Objective To evaluate the impact of sharing electronic health records (EHRs) with patients and map it across six domains of quality of care (ie, patient-centredness, effectiveness, efficiency, timeliness, equity and safety).
Design Systematic review and meta-analysis.
Data sources CINAHL, Cochrane, Embase, HMIC, Medline/PubMed and PsycINFO, from 1997 to 2017.
Eligibility criteria Randomised trials focusing on adult subjects, testing an intervention consisting of sharing EHRs with patients, and with an outcome in one of the six domains of quality of care.
Data analysis The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Title and abstract screening were performed by two pairs of investigators and assessed using the Cochrane Risk of Bias Tool. For each domain, a narrative synthesis of the results was performed, and significant differences in results between low risk and high/unclear risk of bias studies were tested (t-test, p<0.05). Continuous outcomes evaluated in four studies or more (glycated haemoglobin (HbA1c), systolic blood pressure (SBP) and diastolic blood pressure (DBP)) were pooled as weighted mean difference (WMD) using random effects meta-analysis. Sensitivity analyses were performed for low risk of bias studies, and long-term interventions only (lasting more than 12 months).
Results Twenty studies were included (17 387 participants). The domain most frequently assessed was effectiveness (n=14), and the least were timeliness and equity (n=0). Inconsistent results were found for patient-centredness outcomes (ie, satisfaction, activation, self-efficacy, empowerment or health literacy), with 54.5% of the studies (n=6) demonstrating a beneficial effect. Meta-analyses showed a beneficial effect in effectiveness by reducing absolute values of HbA1c (unit: %; WMD=−0.316; 95% CI −0.540 to −0.093, p=0.005, I2=0%), which remained significant in the sensitivity analyses for low risk of bias studies (WMD= −0.405; 95% CI −0.711 to −0.099), and long-term interventions only (WMD=−0.272; 95% CI −0.482 to −0.062). A significant reduction of absolute values of SBP (unit: mm Hg) was found but lost in sensitivity analysis for studies with low risk of bias (WMD= −1.375; 95% CI −2.791 to 0.041). No significant effect was found for DBP (unit: mm Hg; WMD=−0.918; 95% CI −2.078 to 0.242, p=0.121, I2=0%). Concerning efficiency, most studies (80%, n=4) found either a reduction of healthcare usage or no change. A beneficial effect was observed in a range of safety outcomes (ie, general adherence, medication safety), but not in medication adherence. The proportion of studies reporting a beneficial effect did not differ between low risk and high/unclear risk studies, for the domains evaluated.
Discussion Our analysis supports that sharing EHRs with patients is effective in reducing HbA1c levels, a major predictor of mortality in type 2 diabetes (mean decrease of −0.405, unit: %) and could improve patient safety. More studies are necessary to enhance meta-analytical power and assess the impact in other domains of care.
Protocol registration http://www.crd.york.ac.uk/PROSPERO (CRD42017070092).
- patient safety
- health policy
- patient-centred care
- information technology
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Contributors Conception and design of the work: ALN, AWC. Database searching: ALN, LF. Full text screening: ALN, LF. Outcome data extraction: ALN, LF. Risk of bias: ALN, LL, LF. Data analysis and interpretation: ALN, LL, LF, AWC, EM. Critical revision of drafts for important intellectual content. ALN, AWC, LF, LL, EM, AD. Final approval of the version to be published: ALN, AWC, LF, LL, EM, AD.
Funding This work is supported by the National Institute for Health Research (NIHR) Imperial Patient Safety Translation Research Centre. Infrastructure support was provided by the NIHR Imperial Biomedical Research Centre. The study funder(s) did not play a role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. In addition, researchers were independent from funders, and all authors had full access to all of the data included in this study and can take responsibility for the integrity of the data and the accuracy of the data analysis.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. Data supporting the findings of this study are available within the article and its supplementary materials.
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