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Original Paper

Defining Empowerment and Supporting Engagement Using Patient
Views From the Citizen Health Information Portal: Qualitative
Study
Tracie Risling*, RN, PhD; Juan Martinez*, RN, BSN, BSc; Jeremy Young*, RN, BSN, BSc; Nancy Thorp-Froslie*,
BS, MPH
College of Nursing, University of Saskatchewan, Saskatoon, SK, Canada*

all authors contributed equally

Corresponding Author:
Tracie Risling, RN, PhD
College of Nursing
University of Saskatchewan
4218 Health Sciences Building, E-Wing
104 Clinic Place
Saskatoon, SK, S7N 2Z4
CanadaPhone: 1 306 966 6232
Email: tracie.risling@usask.ca

Abstract
Background: The increasing presence of technology in health care has created new opportunities for patient engagement andwith this, an intensified exploration of patient empowerment within the digital health context. While the use of technology, suchas patient portals, has been positively received, a clear linkage between digital health solutions, patient empowerment, and healthoutcomes remains elusive.
Objective: The primary objective of this research was to explore the views of participants enrolled in an electronic health record
portal access trial regarding the resultant influence of this technology on their feelings of patient empowerment.
Methods: The exploration of patient empowerment within a digital health context was done with participants in a tetheredpatient portal trial using interpretive description. Interpretive description is a qualitative methodology developed to pragmaticallyaddress clinical health questions. Patient demographics, self-reported health status, and self-identified technology adaptation
contributed to the assessment of empowerment in this qualitative approach.
Results: This research produced a view of patient empowerment within the digital health context summarized in two overarchingcategories: (1) Being Heard and (2) Moving Forward. In each of these, two subcategories further delineate the aspects of
empowerment, as viewed by these participants: Knowing More and Seeing What They See under Being Heard, and Owning
Future Steps and Promoting Future Care under Moving Forward. This work also highlighted an ongoing interconnectedness
between the concepts of patient empowerment, engagement, and activation and the need to further articulate the unique aspectsof each of these.
Conclusions: The results of this study contribute needed patient voice to the ongoing evolution of the concept of patient
empowerment. In order to move toward more concrete and accurate measure of patient empowerment and engagement in digital
health, there must be further consideration of what patients themselves identify as essential aspects of these complex concepts.
This research has revealed relational and informational elements as two key areas of focus in the ongoing evolution of patient
empowerment operationalization and measure.
(JMIR Med Inform 2018;6(3):e43) doi: 10.2196/medinform.8828
KEYWORDS
digital health; electronic health record; patient engagement; patient empowerment; patient portal

