操作性挑战。”心脏病学计算37(2010):225–28。

9.Yang, M., et al. “iCARDEA—An Approach to Reducing Human Workload in Cardiovascular Implantable Electronic Device Follow-Ups.”Computing in Cardiology37(2010):221–24。

10.Rubel, P., et al. “Toward Personal eHealth in Cardiology: Results from the EPI-MEDICS Telemedicine Project.”Journal of Electrocardiology38, no. 4 (2005): 100–106.

11.Tuil,W。等。“以患者为中心的护理:在IVF实践中使用在线个人病历。”Human Reproduction21日,没有。11(2006): 2955 - 59。

12.Wang, M.-Y., P. Tsai, J. Liu, and J. Zao. “Wedjat: A Mobile Phone Based Medicine In-take Reminder and Monitor.”2009 Ninth IEEE International Conference on Bioinformatics and Bioengineering Proceedings, June 22–24, 2009. Available athttp://ieeexplore.ieee.org/stamp/stamp.jsp?tp=&arnumber=5211229.

13.Helmer, A., et al. “A Sensor-Enhanced Health Information System to Support Automatically Controlled Exercise Training of COPD Patients: Concept and Prototype.”第四届国际医疗保健普遍计算技术会议(Pervasive Health)会议记录,2010年. Available athttp://ieeexplore.ieee.org/stamp/stamp.jsp?tp=&arnumber=5482235&tag=1.

14.Wiljer, D., et al. “The Anxious Wait: Assessing the Impact of Patient Accessible EHRs for Breast Cancer Patients.”BMC Medical Informatics and Decision Making10, no. 46 (2010).

15.Sands, D., and J. Halamka. “PatientSite: Patient-Centered Communication, Services, and Access to Information.” In R. Nelson and M. J. Ball (Editors),Consumer Informatics: Applications and Strategies in Cyber Health Care. New York: Springer, 2004, 20–32.

16.Sequist, T., A. M. Zaslavsky, G. A. Colditz, and J. Z. Ayanian. “Electronic Patient Messages to Promote Colorectal Cancer Screening: A Randomized Controlled Trial.”Archives of Internal Medicine171, no. 7 (2011): 636–41.

17.Bourgeois, F., W. W. Simons, K. Olson, J. S. Brownstein, and K. D. Mandl. “Evaluation of Influenza Prevention in the Workplace Using a Personally Controlled Health Record: Randomized Controlled Trial.”Journal of Medical Internet Research10, no. 1 (2008): e5.

18.Grant, R., et al. “Practice-Linked Online Personal Health Records for Type 2 Diabetes Mellitus: A Randomized Controlled Trial.”Archives of Internal Medicine168, no. 16 (2008): 1776–82.

19.。赖特,et al . "随机对照试验Health Maintenance Reminders Provided Directly to Patients through an Electronic PHR.”Journal of General Internal Medicine27, no. 1 (2012): 85–92.

20.Chronaki,C。等。“可植入除颤器患者的健康管理中的互操作性挑战。”

21.Yang, M., et al. “iCARDEA—An Approach to Reducing Human Workload in Cardiovascular Implantable Electronic Device Follow-Ups.”

22.Rubel, P., et al. “Toward Personal eHealth in Cardiology: Results from the EPI-MEDICS Telemedicine Project.”

23.Wang, M.-Y., P. Tsai, J. Liu, and J. Zao. “Wedjat: A Mobile Phone Based Medicine In-take Reminder and Monitor.”

24.Wiljer, D., et al. “The Anxious Wait: Assessing the Impact of Patient Accessible EHRs for Breast Cancer Patients.”

25.“New-Age PHR Comes with Decision-Support, Multiple Opportunities for DM.”Disease Management Advisor12,不。12(2006):140–42。

26.Fonda, S., R. J. Kedziora, R. A. Vigersky, and S. E. Bursell. “Combining iGoogle and Personal Health Records to Create a Prototype Personal Health Application for Diabetes Self-Management.” Telemedicine and e-Health 16, no. 4 (2010): 480–89.

