Engaging patients through open notes: an evaluation using mixed methods

Adolescents' and Young Adults' Satisfaction with and Understanding of Medical Notes from a Pediatric Gastroenterology Practice: A Cross-Sectional Cohort Study

Medical note sharing enhances patient-physician relationships, increases medication adherence, and improves self-care. However, many institutions do not release medical notes to adolescents, citing poor understanding and patient harm concerns. We evaluated the results of medical note sharing among adolescents with chronic disease and found high satisfaction and adequate comprehension.

Quality Measurement of Serious Illness Communication: Recommendations for Health Systems Based on Findings from a Symposium of National Experts

Background: Communication between clinicians and patients fundamentally shapes the experience of serious illness. There is increasing recognition that health systems should routinely implement structures and processes to assure high-quality serious illness communication (SIC) and measure the effectiveness of their efforts on key outcomes. The absence, underdevelopment, or limited applicability of quality measures related specifically to SIC, and their limited application only to those seen by specialist palliative and hospice care teams, hinder efforts to improve care planning, service delivery, and health outcomes for all seriously ill patients. Objective: We convened an expert stakeholder symposium and subsequently surveyed participants to consider challenges, opportunities, priorities, and strategies to improve quality measurement specific to SIC. Results: We identified several barriers and opportunities to improving quality measurement of SIC. These include issues related to the definition of SIC, methodological challenges related to measuring SIC and related outcomes, underutilization of technologies that can facilitate measurement, and measurement development, and dissemination. Conclusions: Patients, clinicians, and health systems increasingly align around the importance of high-quality communication in serious illness. We offer recommendations for various stakeholder groups to advance SIC quality measurement. Enthusiasm and a sense of urgency among health systems to drive and measure communication improvements inform our proposal for a set of example measures for implementation now.

Value-based surgical care: a view from the surgeon's knife

NHS trusts across the country are facing unprecedented financial pressures, along with rising levels of demand and widespread variation in surgical quality and cost. There is a moral and financial imperative to provide the most efficient use of resources in order to ensure sustainability of a system that is free at the point of use, and provide consistently high-value care for patients across the country. Delivering 'value' does not mean any reduction in the quality of care - it means achieving the same or higher quality at the same or lower cost. Avoidable and costly incidents in surgery occur every day: patients do not receive the right care, procedures or tests are performed without real benefit, complications lead to prolonged hospital stays, to readmissions and re-interventions. Put simply: poor quality surgical care is expensive. The concept of value-based health care is well known in the UK, yet its principles are not yet fully embedded in the health-care system, surgical training or practice. The shift towards better value-based care with a focus on delivery system reform (Getting It Right First Time), outcomes-based commissioning and payment reform (accountable care systems and integrated care systems) provides an opportunity to make significant improvements in surgical care. Radical and immediate change is required, and everyone, from trainees at the frontline, to clinical leaders, trust chief executives, local commissioners and policy-makers, has vital roles to play. The health-care system needs to be designed, organized and paid for differently to deliver better surgical value for patients.

Alpine Ski Coaches' and Athletes' Perceptions of Factors Influencing Adaptation to Stress in the Classroom and on the Slopes

Research examining the student-athlete experience proposes a number of factors that can be both sources of stress and/or support. The dual career pathway offers a number of potential positive outcomes including psychological, social, and financial benefits; however, challenges including time management, fatigue, and restricted social activities are well documented. In consideration of the multidimensional student-athlete experience and the numerous factors that influence the complexity of potential stress, a mixed methods research study design was used in the study. First, data collected from surveys completed by 173 elite junior alpine skiers were analyzed to identify the degree to which athletes report experiencing stress associated with specific aspects pertaining to training, life, and organizational factors. These factors were then explored through semi-structured interviews with six coaches at the associated national elite sport schools. Taken collectively, athletes' reports of psychophysiological training stress on the Multidimensional Training Distress Scale were low. Scores on the college student-athletes' life stress scale revealed very low levels of general life stress; although the subscales associated with "performance demand" and "academic requirements" scored marginally higher. Scores on the Organizational Stressor Indicator for Sport Performers indicated low levels of organizational stress. The interviews with coaches elucidated the underlying factors potentially influencing athletes' positive adaptations to stress as they reported programming a number of strategies to reduce negative outcomes. Coaches aimed to teach athletes self-awareness and regulation strategies through the use of the training diaries and ongoing communication to promote positive adaptation to stress. A number of coaches also worked with sport psychology consultants to optimize athletes' training and study situations. Traditionally, research has noted high levels of stress in student-athletes due to co-occurring demands (school & sport); however, the data in the present study suggests that optimizing support mechanisms across domains can promote positive adaptations to potential sources of stress.

