Evaluating Mobile App Interoperability for Health Data: mPHR in Emergency Depts., Guías, Proyectos, Investigaciones de Programación C

¡Descarga Evaluating Mobile App Interoperability for Health Data: mPHR in Emergency Depts. y más Guías, Proyectos, Investigaciones en PDF de Programación C solo en Docsity! applied sciences Article Development of a Mobile Personal Health Record Application Designed for Emergency Care in Korea; Integrated Information from Multicenter Electronic Medical Records Yuri Choi 1,†, June-sung Kim 2,†, In Ho Kwon 1,*, Taerim Kim 3 , Su Min Kim 4, Wonchul Cha 3,4,5, Jinwoo Jeong 1 and Jae-Ho Lee 2,6 1 Department of Emergency Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan 49201, Korea; yurichoi@damc.or.kr (Y.C.); jinwoo@dau.ac.kr (J.J.) 2 Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; jstyle06@amc.seoul.kr (J.-s.K.); jaeholee@amc.seoul.kr (J.-H.L.) 3 Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; taerimi.kim@samsung.com (T.K.); wc.cha@samsung.com (W.C.) 4 Department of Digital Health, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul 06355, Korea; ksm1003@g.skku.edu 5 Health Information and Strategy Center, Samsung Medical Center, Seoul 06351, Korea 6 Department of Information Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea * Correspondence: kwoninho@dau.ac.kr; Tel.: +82-51-240-5590 † Yuri Choi and June-sung Kim equally contributed to this study. Received: 21 August 2020; Accepted: 22 September 2020; Published: 25 September 2020



 Abstract: Collecting patient’s medical data is essential for emergency care. Although hospital-tethered personal health records (PHRs) can provide accurate data, they are not available as electronic information when the hospital does not develop and supply PHRs. The objective of this research was to evaluate whether a mobile app can assemble health data from different hospitals and enable interoperability. Moreover, we identified numerous barriers to overcome for putting health data into one place. The new mobile PHR (mPHR) application was developed and evaluated according to the four phases of the system development life cycle: defining input data and functions, developing a prototype, developing a mobile application, and implementation testing. We successfully introduced the FirstER (First for Emergency Room) platform on 23 September 2019. Additionally, validation in three tertiary hospitals has been carried out since the launch date. From 14 October to 29 November 2019, 1051 cases registered with the FirstER, and the total download count was 15,951 records. We developed and successfully implemented the mPHR service, which can be used as a health information exchange tool in emergency care, by integrating medical records from three different tertiary hospitals. By recognizing the significance and limitations of this service, it is necessary to study the development and implementation of mPHR services that are more suitable for emergency care. Keywords: emergency medicine; interoperability; mobile applications; personal health records; electronic medical records 1. Introduction Collecting data about underlying diseases, food or drug allergies, and prescribed medications is essential whenever physicians see patients [1]. These data make it possible to efficiently diagnose and treat patients by reducing unnecessary laboratory or imaging tests [2]. When patients go to Appl. Sci. 2020, 10, 6711; doi:10.3390/app10196711 www.mdpi.com/journal/applsci Appl. Sci. 2020, 10, 6711 2 of 13 an emergency department (ED) that they regularly visit, physicians can obtain medical information without any additional effort [3]. In South Korea, medical records are transferred by paper or telephone when patients decide to move from one hospital to the other. Meanwhile, in the case of an unexpected visit to a nearby hospital, especially in an emergency, it is hard to know a patient’s detailed history because patients do not remember exactly their prior illnesses, doses, or types of drugs taken [4]. Although hospital-tethered personal health records (PHRs) can provide accurate data, they are not available as electronic information when the hospital does not develop and supply PHRs [5]. Although the need for convenient access to medical information has been increasing, several factors have limited the development of a PHR platform: related laws, ownership of data, privacy, and security [6]. The patient Privacy Act states that electronic medical records (EMRs) must not be leaked or stored outside of hospitals [7]. However, on account of the high penetration rate of EMRs and the elevated usage rate of smartphones in the country, there has been sufficient social consensus for developing PHRs [8]. Meanwhile, established policies and systems for collecting and utilizing individual medical records have been implemented that have enabled the storage of EMR data in cloud systems outside the boundaries of hospitals. Additionally, operable PHR apps have become available that tether EMRs and link several hospitals [9]. In this context, the Korean government announced a voluntary program called “MyData” in 2019, which