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The electronic health record (EHR) has been fully established in all Norwegian hospitals. Patient-accessible electronic health records (PAEHRs) are available to citizens aged 16 years and older through the national health portal Helsenorge.
This study aimed at understanding how patients use PAEHRs. Three research questions were addressed in order to explore (1) characteristics of users, (2) patients’ use of the service, and (3) patient experience with the service.
We conducted an online survey of users who had accessed their EHR online at least once through the national health portal. Patients from two of the four health regions in Norway were invited to participate. Quantitative data were supplemented by qualitative information.
A total of 1037 respondents participated in the survey, most of whom used the PAEHR regularly (305/1037, 29.4%) or when necessary (303/1037, 29.2%). Service utilization was associated with self-reported health, age, gender, education, and health care professional background. Patients found the service useful to look up health information (687/778, 88.3%), keep track of their treatment (684/778, 87.9%), prepare for a hospital appointment (498/778, 64.0%), and share documents with their general practitioner (292/778, 37.5%) or family (194/778, 24.9%). Most users found it easy to access their EHR online (965/1037, 93.1%) and did not encounter technical challenges. The vast majority of respondents (643/755, 85.2%) understood the content, despite over half of them acknowledging some difficulties with medical terms or phrases. The overall satisfaction with the service was very high (700/755, 92.7%). Clinical advantages to the patients included enhanced knowledge of their health condition (565/691, 81.8%), easier control over their health status (685/740, 92.6%), better self-care (571/653, 87.4%), greater empowerment (493/674, 73.1%), easier communication with health care providers (493/618, 79.8%), and increased security (655/730, 89.7%). Patients with complex, long-term or chronic conditions seemed to benefit the most. PAEHRs were described as useful, informative, effective, helpful, easy, practical, and safe.
PAEHRs in Norway are becoming a mature service and are perceived as useful by patients. Future studies should include experimental designs focused on specific populations or chronic conditions that are more likely to achieve clinically meaningful benefits. Continuous evaluation programs should be conducted to assess implementation and changes of wide-scale routine services over time.
With the rapid rise in the adoption of patient portals, many patients are gaining access to their personal health information online for the first time [
An electronic health record (EHR) is the electronic collection of clinical data and can include clinical assessments, laboratory results, radiology findings, nursing documentation, allergy information, medication information, and discharge letters [
Patients’ increasing demands for medical information, the digitization of health records, and the fast spread of internet access form the basis for introducing new digital health services [
All citizens and residents in Norway have the right to access their health records created by a health care provider (eg, hospital, general practitioner [GP] office, dentist) [
The EHR is fully established by all Norwegian hospitals. The national health portal Helsenorge [
Through the national health portal patients can also retrieve the access log, which shows a list of all those who have accessed their EHR for health or administrative reasons. Use of the PAEHR is not mandatory, and patients can choose not to have their EHR accessible online. The EHR consists of many different types of documents, some of which have been manually scanned. Patients can report errors in the documents to the responsible health care provider so that they can be corrected as soon as possible.
To date, only a few studies have been performed on large-scale implementation of a national PAEHR and its use by citizens. Evaluations of digital health services are often done from a health care provider perspective, focusing on aspects that are considered important to health care professionals and decision makers. Experiences of evaluations from the perspective of the patients are still scarce [
This study aimed at understanding how patients use online access to their EHRs through a survey consisting of quantitative data supplemented by qualitative information. In particular, three main research questions were addressed to explore (1) characteristics of the users, (2) patients’ use of the service, and (3) patient experience with the service.
We conducted an online survey of users who had activated their personal account at the national health portal and accessed their EHR online at least once. Only citizens with access to the service by October 2016 were invited to participate. These included citizens living in two health regions, Northern Norway and Western Norway. The survey was available after secure log-in on the national health portal. All active users who accessed their EHR online received an invitation through a pop-up window with a brief description of the study and a link to the survey.
The online survey included questions regarding (1) background characteristics, (2) use of the service, and (3) experience with the service (
The online survey was developed by the Norwegian Centre for E-health Research in collaboration with the project implementing the PAEHR service in Northern Norway on behalf of the Northern Norway Regional Health Authority. The survey was published on the national portal by the Norwegian Directorate of eHealth. The link to the survey was available for a period of 4 weeks. All information collected through the survey was anonymous and not personally identifiable. Participation in the survey was based on consent wherein each respondent could choose not to answer the questionnaire. Ethics approval from the Regional Committees for Medical and Health Research Ethics was deemed not necessary according to the Health Research Act on medical and health research entered into force in Norway in 2009. The study was approved by the Data Protection Officer of the University Hospital of North Norway. The Checklist for Reporting Results of Internet E-Surveys (CHERRIES) was used to develop the survey and report its results [
Respondents were analyzed by age according to the following groups: 16 to 24 years, 25 to 34 years, 35 to 44 years, 45 to 54 years, 55 to 64 years, and over 65 years. Population data for the year 2015 were provided by the Center for Clinical Documentation and Evaluation and used to compare the demographic characteristics of the respondents with the general population and patients receiving specialist health care. Participation and completion rates were not reported, as data on unique visitors were not available. The selection of respondents to this survey was assumed to be representative of those who actually used the service.