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Introduction
Patient-centered care has long been promoted, debated, andpursued, yet substantial reform to established institutional
approaches has proved challenging. The increasing presence oftechnology in health care delivery, coupled with consumer
demand, is contributing to a remarkable shift in traditional
practices and a renewed interest in patient empowerment as ameans to advance this long-sought reform [1,2]. However,decades of debate and varied conceptual application haveresulted in a lack of clarity in how to best operationalize or evenconsistently define patient empowerment [3-6]. Despite thesechallenges, recent reviews on patient empowerment reveal a
global interest in this concept [2,3,5]. The World HealthOrganization (WHO) European Regional Office included
empowerment and patient-centered practice as key elements in
its Health 2020 report [7], a follow-up on previous WHO study
on the effectiveness of empowerment to improve health [8]. In
this earlier work, WHO identified empowerment as an essential
public health strategy and also noted a scarcity of refinedevaluative measures [8]. Many years later, this need for acomprehensive operational definition of patient empowerment
and robust measures to evaluate the concept remains [2,3,5].
Publication on patient empowerment is increasingly present indigital health literature [9-12], with an emerging considerationthat “the future of patient empowerment may lie in technologicaladvancements and better access of patients to thesetechnologies” [13]. As technology is promoted as a means toadvance patient empowerment [9,10,14,15], the need to addresscontextual considerations in applying this concept to digital
health has also been raised [12,16]. Patient empowerment has
been examined in conjunction with technological apps such as
electronic personal health records [17,18], patient Web portals[19], and electronic medical records [20]. Patient portals or“tethered” electronic personal health records are Web-based
portals linked to electronic health records (EHRs) [14]. Studies
on patient portals seem to have emerged as a focal point in thisstudy, with connections made between portal use, patient
empowerment, engagement, and activation and ultimately
improved personal health outcomes [21-24].
Despite this promising beginning in the exploration of patient
empowerment in digital health, a clear linkage among the useof digital health services, patient empowerment, and healthoutcomes remains elusive. Previous work has characterized thechallenges of advancing a clear and comprehensive definitionof patient empowerment in digital health app [3-5]. Suchchallenges emerge from the mixed or combined use of patient
empowerment with terms such as patient engagement,
enablement, activation, and even patient-centeredness, although
calls for the distinct use and application of each of theseconceptual entities have repeatedly been made [5,25,26]. A
previously published scoping review, by these authors on patient
empowerment measures, further highlighted the current discordin operationalizing patient empowerment [27]. The gaps andinconsistencies in the measures of empowerment are further
exacerbated by negligible contributions of patient voice [3,27].
As such, incorporating patient perceptions into the developmentof patient empowerment measures has emerged as a critical
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Risling et al
need to disentangle the interconnectedness between patient
empowerment, engagement, and activation, specifically withregards to the use of patient portals in digital health [3,27]. The
primary objective of this qualitative study was to explore theinfluence of the patient portal use on patient views andperceptions of empowerment. Incorporating an underrepresented
qualitative narrative with the current empowerment study
maximizes opportunities for patient voice to direct
patient-centered care while contributing to the needed
delineation of empowerment aspects associated with patient
portal use.

Methods
Study Aim
This study aimed to characterize participant experiences andviews of empowerment related to the use of patient portals. This
study was supported by a previous scoping review, by theseauthors, which explored current practices in theoperationalization of patient empowerment in relation to theuse of tethered patient portals [27].

Recruitment, Appraisal of Health, and Technology
Adaptation
Following the approval from the Research Ethics Board of thelead author’s institution, participant recruitment was conductedin collaboration with eHealth Saskatchewan, which, with thesupport of Canada Health Infoway, had recently deployed alimited launch of the Citizen Health Information Portal (CHIP).
This tethered patient portal was provided to approximately 1000
provincial residents facilitating access to data contained in their
EHR. The portal allowed patients to add medical history
information and provided views of laboratory results,
immunizations, prescriptions, and hospital discharge summaries,
as well as an opportunity to set reminders for medications andappointments [28]. All CHIP participants received an email
invitation to participate in the study. No geographical limits
were imposed during recruitment, but participants did need to
be English speakers. The recruitment process resulted in apurposive sample of 26 participants for the study.
Regarding the demographic data collection, participants wereasked to self-identify their current health status. The primarymeans of accessing Web-based information was also assessedby self-report in this group. Finally, the research team used amodified adaptation of Rogers’ diffusion of innovations theory[29] to explore participant comfort in adopting and using newtechnologies. Rogers used the following 5 stages to identify
how innovations are transmitted and taken up by members ofa social system: (1) Innovators, these individuals are typicallyrisk-takers and lead the way when it comes to new technologies;(2) Early Adopters, includes individuals who will be among thefirst to try new technologies; (3) Early Majority, represents
individuals who take time to consider trying out something new
before acquiring and using it; (4) Late Majority, includes thegroup of individuals that is somewhat cautious about trying newtechnologies and will tend to adopt the use of technology more
slowly than the average; and (5) Questioners, representing thelast group that will uptake a new technology with users that
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typically require proof that new technology is worth investingin [29].