gives consumers increased access to their data in portable electronic devices, such as smartphones. This program is a paradigm shift of personal data storage and management that propels the current institution-centric system to a person-centric system, which has already been adopted in medical fields in numerous countries [10]. The MyData program has been applied to various fields, including the health industry, and enables individuals to manage their own health data more actively and efficiently. The development of a new PHR application for emergencies was carried out as the medical part of this program. This PHR application was designed to enable medical information to be owned by patients, not hospitals, and for patients to provide that information to healthcare providers by appropriately utilizing it when necessary. Two tertiary hospitals (Asan Medical Center (AMC) and Samsung Medical Center (SMC)) already have applications for PHR-tethered EMRs (My chart in my hand, SMC mobile) since 2015 and 2013 [11]. However, there are no applications that could link different hospitals across the country. Therefore, we formed a consortium that consisted of one application developer, called value through Technology and Wisdom (vTW) and three tertiary hospitals (AMC, SMC, and Dong-A Medical Center (DAMC)) and developed a new PHR platform that especially targets emergency situations. The objective of this research was to evaluate whether a mobile app can assemble health data from different hospitals and enable interoperability. Moreover, we identified numerous barriers to overcome when putting health data into one place. 2. Methods To develop a mobile PHR (mPHR) application for use in emergency situations, a consortium was formed consisting of data-providing hospitals, data-utilizing hospitals, and an application developer. Three academic tertiary hospitals (AMC, SMC, and Dong-A Medical Center (DAMC)) with integrated full-scale hospital information systems, which were essential for providing data to build a system, participated as data-providing and data-utilizing centers. These hospitals are located in two large metropolitan cities, Seoul and Busan, and have different EMR systems that were established in 2003, 2005, and 2013. The annual numbers of visits to the EDs of these centers are 100,000, 130,000, and 35,000, respectively. These centers have about 2000, 2000, and 990 inpatient beds. The application developer (vTW) designed a service model, built a platform and cloud service, and operated the mPHR service. The three hospitals built the foundation for the extraction of personal data from the EMRs, standardized medical records, and data to be used in the application. In addition, two local secondary-care hospitals (Hyemin Hospital, Chung Hospital) that are closely related to the three hospitals were offered the data provided. Appl. Sci. 2020, 10, 6711 5 of 13 have different EMR systems and data recorded, which are coded in different ways for each hospital. For interoperability and standardization of data, an NEDIS conversion method was used. The coding method used to send data to the NEDIS is universal in all EDs across the country. This method enabled various information that existed in different forms at each hospital to be converted into one form. Similarly, data on medications prescribed in the ED are sent to the National Health Insurance, which also uses the electronic data interchange (EDI) code of the country’s single insurer. Further, information for each medication was mapped using data from the Korea Pharmaceutical Information Center. There are technical limitations when trying to include all the laboratory tests; thus, the most frequent test items were extracted from the three hospitals’ data. Two ED doctors from each hospital (Y.C., I.H.K., J.K., J.-H.L., T.K., and W.C.) reviewed the whole list of extracted laboratory tests and discussed the clinical importance of the laboratory tests for making treatment decisions in the ED. The items of the PGHD were determined by considering those items that are valuable for suspecting and diagnosing a disease in the ED. 2.1.2. Development of the System and Server A server for each data-providing hospital linked to a main server and a private cloud was planned for the system. When selecting the private cloud, legal considerations and the system’s suitability were taken into account. There were several discussions with the computer experts of the three hospitals and the app developer, leading to the building of the MyData server, which connects to the main server. 2.2. Development of the Prototype Based on the previous arrangement of the core data and function, the application developer (vTW) developed a prototype of the PHR application by laying out the screen, modeling the data, constructing the technical architecture, and designing the interface using a design toolkit (Sketch© 2020, online. Sketch B.V.). Through several meetings, the participating researchers from the three hospitals corrected and supplemented the prototype by providing feedback on the user interface, correcting typos, and showing how to indicate the reference values of the laboratory test results. 