Data on patient use and experience with the service were summarized by descriptive statistics as well as by graphs. In the analysis of the questions concerning user satisfaction with the service, results were summarized by the proportion of respondents who agreed with a certain aspect (scores 3 and 4) and those who disagreed (scores 1 and 2). Possible variations in service utilization among respondents were explored by analyzing frequency of use (light users vs regular users) against patient characteristics. A Pearson Chi-square test was used to explore associations between the two categorical variables.
Qualitative data provided in the open text fields were subject to content analysis [
Data analysis was performed by NORCE Northern Research Centre and the Norwegian Centre for E-health Research. Data were extracted in Excel (Microsoft Corp) and further analyzed in SPSS Statistics version 25 (IBM Corp) and R version 3.4.2 (R Foundation for Statistical Computing).
The online survey was available on the national portal from October 24, 2016, to November 21, 2016. In total, 1037 users answered the survey. Of these, 569 respondents (54.9%) were from Western Norway, 395 respondents (38.1%) were from Northern Norway, and 73 respondents (7.0%) had received health care in both regions (
Respondents were almost equally distributed by gender, with a slightly higher proportion of female users. Users in all age groups accessed their EHR online. Use of the service was higher for people aged 25 to 54 years (ie, citizens in their prime working lives). Access was lower for citizens in the age group over 65 years compared with the general population and those receiving specialist health care (
Only 9.3% (96/1037) of the respondents had an education at primary or secondary school level. Almost half of the users (491/1037, 47.3%) had an education at university level or higher. About a third of the respondents had a health care professional background.
About half of the respondents described their health status as good, while 18.6% (193/1037) considered themselves to be in poor health. Overall, 90.3% (937/1037) of the users reported to have sought a doctor (including hospitalizations) at least once in the previous year.
Characteristics of the users.
Characteristic | Value, n (%) | ||
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Northern Norway | 395 (38.1) | |
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Western Norway | 569 (54.9) | |
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Both regions | 73 (7.0) | |
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Male | 447 (43.1) | |
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Female | 590 (56.9) | |
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16-24 | 114 (11.0) | |
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25-34 | 232 (22.4) | |
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35-44 | 225 (21.7) | |
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45-54 | 207 (20.0) | |
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55-64 | 152 (14.6) | |
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Over 65 | 107 (10.3) | |
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Primary school | 11 (1.1) | |
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Secondary school | 85 (8.2) | |
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Technical school | 55 (5.3) | |
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High school | 395 (38.1) | |
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University | 475 (45.8) | |
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Doctoral degree | 16 (1.5) | |
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Yes | 266 (25.7) | |
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No | 771 (74.3) | |
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Very good | 165 (15.9) | |
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Good | 361 (34.8) | |
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Moderate | 283 (27.3) | |
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Bad | 159 (15.3) | |
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Very bad | 34 (3.3) | |
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N/A | 35 (3.4) | |
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Yes | 937 (90.3) | |
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No | 64 (6.2) | |
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N/A | 36 (3.5) | |
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1-5 | 365 (52.0) | |
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6-10 | 200 (28.5) | |
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11-20 | 62 (8.8) | |
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Over 20 | 75 (10.7) |
Distribution of users by age groups compared with patients receiving specialist health care and the general population.
About a third of the respondents (305/1037, 29.4%) accessed their EHR online regularly, and a similar proportion of respondents (303/1037, 29.2%) used the service when necessary (
The vast majority of users accessed their EHRs online to look up health information received from the health care provider (687/778, 88.3%) or to keep track of their treatment (684/778, 87.9%). Another important reason for using the service was to prepare for an appointment or a hospital admission. Patients also considered it useful to share documents with their GP, other health care professionals, family, or friends.
Over half of the respondents (432/778, 55.5%) found the service while exploring another section of the national portal [
The analysis of service utilization against patient characteristics (
Patient use of online access to electronic health records.