Data Collection and Analysis
Data collection was primarily achieved through semistructured
interviews (Multimedia Appendix 1), and members of theresearch team also observed and collected data during a CHIP
pilot participant focus group run by eHealth Saskatchewan.
Once complete, the digital data files were transcribed,
deidentified, and reviewed for accuracy, in preparation foranalysis.
In this study, interpretive description (ID) was used, a qualitative
methodology first detailed by Thorne et al [30]. ID wasdeveloped as a way of generating clinically relevant knowledge
for health disciplines, and Thorne has since published, andrecently updated, full text on this approach [31]. Initially, adetailed line-by-line coding of the data was undertaken within
the transcript documents to provide an initial sense of the scopeof the data. These early coding efforts revealed a wide diversity
in the topic, enhanced by the line-by-line approach. The researchteam returned to the transcriptions to create a more focused
dataset by collating all passages related to empowerment andengagement. In addition, the study team included any mentionof either, or both, of these terms in the dataset based on theestablished interconnection of the concepts in the previously
conducted scoping review [27].
The dataset was prepared in a split-page word document format,
and the research team returned to the coding process. Moving
away from the granular line-by-line approach, the data wereinstead examined, as Thorne recommended, through an“exploration of commonalities and differences among andbetween individual experiences” [32], reflective memoing wasused during the analysis along with regular interchanges between
research team members to share emerging interpretations andcode categories. The ongoing dialogue supported the explorationof outlier data and allowed the team to come to consensus on

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how to integrate these findings. As the code categories began
to coalesce and the interpretation emerged, the research teamused the proposed descriptive categories and returned to the fulltranscript data set for a final review; this was done to ensure noother experiences or elements needed to be integrated into theanalysis and final interpretation.

Results
Participant Demographics
All participants (N=26) resided in one Western Canadianprovince. The majority of participants were females (n=18),
with fewer (n=8) male participants. Although the age ofparticipants ranged 20-85 years, the predominant age category
was 60-69 years (n=14), as shown in Figure 1.
As summarized in Figure 2, there was a diversity of self-reported
health status, with the majority of participants rating their healthwithin the well options. The way through which participants
gained access to their health information on the portal varied,with most using a combination of personal computers, tablets,
and mobile devices (n=15; data not shown). Figure 3 shows therange of self-identified technology adoption among the study
participants, spanning the full scope of Rogers’ continuum.

Interpretive Description Findings
Categories
From the experiences shared by CHIP participants (N=26) inthis qualitative exploration of empowerment and engagement,
the following two overarching categories emerged: Being Heard
and Moving Forward. For each of these, 2 subcategories were
defined to delineate the aspects of empowerment andengagement further, as viewed by these participants: Knowing
More and Seeing What They See (under Being Heard) andOwning Future Steps and Promoting Future Care (under Moving
Forward). Figure 4 presents these categories, and each will be
reviewed further.

Figure 1. Participants’ age ranges.

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Figure 2. Self-identified health status of participants ranging from well to acutely ill with chronic illness(es).

Figure 3. Technology adoption by participants.

ID is especially useful in considering the voice of the outlier orcontrasting case [31]. In this way, ID is an opportunity tooperationalize a patient-centered approach in the research app.
In the case of this interpretive work on empowerment andengagement in relation to the patient portal experience, theresearch team encountered a participant whose view of
empowerment was contrary to what had been commonly
expressed. These data supported the emergence of the firstoverarching category in this interpretation, Being Heard.

Being Heard
Very early in the exploration of the participant transcripts, strong
support emerged for empowerment, and many positive views
about the concept were expressed. However, 1 participant did
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not seem to share this certainty when asked about the conceptof patient empowerment, he responded:
I don’t know if I like that word. It is just encouraging
to see that healthcare is going in a positive direction
these days, and it just tells me and it makes me feellike I do have a say in my healthcare and how it’sadministered to me and I want people to hear me thefirst time I present them with an issue, and that’s
something I really appreciate.
Although the participant was unsure about the use of patient
empowerment, there existed an essential element that arosefrom his statement about being heard the first time that resonatedwith the research team. A code category Being Heard was
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proposed, and the team returned to the data using the lens of
this outlier view to determine whether other participants
expressed similar sentiments. From this exploration, theoverarching category of Being Heard was established. During
the interpretative analysis, this category evolved to include 2
further subcategories or themes: Knowing More and Seeing
What They See. Table 1 summarizes participant quotes
supporting the development of this category and the included
themes.