2.3. Development of the mPHR Application The new mPHR application was developed and evaluated according to the four phases of the system development life cycle. According to this method, it proceeded as a process consisting of planning, analysis, design, and implementation. Each phase was reviewed and advised on by the participating researchers and revised by the application developers. Based on the modified prototype, standards for details were defined, and each unit module was developed. To design a user-centered screen, we targeted three groups of users: patients, ED staff, and program managers. Mobile Application Content Accessibility Guideline 2.0, a modification of the Web Content Accessibility Guideline 2.0 for implementation in Korea, was complied with by vTW. The mPHR application was developed with the Android Software Development Kit 28 using Android Studio 3.5 (Google LLC) and Swift 4.0 using Xcode 11© (1999–2020 Apple Inc.). The Spring tool suite 4© (2020 VMware, Inc.) was used to program the web service. In order to comply with the Privacy Act of Korea, legal advice was sought at the time of app development. 2.4. Testing the New mPHR Application The developed application was subjected to unit tests and integration tests. Unit tests were conducted twice by the computer experts of the three hospitals and the app developer on 20–27 September. The integration test was conducted twice on 4–11 October in the same way. Appl. Sci. 2020, 10, 6711 6 of 13 3. Results We successfully introduced the FirstER (First for Emergency Room) platform on 23 September 2019. Moreover, it has been implemented in three tertiary hospitals since the launch date. 3.1. Services Provided by the Novel PHR Application for Emergency Situations: FirstER 3.1.1. Main Function The user-centered screen was designed considering the main functions (Figure 2). The essential functions for the patient as the owner of the entire set of information include registration, management of his or her health record, download and viewing, disclosure of the PHR-tethered EMR of the hospital, contact with care providers, and setting of the degree of information disclosure. ED staff receive a temporary URL so that a patient’s information could be viewed within the limits allowed by him or her. Appl. Sci. 2019, 9, x FOR PEER REVIEW 6 of 13 2.4. Testing the New mPHR Application The developed application was subjected to unit tests and integration tests. Unit tests were conducted twice by the computer experts of the three hospitals and the app developer on 20–27 September. The integration test was conducted twice on 4–11 October in the same way. 3. Results We successfully introduced the FirstER (First for Emergency Room) platform on 23 September 2019. Moreover, it has been implemented in three tertiary hospitals since the launch date. 3.1. Services Provided by the Novel PHR Application for Emergency Situations: FirstER 3.1.1. Main Function The user-centered screen was designed considering the ain functions (Figure 2). The essential functions for the patient as the owner of the entire set of information include registration, management of his or her health record, download and viewing, disclosure of the PHR-tethered EMR of the hospital, contact with care providers, and setting of the degree of information disclosure. ED staff receive a temporary URL so that a patient’s information could be viewed within the limits allowed by him or her. Figure 2. The functional structure of FirstER. The main functions for patients were categorized into registration, management of health records and emergency ID, download and view, disclosure of the PHR-tethered EMR of the hospital, and setting of the degree of information disclosure. (ID: identification, PHR: personal health record) 3.1.2. Data Provided by FirstER Patients’ ED records (name, gender, age, diagnosis, vital signs, hospital visited, visiting date and time, etc.) coded by the NEDIS method were integrated among the three data-providing tertiary hospitals. Medication information coded by the EDI mapped with different drug codes from each hospital was successfully extracted. Twenty-nine items most frequently referred to by emergency physicians were selected for the most frequent test categories (Table 2). These data extracted from the hospital information system constituted a “core dataset” to be sent to the private cloud. Table 2. Extraction and standardization of the most frequent laboratory examinations. Sample Name of Laboratory Test Blood White blood cell count Blood Hemoglobin Blood Platelet count Blood Absolute neutrophil count Blood Prothrombin time Figure 2. The functional struct re f irst . e ai f cti s f r atie ts ere categorized into registration, a a e e t f health records and emergency ID, download and view, disclosure of the PHR-tethered EMR of the hospital, and setting of the degree of i for ation isclosure. (ID: identification, PHR: personal health record) 3.1.2. Data Provided by First Patients’ r r s ( a e, gender, age, diagnosis, vital signs, hospital visited, visiting date and time, et .) coded