Patient use of the service | Value, n (%) | |
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First time | 283 (27.3) |
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A couple of times | 146 (14.1) |
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When needed | 303 (29.2) |
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Regularly | 305 (29.4) |
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None | 259 (25.0) |
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1-50 | 601 (58.0) |
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50-99 | 96 (9.2) |
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100-499 | 60 (5.8) |
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>500 | 21 (2.0) |
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Less than 15% | 88 (11.3) |
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15%-49% | 78 (10.0) |
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50%-79% | 96 (12.3) |
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80%-99% | 206 (26.5) |
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100% | 310 (39.9) |
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Look up health information | 687 (88.3) |
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Keep track of the treatment | 684 (87.9) |
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Prepare for an appointment or admission | 498 (64.0) |
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Share documents with GPa or other health care professionals | 292 (37.5) |
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Share documents with family and friends | 194 (24.9) |
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Helsenorge | 432 (55.5) |
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Media (newspaper, radio, TV, social media, etc) | 129 (16.6) |
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Health care professionals | 115 (14.8) |
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Written information at the hospital | 110 (14.1) |
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Other | 76 (9.8) |
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Family or friends | 72 (9.3) |
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Yes | 119 (15.3) |
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No | 659 (84.7) |
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Yes | 14 (35.9) |
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No | 25 (64.1) |
aGP: general practitioner.
Association between service utilization and patient characteristics.
Patient characteristics | Light usera, n (%) | Regular userb, n (%) | ||
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Northern Norway (n=395) | 129 (32.7) | 266 (67.3) |
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Western Norway (n=569) | 251 (44.1) | 318 (55.9) |
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Male (n=447) | 215 (48.1) | 232 (51.9) |
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Female (n=590) | 214 (36.3) | 376 (63.7) |
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16-24 (n=114) | 63 (55.3) | 51 (44.7) |
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25-34 (n=232) | 102 (44.0) | 130 (56.0) |
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35-44 (n=225) | 87 (38.7) | 138 (61.3) |
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45-54 (n=207) | 79 (38.2) | 128 (61.8) |
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55-64 (n=152) | 54 (35.5) | 98 (64.5) |
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Over 65 (n=107) | 44 (41.1) | 63 (58.9) |
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Primary school (n=11) | 5 (45.5) | 6 (54.5) |
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Secondary school (n=85) | 29 (34.1) | 56 (65.9) |
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Technical school (n=55) | 22 (40.0) | 33 (60.0) |
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High school (n=395) | 158 (40.0) | 237 (60.0) |
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University (n=475) | 210 (44.2) | 265 (55.8) |
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Doctoral degree (n=16) | 5 (31.3) | 11 (68.8) |
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Yes (n=266) | 90 (33.8) | 176 (66.2) |
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No (n=771) | 339 (44.0) | 432 (56.0) |
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Very good (n=165) | 109 (66.1) | 56 (33.9) |
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Good (n=361) | 157 (43.5) | 204 (56.5) |
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Moderate (n=283) | 90 (31.8) | 193 (68.2) |
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Bad (n=159) | 52 (32.7) | 107 (67.3) |
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Very bad (n=34) | 9 (26.5) | 25 (73.5) |
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Yes (n=937) | 354 (38.0) | 583 (62) |
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No (n=64) | 54 (84) | 10 (16) |
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None (n=259) | 223 (86.1) | 36 (13.9) |
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1-50 (n=601) | 189 (31.4) | 412 (68.6) |
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50-99 (n=96) | 8 (8.3) | 88 (91.7) |
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100-499 (n=60) | 6 (10.0) | 54 (90.0) |
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>500 (n=21) | 3 (14.3) | 18 (85.7) |
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aUsed the service for the first time/a couple of times.
bUsed the service when needed/regularly.
The vast majority (965/1037, 93.1%) of the users found it easy to access their EHR online (
About two-thirds of respondents (476/713, 66.8%) expected to have more documents accessible through the service, while only a small percentage of patients (40/703, 5.7%) thought that there were too many documents (
Clinical advantages to the patients included a better understanding of their health condition (565/691, 81.8%) and easier control of their health status (685/740, 92.6%). After using the service, most users acknowledged that they felt better prepared for future hospital visits or admissions (571/653, 87.4%) and that it became easier to communicate with health care professionals at the hospital (493/618, 79.8%). Patients also experienced increased empowerment. They felt more responsible for their treatment (413/660, 62.6%) and thought that they could better influence its progress (493/674, 73.1%). Only a small proportion of patients (136/707, 19.2%) expressed concerns about the information accessible online. Users also experienced better security (655/730, 89.7%) when accessing their EHR online.