27.Hess, R., et al. “Exploring Challenges and Potentials of Personal Health Records in Diabetes Self-Management: Implementation and Initial Assessment.”Telemedicine and e-Health13, no. 5 (2007): 509–17.

28.Helmer, A., et al. “A Sensor-Enhanced Health Information System to Support Automatically Controlled Exercise Training of COPD Patients: Concept and Prototype.”

29.Tang, P. C., and D. Lansky. “The Missing Link: Bridging the Patient-Provider Health Information Gap.”卫生事务24, no. 5 (2005): 1290–95.

30。McInnes, D., et al. “Use of Electronic Personal Health Record Systems to Encourage HIV Screening: An Exploratory Study of Patient and Provider Perspectives.”BMC Research Notes295,没有。4(2011)。

31.。赖特,et al . "随机对照试验Health Maintenance Reminders Provided Directly to Patients through an Electronic PHR.”

32.Tuil,W。等。“以患者为中心的护理:在IVF实践中使用在线个人病历。”

33.Slagle, J., et al. “MyMediHealth—Designing a Next Generation System for Child-Centered Medication Management.”Journal of Biomedical Informatics43,不。5(2010):S27 – S31。

34.Sequist, T., A. M. Zaslavsky, G. A. Colditz, and J. Z. Ayanian. “Electronic Patient Messages to Promote Colorectal Cancer Screening: A Randomized Controlled Trial.”

35.Luo,G.,C。Tang和S. Thomas。“智能个人健康记录:经验和开放问题。”Journal of Medical Systems(2011): 1–18.

36.Sands, D., and J. Halamka. “PatientSite: Patient-Centered Communication, Services, and Access to Information.”

37.Grant, R., et al. “Practice-Linked Online Personal Health Records for Type 2 Diabetes Mellitus: A Randomized Controlled Trial.”

38.Tuil,W。等。“以患者为中心的护理:在IVF实践中使用在线个人病历。”

39.Zeng, K., O. Bodenreider, and S. Nelson. “Design and Implementation of a Personal Medication Record—MyMedicationList.”AMIA Annual Symposium Proceedings(2008): 844–848. Available athttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2656100/pdf/amia-0844-s2008.pdf.

40。Chira, P., et al. “Living Profiles: Design of a Health Media Platform for Teens with Special Healthcare Needs.”Journal of Biomedical Informatics43,不。5(2010):S9 – S12。

41。Mandl, D., W. W. Simons, W. C. Crawford, and J. M. Abbett. “Indivo: A Personally Controlled Health Record for Health Information Exchange and Communication.”BMC Medical Informatics and Decision Making25,不。7(2007)。

42。Bourgeois, F., W. W. Simons, K. Olson, J. S. Brownstein, and K. D. Mandl. “Evaluation of Influenza Prevention in the Workplace Using a Personally Controlled Health Record: Randomized Controlled Trial.”

43.Chira, P., et al. “Living Profiles: Design of a Health Media Platform for Teens with Special Healthcare Needs.”

44.Slagle, J., et al. “MyMediHealth—Designing a Next Generation System for Child-Centered Medication Management.”

45.Chronaki,C。等。“可植入除颤器患者的健康管理中的互操作性挑战。”

46.Yang, M., et al. “iCARDEA—An Approach to Reducing Human Workload in Cardiovascular Implantable Electronic Device Follow-Ups.”

47.Rubel, P., et al. “Toward Personal eHealth in Cardiology: Results from the EPI-MEDICS Telemedicine Project.”

48.Helmer, A., et al. “A Sensor-Enhanced Health Information System to Support Automatically Controlled Exercise Training of COPD Patients: Concept and Prototype.”

49.Chira, P., et al. “Living Profiles: Design of a Health Media Platform for Teens with Special Healthcare Needs.”

50。Slagle, J., et al. “MyMediHealth—Designing a Next Generation System for Child-Centered Medication Management.”

51。Wiljer, D., et al. “The Anxious Wait: Assessing the Impact of Patient Accessible EHRs for Breast Cancer Patients.”

52。Sequist, T., A. M. Zaslavsky, G. A. Colditz, and J. Z. Ayanian. “Electronic Patient Messages to Promote Colorectal Cancer Screening: A Randomized Controlled Trial.”