by the NEDIS method w re integrated among the thr e data-providing tertiary hospitals. e i I ed ith different drug codes from each hospital was suc es ful y extract . i it s ost frequently refe red to by emergency physicians were selected for the ost fre t ese data extracted from the hospital information syste constituted a “c re t t . Appl. Sci. 2020, 10, 6711 7 of 13 Table 2. Extraction and standardization of the most frequent laboratory examinations. Sample Name of Laboratory Test Blood White blood cell count Blood Hemoglobin Blood Platelet count Blood Absolute neutrophil count Blood Prothrombin time Blood Activated prothrombin time Blood Blood urea nitrogen Blood Creatinine Blood Total bilirubin Blood Gamma glutamyl transpeptidase Blood Alkaline phosphatase Blood Alanine transaminase Blood Aspartate transaminase Blood Amylase Blood Lipase Blood Sodium Blood Potassium Blood Uric acid Blood Hemoglobin A1c Blood Creatine kinase Blood Creatine kinase-myocardial band fraction Blood Troponin I Blood C-reactive protein Blood N-terminal pro-B-type natriuretic peptide Blood Brain natriuretic peptide Urine pH Urine Occult hematuria Blood ABO blood typing Others Influenza antigen immunoassay 3.1.3. Developed System and Server of FirstER Based on privacy legislation, the medical cloud zone, an IaaS (Infrastructure as a Service) provided by Samsung Data System (Seoul, Korea), met the facilities and equipment standards necessary for the management and preservation of EMRs, which is a requirement for the remote storage of EMRs. Data transmission and reception between the hospitals and the MyData cloud servers were linked by RESTful API (Representational State Transfer Application Programming Interface), SSL (Secure Socket Layer, https), and JSON (JavaScript Object Notation, data format). (Figure 3). A patient sends subscriber information (patient hospital ID) to the hospital information system (HIS) through the private cloud platform when the patient agrees to subscribe to the mobile app and to the collection/use of their personal information. After validation of the subscriber information, the ED core data of the patient are extracted from the HIS server to the MyData-linked server in the hospital. Afterwards, when a patient requests “download”, the core data of the patient are transferred from the connected server in the hospital to the MyData cloud platform. Appl. Sci. 2020, 10, 6711 10 of 13 3.4. Frequency of System Access and Utilization From 14 October to 29 November 2019, the registration desks were operated in three EDs. While the desks were running, about 5100 patients were discharged at the EDs, and about 20% of the patients (1051 patients) installed the mobile app with informed consent. The number of EMR-tethered records that were downloaded per user request was 15,951 records in total. These records were categorized into visiting records, consultation records, laboratory records, operation records, and prescription records (Table 3). In two local secondary hospitals that only received data, there were a total of 22 downloads. Additionally, 265 cases had PGHD inputted. Table 3. Frequency of system access and utilization. Numbers indicate counts of EMR-tethered data provided during the study period. Category of EMR-Tethered Data Provided Samsung Medical Center Asan Medical Center Dong-A University Hospital Total (%) Visit 4523 1694 2398 8615 (54.0) Consultation history 16 0 0 16 (0.0) Laboratory test 2699 886 1636 5221 (32.7) Operation history 10 0 2 12 (0.0) Prescription data 1285 241 561 2087 (13.1) Total 8533 2821 4597 15,951 EMR: electronic medical record. 4. Discussion In this study, we introduced a newly developed mobile app, called FirstER, which enables the aggregation of data from three hospitals and yields PHRs to others if needed. Even though FirstER needs further validation, it demonstrates that mobile apps can enable interoperability between different sources of PHRs from different hospitals. Medical record interoperability has been recognized to improve convenience and clinical outcomes for patients. With the rapid uptake of smartphones and the digitalization of medical records, healthcare services have planned the development of mobile health apps. Jung et al. previously introduced a mobile application to provide diabetes self-management, including cardio-cerebrovascular risk evaluation, stress evaluation, and an exercise tutor [14]. Wagner et al. evaluated the usefulness of PHRs for patients with hypertension and concluded that they might have a limited impact. However, these studies focused on non-emergency situations [15]. One pilot study announced the development of a mobile emergency app to improve interoperability between pre-hospital services and hospitals in a mass-casualty situation [16]. Although this application might be useful for emergency physicians, it was not intended for patients. To the best of our knowledge, FirstER is the first mobile app prototype for patients who visit the ED and use their PHRs at other hospitals in an emergency. Whenever patients unintentionally first visited nearby hospitals, FirstER enabled medical personnel