Together, Knowing More and Seeing What They See represent
the empowered view of Being Heard. Overwhelmingly, study
participants shared views that demonstrated that they werelooking for opportunities to not only be further engaged in theirown health care but also feel as though they were valued andknowledgeable team members in the decision making anddelivery of this care. This sense of empowerment in future
direction was represented in the second category of Moving
Forward.

Knowing More
Pilot participants in the CHIP project could access their EHR,
and a familiar sentiment about the availability of this new sourceof personal data was expressed by 1 study participant: “I guess
I could go back to the old adage where you hear people say
information is power.” In general, there was a significant
response to the value of having direct access to personal healthcare data, especially as laboratory and medication information
was updated in near real-time. This knowledge was often
connected to the sense of empowerment, as demonstrated in thequoted excerpts in Table 1. Furthermore, the access to
information was a foundational element of empowerment forthese participants and a primary driver for their ongoinginteractions with the portal. Moreover, Knowing More was a
crucial foundation to support the pursuit of Being Heard.

Moving Forward

Seeing What They See
The second element of Being Heard was a focus on what could
be seen. Moving beyond the experience of simply Knowing
More, Seeing What They See reflected not only the information
but also an empowered sense of shared access to timely healthcare data with providers themselves. This access supported avariety of patient initiatives, as detailed in a few patient excerpts
highlighting this theme in Table 1. Although some mixed
feelings were reported regarding having access to test results,
as well as differing opinion on whether this would increase or
decrease physician workload, the overall sense of equality inbeing provided the same type of information that their own
providers received was remarkable for study participants. There
were recommendations that additional information, or
suggestions, from providers to support self-care or behavioral
changes, based on the data available in the portal, beincorporated in future offerings.

This second overarching categorization comprised 2
subcategories or themes, Owning Future Steps and Promoting
Future Care; these summarize the views of participants first in
relation to their own self-care and second regarding their hopesand expectations for future technological advancements to
support their ongoing involvement and engagement in theirhealth care. Table 1 details participant quotes supporting thiscategory and resultant themes.
Owning Future Steps
Although many participants in this study reported a history of
substantial involvement in directing their own health, there wasa profound sense of the significance of this portal technology
in cementing the role of patients in the care relationship,especially in relation to decision making and engaging in
self-care behaviors, as depicted in several quotes in Table 1.
Where Being Heard was about taking in information and feelingempowered in the patient-provider relationship, Moving
Forward, and in particular, Owning Future Steps, represented
the resulting action when patients worked from an empowered
position. Finally, the significance of the portal access in the
lives of these participants, and its influence on their views ofan evolving digital health care landscape, was summed in
Promoting Future Care.
Promoting Future Care
Participants in this study provided a powerful contrasting viewof a commonly held perception about the willingness of older
patients to engage in technological health care solutions.
Promoting Future Care not only highlights the desire of theseparticipants to have continued access to the citizen portal but
also for other technologies that could provide a more connected
and supported health care future; details of this can be seen in
the participant quotes for this theme in Table 1.

Figure 4. Interpretive categories identified in the qualitative study.

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Table 1. Participant quotations supporting the themes in the category Being Heard.
Category and theme