53。Fonda, S., R. J. Kedziora, R. A. Vigersky, and S. E. Bursell. “Combining iGoogle and Personal Health Records to Create a Prototype Personal Health Application for Diabetes Self-Management.”

54。Grant, R., et al. “Practice-Linked Online Personal Health Records for Type 2 Diabetes Mellitus: A Randomized Controlled Trial.”

55.Hess, R., et al. “Exploring Challenges and Potentials of Personal Health Records in Diabetes Self-Management: Implementation and Initial Assessment.”

56.“New-Age PHR Comes with Decision-Support, Multiple Opportunities for DM.”

57.Luo,G.,C。Tang和S. Thomas。“智能个人健康记录:经验和开放问题。”

58.Sands, D., and J. Halamka. “PatientSite: Patient-Centered Communication, Services, and Access to Information.”

59.Zeng, K., O. Bodenreider, and S. Nelson. “Design and Implementation of a Personal Medication Record—MyMedicationList.”

60.Tang, P. C., and D. Lansky. “The Missing Link: Bridging the Patient-Provider Health Information Gap.”

61。Rubel, P., et al. “Toward Personal eHealth in Cardiology: Results from the EPI-MEDICS Telemedicine Project.”

62。Wang, M.-Y., P. Tsai, J. Liu, and J. Zao. “Wedjat: A Mobile Phone Based Medicine In-take Reminder and Monitor.”

63。Chira, P., et al. “Living Profiles: Design of a Health Media Platform for Teens with Special Healthcare Needs.”

64。Slagle, J., et al. “MyMediHealth—Designing a Next Generation System for Child-Centered Medication Management.”

65。Fonda, S., R. J. Kedziora, R. A. Vigersky, and S. E. Bursell. “Combining iGoogle and Personal Health Records to Create a Prototype Personal Health Application for Diabetes Self-Management.”

66。Sequist, T., A. M. Zaslavsky, G. A. Colditz, and J. Z. Ayanian. “Electronic Patient Messages to Promote Colorectal Cancer Screening: A Randomized Controlled Trial.”

67.Hess, R., et al. “Exploring Challenges and Potentials of Personal Health Records in Diabetes Self-Management: Implementation and Initial Assessment.”

68.。赖特,et al . "随机对照试验Health Maintenance Reminders Provided Directly to Patients through an Electronic PHR.”

69.Chronaki,C。等。“可植入除颤器患者的健康管理中的互操作性挑战。”

70.Yang, M., et al. “iCARDEA—An Approach to Reducing Human Workload in Cardiovascular Implantable Electronic Device Follow-Ups.”

71.Rubel, P., et al. “Toward Personal eHealth in Cardiology: Results from the EPI-MEDICS Telemedicine Project.”

72.Helmer, A., et al. “A Sensor-Enhanced Health Information System to Support Automatically Controlled Exercise Training of COPD Patients: Concept and Prototype.”

73。Fonda, S., R. J. Kedziora, R. A. Vigersky, and S. E. Bursell. “Combining iGoogle and Personal Health Records to Create a Prototype Personal Health Application for Diabetes Self-Management.”

74。Wang, M.-Y., P. Tsai, J. Liu, and J. Zao. “Wedjat: A Mobile Phone Based Medicine In-take Reminder and Monitor.”

75。Slagle, J., et al. “MyMediHealth—Designing a Next Generation System for Child-Centered Medication Management.”

76。“New-Age PHR Comes with Decision-Support, Multiple Opportunities for DM.”

77。Fonda, S., R. J. Kedziora, R. A. Vigersky, and S. E. Bursell. “Combining iGoogle and Personal Health Records to Create a Prototype Personal Health Application for Diabetes Self-Management.”

78。Hess, R., et al. “Exploring Challenges and Potentials of Personal Health Records in Diabetes Self-Management: Implementation and Initial Assessment.”

79.“New-Age PHR Comes with Decision-Support, Multiple Opportunities for DM.”

80.Bourgeois, F., W. W. Simons, K. Olson, J. S. Brownstein, and K. D. Mandl. “Evaluation of Influenza Prevention in the Workplace Using a Personally Controlled Health Record: Randomized Controlled Trial.”