to know about the patients’ previous underlying diseases, the reasons why they visited other hospitals, and what they were prescribed [17]. Furthermore, we also enabled patients to input their health records (i.e., patient-generated health data), such as conditions and blood pressure results, into FirstER, which then provided physicians with these data to help understand patients’ conditions [18]. Using wearable devices with FirstER could provide more expansive and diverse datasets to help clinicians with decision-making about care plans [19,20]. In this investigation, we focused on variables that are commonly useful for emergencies by analyzing the frequencies of prescriptions. Furthermore, emergency medicine physicians discussed with each other the clinical importance of the variables and reached a consensus on which ones to include. The parameters needed to be reliable, accurate, and easy to access. Regarding the selection of such parameters, we considered numerous issues. At first, we attempted to insert radiologic examinations, which could be helpful for efficient diagnosis and treatment. Nevertheless, the final Appl. Sci. 2020, 10, 6711 11 of 13 version of the app did not contain such data because of storage and bandwidth issues. Radiologic reports without images were not provided because these frequently mislead both patients and physicians. Secondly, we also did not include the results of bacterial or viral cultures, including those for multi-resistance bacteria, sexually transmitted diseases, or new emerging infections. We thought that hiding such data could be problematic in specific situations. However, after reviewing Korean Privacy Act issues, we decided to exclude sensitive health records, including those relating to sexually transmitted diseases. This was largely because there tends to be a stigma in our country around revealing delicate past medical histories. Even though there were several limitations, as we mentioned above, FirstER is well-designed and developed for our initial purpose. The usability of this prototype may be expanded by having more participating hospitals, containing admission records, and having other medical data, such as radiological examinations. Moreover, further updates would focus on covering detailed data on chronic medical illnesses and recent emerging infectious diseases. Research about the validity and reliability of FirstER has been progressing in another study with survey analyses from both healthcare providers and patients. It is promising that FirstER has already been downloaded more than 1000 times, and most responses to questions about usability in the pilot surveys have shown user satisfaction. Meanwhile, dissatisfaction, because the app was hard to use the first time, was one of the most common answers on the surveys, especially for those patients who were not familiar with using a smartphone. After developing FirstER and installing the app on a user’s device, there were some cases in which the app did not work due to conflicts between the app and certain versions of mobile phones. Most such problems were solved by stabilizing the cloud server and updating the app. However, the app did not work in very remote versions in a few mobile phones despite continuously updating the app. Furthermore, the patients need to follow multiple steps with many instances of giving informed consent to provide their records to physicians. These complicated processes are largely to protect the patients’ privacy; however, involving patients’ caregivers to introduce manuals for the app and further updates would improve usability. With the developing platform for the mPHR, ED physicians could diagnose and treat their patients more quickly and efficiently, because problems similar to previous ones could be solved without duplicated tests. Fewer clinical tests due to decreased duplicated tests might have a positive effect on improving overcrowding in EDs, though this needs further evaluation. Previous studies reported that the turnaround time for laboratory and radiologic tests negatively impacts ED overcrowding and length of stay [21,22]. Improving the quality of care and enhancing the safety of patients is multifactorial, and one of the most effective ways to diminish overcrowding can be by avoiding unnecessary laboratory and imaging examinations [23]. Future studies need to focus on which information on the PHRs can improve patient outcome. Also, research on PHR-based emergency medical services can further progress by expanding the mobile app. Categorizing the data provided, it was found that the app users requested their laboratory results in addition to the visit data that are provided by default. We noticed several limitations while developing and applying FirstER. First, the patients’ usability and satisfaction might be lower than expected because a relatively small number of hospitals participated. If the clinical data could be connected between tertiary hospitals and primary clinics, the app’s usability would be improved. For example, patients with mild infectious illnesses or simple minor trauma cases could provide their