Quotations

Being Heard
Knowing More

•
•
•
•
•
•
•
•

Seeing What They See

•
•
•
•

“I mean when I say empower, it empowers me, I would say it just gives me the confidence to know whether I’masking the right questions or I have asked the right questions.”“It (the CHIP information) makes me a little bit more empowered to help make those decisions.”“Empowerment, so you can understand and know what’s going on.”“To be empowered means to be aware of what is happening with your health.”“I can look up and see that information, make decisions, have less repetitive questions with my doctor and focus
on the things that I really need to know.”“It’s helping me assume responsibility and to be knowledgeable and I think to just be better prepared when I go
see the doctor so I can ask meaningful questions.”“You’re not anxious about it and, you know, if you’re worried about something, you have a resource now thatkind of tells you where to go with it or helps you determine where to go with it.”“I think it provides me with some peace of mind, because like I said, instead of hoping and being pretty sure it’s
all fine, you can look, and you can know.”“If I can see what they are seeing maybe in a little bit in advance, then I can be better prepared when I go to my
doctor’s office; like have my list of questions ready.”“I go back and look at my numbers, try to make some changes right there. So it gives me more up-to-date informationand not having to wait to get in to see the doctor if there was something that’s off. If it’s something that I’d try tocontrol myself like the blood sugar levels or A1C then that’s something that I can take into my own consideration.”“CHIP has literally been a lifesaver for me, because I’ve been able to get my results before I even see the doctors,
I’m able to formulate the questions that I need to ask the doctor and get far more engaged in my health care.”“To be empowered means to be aware of what is happening with your health, and test results can help that. Information from doctors and health care people can help that, and that way you can make the changes and adjustmentsthat you may need to be well.”Moving Forward
Owning Future Steps

•
•
•
•
•

Promoting Future Care •
•
•
•
•
•
•
•
•

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RenderX“When I become engaged in my healthcare and utilizing the resources I can access, I try to garner enough knowledge
and understanding to feel empowered to take the next step.”“It has become very apparent the importance of informed self-care, not taking the doctors and the health professionals out of the equation, but to be able to take some of that information and look at what I can do as an individual to help myself.”“I need to be able to manage that, because I’m the one that’s doing it every day.”“I can see that it’s vital, the way they we’re moving, that we have that self-empowerment that comes from using
this information, having access and using this information ourselves.”“Well, I think something like that will give you more empowerment because it’ll give you a track to follow, it
should give you something to follow, and I think that there’s even something else that could be done with that, in
terms of empowering your healthcare.”“I think if you want people engaged in the health system, you need to make the health system accessible, and I
think this is certainly one way to do it.”“I think this type of technology will also empower physicians to be able to give patients better care, or more
timely care.”“So I think that when you talk about technology and what it means, I think it’s just endless. There’s so much andI think it really has a future that will allow for a whole different kind of coordination and communication.”“CHIP is wonderful. I want very much for it to continue and I would encourage over time for more information
to be shared on it, I mean things like perhaps radiologist reports and those kinds of things.”“I think it’s a great idea, I really do. We live in a technology age, we’re in an online age. People want information
at their fingertips, they do a lot of this kind of stuff from home or from their smartphone or whatever. I think thisis an idea whose time is here.”“I personally think it’s amazing, obviously, it has its limitations, but the only challenge will be presenting it in a
way that people with different demographics and all types of background will accept it and be on board.”“I have mixed feelings about the increasing presence [of technology]. I love the access, I like the idea that if I
needed care in a hurry people would have access to my information. I think that the more that happens the better,but the trade-off of that is the risk of somebody going in and looking at your information to use it to do you harm.”“Well, I’m probably as ambivalent as a lot of people are. Worrying a bit about security of information, enjoying
having the access to it but still kind of okay, is it secure? How secure is it?”“Technology is, I mean I see it as a double-edged sword. It’s lifesaving and also costly as heck. I’m sure this whole
CHIP thing doesn’t come for free but as a service I think it’s very—however much it costs— I’m hoping it’s not
too much that they don’t find that it’s not worthwhile, because I think that it is (worthwhile) if it’s affordable.”