The overall satisfaction with the service was very high (700/755, 92.7%). The vast majority of the respondents stated that they would continue accessing their EHR online in the future (753/778, 96.8%) and they recommended the service to others (695/778, 89.3%;
Accessibility and patient preferences with online access to electronic health record.
Patient experience with the service | Value, n (%) | |
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Very easy | 559 (53.9) |
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Easy | 406 (39.2) |
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Difficult | 52 (5.0) |
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Very difficult | 20 (1.9) |
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Yes | 11 (15.3) |
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No | 61 (84.7) |
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Yes | 753 (96.8) |
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Maybe | 18 (2.3) |
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No | 7 (0.9) |
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Yes | 695 (89.3) |
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Maybe | 72 (9.3) |
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No | 11 (1.4) |
Patient satisfaction with online access to electronic health record.
A total of 268 comments, most of which were positive (252/268, 94.0%), were provided in the open text field following the question related to willingness to use the PAEHR in the future. The main reason (203/268, 75.7%) why respondents would continue accessing their EHR online was related to the perceived impact of the service. Patients reported that the PAEHR helped them to gain a better understanding of their health status, obtain a more comprehensive overview of hospital access, and follow their treatment more closely. This was particularly important for patients with complex, long-term, or chronic conditions.
This [service] has a great value to me as a patient. Now I have a much better picture of my own disease than before. I often have visits with specialists who are not very communicative, and now I have the opportunity to prepare questions—and the best expert on my own illness is myself. Why didn't this service come before?
Patients also appreciated the chance to easily read all the information that health personnel wrote about them after attending visits, thus becoming more confident in understanding it, reporting mistakes or misunderstandings, and being better prepared for future visits.
I am under psychiatric evaluation. By accessing the health records between visits I can see if the health personnel has misunderstood something I have said. This can be clarified during the next consultation. When the health personnel writes things which have not been discussed yet, I can be better prepared for the next consultation. The service therefore makes the treatment more effective and more appropriate.
There were also 23 comments (8.6%) regarding practical benefits of using the service. Patients especially appreciated the convenience of accessing their EHRs directly from home, where they could easily find all their digital documents in one place and read them in a peaceful environment. The remaining comments were related to positive feedback of a more general nature (21/268, 7.8%), criticism (16/268, 6.0%), or additional information on health status (5/268, 1.9%).
In the second open text field following the question on whether respondents would recommend using the service to others, a total of 208 comments were expressed, most of which were positive opinions (197/208, 94.7%). Online access to EHRs were described as useful, informative, effective, helpful, easy, practical, and safe.
I think that this service is especially good when you have old parents or very sick family members who do not get all the information when they are at the doctor or at the hospital. A relative can then get permission to read and try to understand the content and follow up with the treatment (for instance, hospitals admissions, etc.). Everything is all gathered here, instead of having papers around your house.
Another advantage perceived by the users was that the PAEHR increased accessibility compared with the traditional practice of requesting a copy of their health records on paper or CD. This, in turn, contributed to improved patient engagement.
Many are interested in what is written in their health record but just not enough to make them ask to get access to it. Through online access it becomes easier for most people to keep themselves up to date on their own health record, as well as on future appointments.
There were 2.4% of respondents (5/208) who expressed mixed comments regarding the utility of the service, which could be more or less beneficial depending on the user characteristics (eg, age, computer literacy) as well as their health condition. There were only 2.9% of comments (6/208) expressing concerns about online access to EHR, some of which was pointed out by users with a health care professional background.
Online access to the health record should not be open to everyone. Now I think first of all about psychiatric patients. I think it can be negative and cause distrust toward health personnel, making them feel like patients and not like persons (due to the way things are formulated and professional expressions). Several of the patients I talk with feel unheard and trust much less in the treatment and health care providers than before...Health professionals also express uncertainty and dissatisfaction with open access to health records.