laboratory results and prescriptions to their primary healthcare provider through this app after adequate treatment in the emergency department. However, FirstER is the first platform in an emergency to support interoperability between hospitals, and further study could make it possible to share PHRs at many hospitals. Second, data for radiologic examinations, such as simple radiographs, computed tomography, and magnetic resonance imaging, could not be provided because of limited storage and bandwidth. Third, there were some reports of errors during the uploading and downloading of data in the mobile app. These errors were mostly because of the different existing platforms between hospitals and different data types with test codes. However, these technical challenges were recognized in the early phase and fixed by standardizing the data from each Appl. Sci. 2020, 10, 6711 12 of 13 hospital. Fourth, this app only covered the clinical data from the emergency department. Information during admission could be more informative, especially for patients admitted for a long duration. Regretfully, this app was a prototype and only included the medical records from the emergency department, including laboratory results, presumed diagnosis, and prescriptions at time of discharge from the emergency department. A future study is planned to update the app to include clinical data during admission. Lastly, we could not evaluate the clinical impacts of the mobile application, such as mortality or length of ED stay, due to the short study period. 5. Conclusions In this study, we developed and successfully implemented an mPHR service that can be used as a health information exchange tool in emergencies by integrating medication information from three different tertiary hospitals. By recognizing the significance and limitations of this service, it is necessary to study the development and implementation of mPHR services that are more suitable for emergency medical services. Author Contributions: Y.C., I.H.K., W.C. and J.-H.L. contributed to conceptualization of new application and platform: S.M.K. helped conduct the data curation and formal analysis. I.H.K., W.C. and J.-H.L. contributed to funding acquisition. Y.C., J.-s.K., I.H.K., T.K. and S.M.K. initiated this study as principle investigators of this project. Y.C., J.K., I.H.K., T.K., W.C. and J.-H.L. contributed to application of the research methodology. Y.C., I.H.K. and T.K. administrated the project. Y.C., I.H.K. and J.-H.L. supervised the entire process; J.J. helped visualize the figures and tables; Y.C., J.-s.K. and I.H.K. drafted the manuscript as first and corresponding authors. T.K. and J.J. reviewed and edited for completion of the manuscript. All authors have read and agreed to the published version of the manuscript. Funding: This study was supported by a grant from the MyData project through the Korea Data Agency, funded by the Ministry of Science and Technology Information and Communication, Korea (grant number:19-Siljeung-On-14, Project principal investigator: Seok Jae Heo of vTW). Acknowledgments: This study included some results of 1st year product of research project supported by a grant from the PHR based personalized health management system development project through the Korea Evaluation Institute of Industrial Technology, funded by the Ministry of Trade, Industry and Energy, Korea (grant number:20004503 Project principal investigator: Seok Jae Heo of vTW). Conflicts of Interest: The authors declare no conflict of interest. References 1. Hudson, P.; Ekholm, J.; Johnson, M.; Langdon, R. Early identification and management of the unstable adult patient in the emergency department. J. Clin. Nurs. 2015, 24, 3138–3146. [CrossRef] 2. Abel, G.A.; Mendonca, S.C.; McPhail, S.; Zhou, Y.; Elliss-Brookes, L.; Lyratzopoulos, G. Emergency diagnosis of cancer and previous general practice consultations: Insights from linked patient survey data. Br. J. Gen. Pract. 2017, 67, e377–e387. [CrossRef] [PubMed] 3. Alimenti, D.; Buydos, S.; Cunliffe, L.; Hunt, A. Improving perceptions of patient safety through standardizing handoffs from the emergency department to the inpatient setting. J. Am. Assoc. Nurse Pract. 2019, 31, 354–363. [CrossRef] [PubMed] 4. Shapiro, J.S.; Kannry, J.; Lipton, M.; Goldberg, E.; Conocenti, P.; Stuard, S.; Wyatt, B.M.; Kuperman, G. Approaches to patient health information exchange and their impact on emergency medicine. Ann. Emerg. Med. 2006, 48, 426–432. [CrossRef] [PubMed] 5. Bouayad, L.; Ialynytchev, A.; Padmanabhan, B. Patient health record systems scope and functionalities: Literature review and future directions. J. Med. Internet Res. 2017, 19, e388. [CrossRef] 6. Bouri, N.; Ravi, S. Going mobile: How mobile personal health records can improve health care during emergencies. JMIR Mhealth Uhealth 2014, 2, e8. [CrossRef] [PubMed] 7. Zhao, J.Y.; Song, B.; Anand, E.; Schwartz, D.; Panesar, M.; Jackson, G.P.; Elkin, P.L. Barriers, facilitators, and solutions to optimal patient portal and personal health record use: A systematic review of the literature. AMIA Annu. Symp. Proc. 2018, 2017, 1913–1922.