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Textbox 1. Participant quotations identifying challenges or limitations with patient portal use.
•

“The amount of information that’s there, you know it’s going to be overwhelming for some people.”•“I don’t really think it changed anything, because I knew enough to ask.”•“I sometimes don’t think it’s always necessary for a doctor to give you that information unless there’s an interpretation required.”•“I don’t know that I want to be more engaged. I don’t know enough about it so I just sort of trust that my doctor’s doing what’s best.”•“The patient engagement is for people who want it, not everybody is going to want it.”Though enthusiastic about the integration of technology into
their health care futures, the study participants also expressedpractical views regarding the potential impact of this shift inaccess and delivery. Concerns about privacy, cost, and theimportance of continuing to focus on people in care wereexpressed. As has been noted, ID promoted the inclusion ofoutlier views in the interpretative process. Textbox 1 summarizes
some key contrasting participants’ views about the portal
technology and engagement in this type of access.
The use of ID serves as a very effective reminder for researchers,
practitioners, and digital solution providers that no single
initiative is going to meet every need regarding patientengagement and empowerment. The ongoing exploration ofviews, like those represented in Textbox 1, is key to recognizing
not only potential research limitations but also those in the larger
digital health milieu. Overall, a strong positivity associated withthe expanding role of technology in health care, especially forservices like patient portals, which allowed for improved patient
access to their health care data.

Discussion
Principal Findings
Although there has been a considerable amount of academic
exploration and publication on patient empowerment, a recent
analysis revealed that a clear definition of the concept is stilllacking [3,5,6]. In addition, there has been little consideration
about the influence digital health may have on key attributes ofpatient empowerment. Overall, these findings support an existing
challenge with the operationalization of this concept for use indigital health research. Following a previously published scoping
review on patient empowerment measure in digital health [27],this qualitative study was conducted to contribute the needed
patient voice to the ongoing discourse on empowerment indigital health and provide insight for the development of future
measures.
Elements of the aspects of empowerment identified in this study
through Being Heard and Moving Forward, and their respective
subcategories, can be noted in previously articulated views of
empowerment summarized by Bravo et al [3] in their recent
analysis of patient empowerment: first, in this widely useddefinition by Funnell et al [33] from the early 1990s, “We havedefined patient empowerment as the discovery and developmentof one’s inherent capacity to be responsible for one’s own life.
People are empowered when they have sufficient knowledge
to make rational decisions, sufficient control and resources toimplement their decisions, and sufficient experience to evaluate
the effectiveness of their decisions” and second in the work of
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Lau [34] “Patient empowerment begins with information andeducation and includes seeking out information about one’s
own illness or condition, and actively participating in treatment
decisions.”
The alignment of this qualitative interpretation with previous
work on conceptualizing patient empowerment is a positive
finding; however, it is important to note further complexities
that have been proposed through the views of these participants,
particularly those that relate to the digital health context.
Findings highlighted in Promoting Future Care speak to a desireby patients for the continued ability to be able to access theirdata electronically, as well as their hopes for the interchange ofdata in the future to support new means of communicating with
providers and ultimately more efficient care. However, there
are also unresolved concerns represented in these participant
views, regarding the privacy and security of information,technology costs, and for some, uncertainty about whether or
not the data are actually wanted.
A direct connection among digital health, patient empowerment,
and particular health outcomes have been difficult to clearly
demonstrate, with conflicting reports on the success ofinterventions summarized in several previous systematic reviews[35-41]. This challenge is reflected in this study as well incontrasting participant views on particular aspects of this digital
health solution. However, despite concerns regarding costs or
potential security risks associated with digital data, participantsin this study still overwhelmingly identified portal access as anempowering force in the management of their health; this isclearly reflected in Knowing More. The impact of having digitalaccess to critical health data appeared to be transformative forparticipants and supported enhanced preparation for practitioner
visits, as a well as an improved sense of well-being or “peaceof mind.”
CHIP participants identified a positive association between theoffered digital health solution and their sense of patient
empowerment, which may prompt further reflection on how alack of patient participation in empowerment conceptualizationand measure, as identified by Bravo et al [3], may havecontributed to the inconclusiveness of some digital healthempowerment study [35-41]. An enhanced understanding of
empowerment incorporating patient views is clearly needed to
produce a more robust conceptualization. Only when thisfoundational work is complete should attempts to advance theevaluation and measurement of this concept move ahead. With
these considerations, future measures should more accurately
demonstrate the effectiveness of digital health tools insupporting patient empowerment. This study has provided apiece of this foundation by using patient voice to provide a set
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JMIR MEDICAL INFORMATICSof conceptual elements from which the work of creating afulsome operationalization of patient empowerment within
digital health can begin.
The results of this study can be used to reflect on the aspects ofpatient portals that may have the most “empowering effects.”
In particular, the combined participant views presented in
Knowing More, Seeing What They See, and Owning Future
Steps lend support to features such as the timely release ofdiagnostic results and the ability of patients to contribute data
into their EHR. Evidence suggests that interventions, such as
patient portals, can improve self-efficacy by giving patients
tools for enhanced self-management, which, in turn, may
contribute to a heightened sense of patient empowerment [9,18].
This study further highlights the empowering sense of equalitythat results when patients feel they have access to the same dataas their health care providers, when they are Seeing What They
See. Several patients noted a change in the dynamics of theirprovider relationships and identified the timely delivery of
information as a critical element for their ongoing engagementin their health management. Furthermore, the ability to securely
exchange information through a portal was acknowledged as apriority for more active patient collaboration and provides
support to ongoing advocacy efforts for increasingly open data
adoption in digital health solutions.