81.“New-Age PHR Comes with Decision-Support, Multiple Opportunities for DM.”

82.Bourgeois, F., W. W. Simons, K. Olson, J. S. Brownstein, and K. D. Mandl. “Evaluation of Influenza Prevention in the Workplace Using a Personally Controlled Health Record: Randomized Controlled Trial.”

83.Sequist, T., A. M. Zaslavsky, G. A. Colditz, and J. Z. Ayanian. “Electronic Patient Messages to Promote Colorectal Cancer Screening: A Randomized Controlled Trial.”

84.Mandl, D., W. W. Simons, W. C. Crawford, and J. M. Abbett. “Indivo: A Personally Controlled Health Record for Health Information Exchange and Communication.”

85。McInnes, D., et al. “Use of Electronic Personal Health Record Systems to Encourage HIV Screening: An Exploratory Study of Patient and Provider Perspectives.”

86。。赖特,et al . "随机对照试验Health Maintenance Reminders Provided Directly to Patients through an Electronic PHR.”

87。Chronaki,C。等。“可植入除颤器患者的健康管理中的互操作性挑战。”

88。Yang, M., et al. “iCARDEA—An Approach to Reducing Human Workload in Cardiovascular Implantable Electronic Device Follow-Ups.”

89。Luo,G.,C。Tang和S. Thomas。“智能个人健康记录:经验和开放问题。”

90.Fonda, S., R. J. Kedziora, R. A. Vigersky, and S. E. Bursell. “Combining iGoogle and Personal Health Records to Create a Prototype Personal Health Application for Diabetes Self-Management.”

91.Chronaki,C。等。“可植入除颤器患者的健康管理中的互操作性挑战。”

92.Yang, M., et al. “iCARDEA—An Approach to Reducing Human Workload in Cardiovascular Implantable Electronic Device Follow-Ups.”

93.Rubel, P., et al. “Toward Personal eHealth in Cardiology: Results from the EPI-MEDICS Telemedicine Project.”

94.Helmer, A., et al. “A Sensor-Enhanced Health Information System to Support Automatically Controlled Exercise Training of COPD Patients: Concept and Prototype.”

95.“New-Age PHR Comes with Decision-Support, Multiple Opportunities for DM.”

96.Grant, R., et al. “Practice-Linked Online Personal Health Records for Type 2 Diabetes Mellitus: A Randomized Controlled Trial.”

97。Hess, R., et al. “Exploring Challenges and Potentials of Personal Health Records in Diabetes Self-Management: Implementation and Initial Assessment.”

98。Tuil,W。等。“以患者为中心的护理:在IVF实践中使用在线个人病历。”

99。Wiljer, D., et al. “The Anxious Wait: Assessing the Impact of Patient Accessible EHRs for Breast Cancer Patients.”

100.Chira, P., et al. “Living Profiles: Design of a Health Media Platform for Teens with Special Healthcare Needs.”

101.Sands, D., and J. Halamka. “PatientSite: Patient-Centered Communication, Services, and Access to Information.”

102.Zeng, K., O. Bodenreider, and S. Nelson. “Design and Implementation of a Personal Medication Record—MyMedicationList.”

103.Tang, P. C., and D. Lansky. “The Missing Link: Bridging the Patient-Provider Health Information Gap.”

104。Chronaki,C。等。“可植入除颤器患者的健康管理中的互操作性挑战。”

105。Yang, M., et al. “iCARDEA—An Approach to Reducing Human Workload in Cardiovascular Implantable Electronic Device Follow-Ups.”

106。Rubel, P., et al. “Toward Personal eHealth in Cardiology: Results from the EPI-MEDICS Telemedicine Project.”

107。Sequist, T., A. M. Zaslavsky, G. A. Colditz, and J. Z. Ayanian. “Electronic Patient Messages to Promote Colorectal Cancer Screening: A Randomized Controlled Trial.”

108。Mandl, D., W. W. Simons, W. C. Crawford, and J. M. Abbett. “Indivo: A Personally Controlled Health Record for Health Information Exchange and Communication.”

