A Re-conceptualization of Access for 21st Century Healthcare

Health Services Research and Development (HSR&D), Center for Mental Health and Outcomes Research, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114, USA.
Journal of General Internal Medicine (Impact Factor: 3.42). 11/2011; 26 Suppl 2(Suppl 2):639-47. DOI: 10.1007/s11606-011-1806-6
Source: PubMed


Many e-health technologies are available to promote virtual patient-provider communication outside the context of face-to-face clinical encounters. Current digital communication modalities include cell phones, smartphones, interactive voice response, text messages, e-mails, clinic-based interactive video, home-based web-cams, mobile smartphone two-way cameras, personal monitoring devices, kiosks, dashboards, personal health records, web-based portals, social networking sites, secure chat rooms, and on-line forums. Improvements in digital access could drastically diminish the geographical, temporal, and cultural access problems faced by many patients. Conversely, a growing digital divide could create greater access disparities for some populations. As the paradigm of healthcare delivery evolves towards greater reliance on non-encounter-based digital communications between patients and their care teams, it is critical that our theoretical conceptualization of access undergoes a concurrent paradigm shift to make it more relevant for the digital age. The traditional conceptualizations and indicators of access are not well adapted to measure access to health services that are delivered digitally outside the context of face-to-face encounters with providers. This paper provides an overview of digital "encounterless" utilization, discusses the weaknesses of traditional conceptual frameworks of access, presents a new access framework, provides recommendations for how to measure access in the new framework, and discusses future directions for research on access.