Finally, 129 comments were provided in the open-ended question included at the end of the survey where users could write additional thoughts. Four common themes were identified after analyzing the content of these answers: availability of documents, information about their health status, technical issues and suggestions for improvement, and experienced satisfaction. There were 36.4% of comments (47/129) concerning the availability of documents online. Some users missed the chance to access older documents, health records from their GP or other health professionals, documents for their children, laboratory test results, and digital imaging tests. There was also a number of comments about the current lack of documents from the two other health regions which had not yet implemented online access to EHRs. Other respondents reported that they had no or little information visible in their PAEHR. A total of 36.4% of users (47/129) voluntarily provided comments with general information about their health status. There were 13 users who underwent cancer treatment, and 16 users who referred to the presence of chronic illness, such as rheumatologic diseases and other musculoskeletal conditions. Other comments were related to different long-lasting conditions, health problems under treatment, or simply additional information about the number of visits to the hospital. There were 17.8% (23/129) comments specifically reporting issues of a technical nature encountered while using the service. Most comments were related to difficulties in opening specific types of documents and file formats, using a mobile phone, logging in, or accessing specific features. Features which could be improved were the possibility of retrieving the access log, marking documents read and unread, and asking to modify or delete documents. Some respondents also suggested new functions. There were, for instance, four users who expressed their wish for a feature where they could register themselves as blood, organ, or body donors. Finally, 9.3% of comments (12/129) included feedback regarding general satisfaction with the service and its benefits for patients, such as a better understanding of their own health condition. Two users expressed some concerns related to how the communication with health personnel changed after accessing their EHR online.
The results obtained from this survey showed that PAEHR in Norway is becoming a mature and useful service. Most of the users accessed their EHR online regularly, for instance when new information became available after a hospital appointment, and read most of the digital documents. The vast majority of the users had at least one doctor's visit in the previous year, meaning that they had digital documents which were recently made available online. There were fewer patients who tried the service for the first time, some of whom did not have any documents accessible. Service utilization for users in Northern Norway was higher than for those in Western Norway, reflecting the earlier implementation of the service in that region.
The findings of this study seemed to be aligned with the most recent version of Andersen's behavioral model used to analyze utilization of health care services based on contextual as well as individual determinants of access to medical care [
Most respondents indicated that the system was easy to use, confirming the positive findings from other studies on patient experience with PAEHRs [
Patients using PAEHRs in Norway perceived a number of clinical benefits that were also found in other studies, including enhanced knowledge of their health and improved self-care [
With a total of 1037 respondents, this survey is one of the few large-scale studies focusing on patient experience with PAEHRs. We were able to collect a large amount of quantitative data from multiple choice questions and use them to describe the characteristics of the users, patient use of the service, and patient experience with the service. Moreover, quantitative data were used to explore the association between different variables and especially how patient characteristics affected service utilization. However, this was mainly a descriptive survey rather than an explorative study. For a robust investigation of the factors affecting service utilization, a more comprehensive data collection process would be needed. Qualitative information was also collected from three open text fields. A total of 605 comments were analyzed and used to support the quantitative data. Users providing additional comments tend to be those who have very positive or negative experiences. To collect more detailed information on relevant topics, such as patient empowerment, in-depth qualitative interviews with randomly selected users should be conducted in future studies.
Despite the number of respondents, one main limitation of this study is related to its design. Although observational studies and surveys have provided evidence of benefits and satisfaction for patients, there is still little reliable evidence of improved health outcomes from experimental studies [
This was one of the largest surveys conducted on the use of PAEHRs, with respondents from two of the four health regions in Norway. By 2019, online access to EHRs will be offered to citizens in South-Eastern Norway, meaning that an even larger proportion of the population will have access to the service. Patient experience with the service might be influenced by a different level of maturity of the service and therefore vary across regions. For such a wide-scale routine service, whose functionalities might change over time, it is important to implement continuous evaluation programs able to simultaneously evaluate digital health interventions while they are being designed, developed, and deployed [
We conducted an online survey of users of the PAEHR in Norway. A total of 1037 respondents participated in the survey, most of whom accessed their EHRs online regularly. Service utilization was associated with self-reported health, age, gender, education, and health care professional background. Patients were highly satisfied with the service and found it useful to look up health information, keep track of their treatment, prepare for a hospital appointment, and share documents with their GP or family. Users also experienced clinical benefits from accessing their EHR online, including enhanced knowledge of their health, improved self-care, greater empowerment, easier communication with health care providers, and increased security. Future studies should include both experimental designs focused on specific populations or chronic conditions that are more likely to achieve clinically meaningful benefits and continuous evaluation programs to evaluate implementation and changes of wide-scale routine services over time.
Online survey (in Norwegian).
Checklist for Reporting Results of Internet E-Surveys
electronic health record
general practitioner
patient-accessible electronic health record
We thank the Norwegian Directorate of eHealth for publishing the survey on the national portal.
PZ contributed to conception and design of the study, acquisition of data, analysis of data, interpretation of data, and drafting and revision of the manuscript. PEK contributed to analysis of data, interpretation of data, and revision of the manuscript. TS contributed to conception and design of the study, interpretation of data, and revision of the manuscript. MAJ contributed to conception and design of the study, interpretation of data, and revision of the manuscript. All authors read and approved the final manuscript.
None declared.