109。“New-Age PHR Comes with Decision-Support, Multiple Opportunities for DM.”

110.Bourgeois, F., W. W. Simons, K. Olson, J. S. Brownstein, and K. D. Mandl. “Evaluation of Influenza Prevention in the Workplace Using a Personally Controlled Health Record: Randomized Controlled Trial.”

111.Luo,G.,C。Tang和S. Thomas。“智能个人健康记录:经验和开放问题。”

112.Chronaki,C。等。“可植入除颤器患者的健康管理中的互操作性挑战。”

113.Yang, M., et al. “iCARDEA—An Approach to Reducing Human Workload in Cardiovascular Implantable Electronic Device Follow-Ups.”

114.Tuil,W。等。“以患者为中心的护理:在IVF实践中使用在线个人病历。”

115.Helmer, A., et al. “A Sensor-Enhanced Health Information System to Support Automatically Controlled Exercise Training of COPD Patients: Concept and Prototype.”

116。“New-Age PHR Comes with Decision-Support, Multiple Opportunities for DM.”

117。Luo,G.,C。Tang和S. Thomas。“智能个人健康记录:经验和开放问题。”

118。Tuil,W。等。“以患者为中心的护理:在IVF实践中使用在线个人病历。”

119。Wang, M.-Y., P. Tsai, J. Liu, and J. Zao. “Wedjat: A Mobile Phone Based Medicine In-take Reminder and Monitor.”

120.Wiljer, D., et al. “The Anxious Wait: Assessing the Impact of Patient Accessible EHRs for Breast Cancer Patients.”

121.Chira, P., et al. “Living Profiles: Design of a Health Media Platform for Teens with Special Healthcare Needs.”

122.Slagle, J., et al. “MyMediHealth—Designing a Next Generation System for Child-Centered Medication Management.”

123.Sands, D., and J. Halamka. “PatientSite: Patient-Centered Communication, Services, and Access to Information.”

124.Zeng, K., O. Bodenreider, and S. Nelson. “Design and Implementation of a Personal Medication Record—MyMedicationList.”

125.Grant, R., et al. “Practice-Linked Online Personal Health Records for Type 2 Diabetes Mellitus: A Randomized Controlled Trial.”

126.Tuil,W。等。“以患者为中心的护理:在IVF实践中使用在线个人病历。”

127.Wiljer, D., et al. “The Anxious Wait: Assessing the Impact of Patient Accessible EHRs for Breast Cancer Patients.”

128.Chira, P., et al. “Living Profiles: Design of a Health Media Platform for Teens with Special Healthcare Needs.”

129。Fonda, S., R. J. Kedziora, R. A. Vigersky, and S. E. Bursell. “Combining iGoogle and Personal Health Records to Create a Prototype Personal Health Application for Diabetes Self-Management.”

130.Sands, D., and J. Halamka. “PatientSite: Patient-Centered Communication, Services, and Access to Information.”

131.Zeng, K., O. Bodenreider, and S. Nelson. “Design and Implementation of a Personal Medication Record—MyMedicationList.”

132.Tang, P. C., and D. Lansky. “The Missing Link: Bridging the Patient-Provider Health Information Gap.”

133.Hess, R., et al. “Exploring Challenges and Potentials of Personal Health Records in Diabetes Self-Management: Implementation and Initial Assessment.”

134.Mandl, D., W. W. Simons, W. C. Crawford, and J. M. Abbett. “Indivo: A Personally Controlled Health Record for Health Information Exchange and Communication.”

135.“New-Age PHR Comes with Decision-Support, Multiple Opportunities for DM.”

136.Bourgeois, F., W. W. Simons, K. Olson, J. S. Brownstein, and K. D. Mandl. “Evaluation of Influenza Prevention in the Workplace Using a Personally Controlled Health Record: Randomized Controlled Trial.”

137.Chronaki,C。等。“可植入除颤器患者的健康管理中的互操作性挑战。”

138.Helmer, A., et al. “A Sensor-Enhanced Health Information System to Support Automatically Controlled Exercise Training of COPD Patients: Concept and Prototype.”