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Available from: James F Burgess
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    • "A major concern among veteran providers is this population's underutilization of mental health care (APA Presidential Task Force on Military Deployment Services for Youth, Families, & Service Members, 2007; Hoge et al., 2004; Seal et al., 2010). There are multiple patient-level barriers to mental health care including lack of access, particularly among rural veterans, stigma, cultural attitudes, denial, and apathy (Fortney et al., 2011; Hoge et al., 2004; Ouimette et al., 2011; Pietrzak et al., 2009). In addition, behaviors honed in the warzone and perceived as adaptive and ego-syntonic by service members, such as avoidance and hypervigilance , come to represent mental health symptoms upon return home. "
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    ABSTRACT: Veterans with posttraumatic stress disorder (PTSD) symptoms frequently present to primary care providers (PCPs) and are reluctant to seek out or accept referrals to specialty mental health care. Most PCPs have not been trained to assess for and manage symptoms of PTSD. Web-based programs are increasingly used for medical education, but there are no published evaluations of online PTSD trainings for PCPs. We developed a 70-min Web-based training that focused on military-related PTSD for PCPs practicing in Veterans Affairs (VA) hospitals, but was applicable to PCPs treating veterans and other trauma-exposed patients outside VA settings. The training consisted of four modules: (1) Detection and Assessment; (2) Comorbid Conditions and Related Problems; (3) Pharmacological Interventions; and (4) Psychotherapeutic Interventions. Clinical vignettes dramatized key training concepts. Seventy-three PCPs completed the training and assessments pre- and posttraining and 30 days later. Paired t tests compared change in PTSD-related knowledge and comfort with PTSD-related skills, and qualitative methods were used to summarize participant feedback. After the training, mean knowledge score improved from 46% to 75% items correct, with sustained improvement at 30 days. Thirty days posttraining, PCPs reported significantly greater comfort regarding PTSD-related skills assessed; 47% reported using training content in their clinical practice. Qualitatively, PCPs appreciated the flexibility of asynchronous, self-paced online modules, but suggested more interactive content. Given the numerous barriers to specialty mental health treatment, coupled with a preference among veterans with PTSD for accessing treatment through primary care, improving PTSD competency among PCPs may help better serve veterans' mental health needs. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
    Full-text · Article · Dec 2013 · Psychological Services
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    • "Future developments should take into consideration that generally Internet use is inversely correlated with an increasing number of medical conditions and lack of financial resources [42]. Also, a decrease of associated costs of mobile devices, i.e. costs for smartphones and tablet computers, may be essential to mitigate the “digital divide": Others have suggested that a portion of the population on the socioeconomic margin may miss out on the benefits of technologies due to prohibitive factors such as device cost [43], [44]. This is supported by the suggestion of "Medication Plan"-users to publish a similar application for other, possibly cheaper systems, as borne out in the mail requests. "
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    ABSTRACT: One of the key problems in the drug therapy of patients with chronic conditions is drug adherence. In 2010 the initiative iNephro was launched ( A software to support regular and correct drug intake was developed for a smartphone platform (iOS). The study investigated whether and how smartphone users deployed such an application. Together with cooperating partners the mobile application "Medikamentenplan" ("Medication Plan") was developed. Users are able to keep and alter a list of their regular medication. A memory function supports regular intake. The application can be downloaded free of charge from the App Store™ by Apple™. After individual consent of users from December 2010 to April 2012 2042338 actions were recorded and analysed from the downloaded applications. Demographic data were collected from 2279 users with a questionnaire. Overall the application was used by 11688 smartphone users. 29% (3406/11688) used it at least once a week for at least four weeks. 27% (3209/11688) used the application for at least 84 days. 68% (1554/2279) of users surveyed were male, the stated age of all users was between 6-87 years (mean 44). 74% of individuals (1697) declared to be suffering from cardiovascular disease, 13% (292) had a previous history of transplantation, 9% (205) were suffering from cancer, 7% (168) reported an impaired renal function and 7% (161) suffered from diabetes mellitus. 69% (1568) of users were on <6 different medications, 9% (201) on 6 - 10 and 1% (26) on more than 10. A new smartphone application, which supports drug adherence, was used regularly by chronically ill users with a wide range of diseases over a longer period of time. The majority of users so far were middle-aged and male.
    Full-text · Article · Oct 2013 · PLoS ONE
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    • "In our study, we were unable to reach 7 patients due to disconnected telephone numbers. The use of mobile technologies to facilitate health communication practices has recently garnered much attention (Fortney, Burgess, Bosworth, Booth, &amp; Kaboli, 2011;Tirado, 2011). A reliance on mobile devices may disadvantage low-income individuals who do not have stable access. "
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    ABSTRACT: Limited patient understanding of hypertension contributes to poor health outcomes. In 2 sequential randomized studies, the authors determined the impact of administering information tailored to health literacy level alone or in combination with preferred learning style on patients' understanding of hypertension. Patients with high blood pressure were recruited in an academic emergency department. In Experiment 1 (N = 85), the control group received only the routine discharge instructions; the intervention group received discharge instructions combined with information consistent with their health literacy level as determined by the Short Test of Functional Health Literacy. In Experiment 2 (N = 87), the information provided to the intervention group was tailored to both health literacy and learning style, as indicated by the VARK™ Questionnaire. To measure learning, the authors compared scores on a hypertension assessment administered during the emergency department visit and 2 weeks after discharge. Participants who received materials tailored to both health literacy level and learning style preference showed greater gains in knowledge than did those receiving information customized for health literacy level only. This study demonstrates that personalizing health information to learning style preferences and literacy level improves patient understanding of hypertension.[Supplementary materials are available for this article. Go to the publisher's online edition of Journal of Health Communication for the following free supplemental resources: Appendix A: High Blood Pressure Questionnaire; and Appendix B: Multivariate linear regression of adjusted association between intervention and knowledge retention (with item 17 included). Appendix A is the hypertension knowledge test developed and previously described (Koonce, Giuse, Alexander, & Storrow, 201130. Koonce , T. Y. , Giuse , N. B. , Alexander , P. T. , & Storrow , A. B. ( 2011 ). Using patient literacy and knowledge to optimize the delivery of health information. Paper presented at the Special Libraries Association, Philadelphia, Pennsylvania. Retrieved from View all references). Appendix B provides the results of the multivariate linear regression analysis of the data set with the inclusion of all 17 quiz items.]
    Preview · Article · Oct 2012 · Journal of Health Communication
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