Limitations

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is not generalizable or representative of the experiences of all
CHIP users or of other patients who are engaged in tetheredpatient portal use. This interpretation of patient empowerment
within a digital health context, focused on the portal use, may
however resonate with other patients, practitioners, and service
providers. Certainly, it has added much needed patient voice tothe ongoing academic pursuit of the comprehensive
conceptualization of patient empowerment.

Conclusions
Providing patients electronic access to timely personal healthinformation is a crucial step in supporting a new era ofcollaborative care. In this study, the use of a tethered patient
portal (CHIP) introduced participants to the benefits oftechnology in supporting positive health outcomes and theirown empowerment. CHIP participants shared their views ofpatient empowerment situated within the context of this digital
health experience. This qualitative study produced a morein-depth patient-centric view of patient empowerment, including
additional considerations relevant to the operationalization ofthis concept within a digital health context. This study supports
the development of a patient empowerment measure to more
effectively capture the influence of digital health initiatives on
this vital outcome. The development of this instrumentation is
the primary objective of ongoing research by members of thisstudy team.

This study is situated in the context in which it was conducted
and represents the views of pilot CHIP participants. As such, it

Acknowledgments
The research team would like to thank the 26 study participants who volunteered their time to contribute to this work and provide
new insights into patient empowerment in digital health. The study team also acknowledges the funding provided by eHealth
Saskatchewan for this research, as well as the role of Canada Health Infoway in supporting the pilot delivery of the CHIP. In
addition, we extend our thanks to the University of Saskatchewan for the provision of funds associated with the undergraduate
summer research assistant program.

Conflicts of Interest
None declared.

Multimedia Appendix 1
Semistructured interview guide.
[PDF File (Adobe PDF File), 55KB-Multimedia Appendix 1]

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Abbreviations
CHIP: Citizen Health Information Portal
EHR: Electronic health record
ID: interpretive description
WHO: World Health Organization

Edited by G Eysenbach; submitted 24.08.17; peer-reviewed by T Irizarry, L Roa, M Johnson, S Martin; comments to author 01.12.17;
revised version received 16.02.18; accepted 28.06.18; published 10.09.18
Please cite as:
Risling T, Martinez J, Young J, Thorp-Froslie N
Defining Empowerment and Supporting Engagement Using Patient Views From the Citizen Health Information Portal: Qualitative
Study
JMIR Med Inform 2018;6(3):e43
URL: http://medinform.jmir.org/2018/3/e43/
doi: 10.2196/medinform.8828
PMID: 30201603©Tracie Risling, Juan Martinez, Jeremy Young, Nancy Thorp-Froslie. Originally published in JMIR Medical Informatics(http://medinform.jmir.org), 10.09.2018. This is an open-access article distributed under the terms of the Creative Commons
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in any medium, provided the original work, first published in JMIR Medical Informatics, is properly cited. The complete
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