139.Fonda, S., R. J. Kedziora, R. A. Vigersky, and S. E. Bursell. “Combining iGoogle and Personal Health Records to Create a Prototype Personal Health Application for Diabetes Self-Management.”

140.Grant, R., et al. “Practice-Linked Online Personal Health Records for Type 2 Diabetes Mellitus: A Randomized Controlled Trial.”

141.Chronaki,C。等。“可植入除颤器患者的健康管理中的互操作性挑战。”

142.Yang, M., et al. “iCARDEA—An Approach to Reducing Human Workload in Cardiovascular Implantable Electronic Device Follow-Ups.”

143.Fonda, S., R. J. Kedziora, R. A. Vigersky, and S. E. Bursell. “Combining iGoogle and Personal Health Records to Create a Prototype Personal Health Application for Diabetes Self-Management.”

144.Tuil,W。等。“以患者为中心的护理:在IVF实践中使用在线个人病历。”

145.Wiljer, D., et al. “The Anxious Wait: Assessing the Impact of Patient Accessible EHRs for Breast Cancer Patients.”

146.Fonda, S., R. J. Kedziora, R. A. Vigersky, and S. E. Bursell. “Combining iGoogle and Personal Health Records to Create a Prototype Personal Health Application for Diabetes Self-Management.”

147.Mandl, D., W. W. Simons, W. C. Crawford, and J. M. Abbett. “Indivo: A Personally Controlled Health Record for Health Information Exchange and Communication.”

148.Tang, P. C., and D. Lansky. “The Missing Link: Bridging the Patient-Provider Health Information Gap.”

149.Hess, R., et al. “Exploring Challenges and Potentials of Personal Health Records in Diabetes Self-Management: Implementation and Initial Assessment.”

150.Chira, P., et al. “Living Profiles: Design of a Health Media Platform for Teens with Special Healthcare Needs.”

151.Slagle, J., et al. “MyMediHealth—Designing a Next Generation System for Child-Centered Medication Management.”

152.McInnes, D., et al. “Use of Electronic Personal Health Record Systems to Encourage HIV Screening: An Exploratory Study of Patient and Provider Perspectives.”

153.Tang, P. C., and D. Lansky. “The Missing Link: Bridging the Patient-Provider Health Information Gap.”

154.Slagle, J., et al. “MyMediHealth—Designing a Next Generation System for Child-Centered Medication Management.”

155.Chira, P., et al. “Living Profiles: Design of a Health Media Platform for Teens with Special Healthcare Needs.”

156.Rubel, P., et al. “Toward Personal eHealth in Cardiology: Results from the EPI-MEDICS Telemedicine Project.”

157.Mandl, D., W. W. Simons, W. C. Crawford, and J. M. Abbett. “Indivo: A Personally Controlled Health Record for Health Information Exchange and Communication.”

158.Wiljer, D., et al. “The Anxious Wait: Assessing the Impact of Patient Accessible EHRs for Breast Cancer Patients.”

159.Hess, R., et al. “Exploring Challenges and Potentials of Personal Health Records in Diabetes Self-Management: Implementation and Initial Assessment.”

160.Tuil,W。等。“以患者为中心的护理:在IVF实践中使用在线个人病历。”

161.Sequist, T., A. M. Zaslavsky, G. A. Colditz, and J. Z. Ayanian. “Electronic Patient Messages to Promote Colorectal Cancer Screening: A Randomized Controlled Trial.”

162.Bourgeois, F., W. W. Simons, K. Olson, J. S. Brownstein, and K. D. Mandl. “Evaluation of Influenza Prevention in the Workplace Using a Personally Controlled Health Record: Randomized Controlled Trial.”

163.Grant, R., et al. “Practice-Linked Online Personal Health Records for Type 2 Diabetes Mellitus: A Randomized Controlled Trial.”

164.。赖特,et al . "随机对照试验Health Maintenance Reminders Provided Directly to Patients through an Electronic PHR.”

Dinara Saparova, MA. “Motivating, Influencing, and Persuading Patients through Personal Health Records: A Scoping Review.”Perspectives in Health Information Management(2012年夏):1-18。

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