Sharing clinical notes with patients: The NP perspective

This article outlines a research project conducted to learn more about NPs' attitudes regarding sharing clinical notes with patients through a patient portal. Perceptions were positive overall. To achieve effective health outcomes, patient and family engagement is essential. Shared clinical notes provide an opportunity to achieve these goals.

The impact of person-centred care on patients’ care experiences in relation to educational level after acute coronary syndrome: secondary outcome analysis of a randomised controlled trial

Background:

Research supporting the benefits of person-centred care is growing, still knowledge about patients’ experiences of person-centred care is limited.

Aim:

To evaluate the effects of person-centred care on patients’ experiences of care, and also in relation to educational level, after an acute coronary syndrome.

Method:

A total of 199 patients aged less than 75 years, hospitalised for acute coronary syndrome, were randomly assigned to either standard cardiac care ( n=105) or person-centred care plus standard cardiac care ( n=94). Experience of care was assessed at three healthcare settings (hospital, outpatient and primary care) using the 15-item Picker patient experience questionnaire plus two questions concerning information and documentation.

Results:

No significant difference was found at the three healthcare settings between the two study groups in the Picker patient experience questionnaire total score. Item level analysis showed that the person-centred care group significantly improved at all three healthcare settings on information received and in documentation of care compared with the standard cardiac care group ( P<0.05). In outpatient care, the person-centred care group reported significantly better family–physician communication ( P=0.004) and information for the family ( P=0.007) compared with the standard cardiac care group. In patients without postsecondary education, the corresponding figures were even more in favour of the person-centred care group ( P=0.0005 and P=0.0049, respectively), and they also reported higher involvement in care decisions ( P=0.023).

Conclusion:

A person-centred care approach after an event of acute coronary syndrome improves patients’ care experiences for information, shared documentation and involvement of family and friends. This effect was especially prominent in patients with a low educational level, who were also more involved in care decisions.

Trial registration:

Swedish registry, Researchweb.org , ID NR 65 791

Qualitative and Quantitative Analysis of Patients' Perceptions of the Patient Portal Experience with OpenNotes

BACKGROUND

Access to medical encounter notes (OpenNotes) is believed to empower patients and improve the quality and safety of care. The impact of such access is not well understood beyond select health care systems and notes from primary care providers.

OBJECTIVES

This article analyzes patients' perceptions about the patient portal experience with access to primary care and specialist's notes and evaluates free-text comments as an improvement opportunity.

MATERIALS AND METHODS

Patients at an academic health care system who accessed the patient portal from February 2016 to May 2016 were provided a link to complete a 15-item online survey. Those who had viewed at least one note were asked about patient characteristics, frequency of note access, note usefulness, note understanding, and if any action was taken after accessing the note. Free-text comments were associated with nine questions which were analyzed using qualitative methods.

RESULTS

A total of 23% (1,487/6,439) of patients who viewed the survey in the portal, participated. Seventy-six percent (1,126/1,487) knew that the notes were available on the portal, and of those, 957 had viewed at least one note to continue the survey. Ninety percent of those were older than 30 years of age, and 90% had some college education. The majority (83%) thought OpenNotes helped them take better care of themselves, without increasing worry (94%) or contacting the physician after reading the note (91%). The qualitative analysis of free-text responses demonstrated multiple positive and negative themes, and they were analyzed for potential improvement opportunities.

CONCLUSION

Our survey confirms that patients who choose to access their primary care and specialists' online medical records perceive benefits of OpenNotes. Additionally, the qualitative analysis of comments revealed positive benefits and several potential patient portal improvement opportunities which could inform implementation of OpenNotes at other health systems.

Principles for Patient and Family Partnership in Care: An American College of Physicians Position Paper

In this position paper, the American College of Physicians (ACP) examines the rationale for patient and family partnership in care and reviews outcomes associated with this concept, including greater adherence to care plans, improved satisfaction, and lower costs. The paper also explores and acknowledges challenges associated with implementing patient- and family-centered models of care. On the basis of a comprehensive literature review and a multistakeholder vetting process, the ACP's Patient Partnership in Healthcare Committee developed a set of principles that form the foundation for authentic patient and family partnership in care. The principles position patients in their rightful place at the center of care while acknowledging the importance of partnership between the care team and patient in improving health care and reducing harm. The principles state that patients and families should be treated with dignity and respect, be active partners in all aspects of their care, contribute to the development and improvement of health care systems, and be partners in the education of health care professionals. This paper also recommends ways to implement these principles in daily practice.

Patients' Experiences of Accessing Their Electronic Health Records: National Patient Survey in Sweden

Background

Internationally, there is a movement toward providing patients a Web-based access to their electronic health records (EHRs). In Sweden, Region Uppsala was the first to introduce patient-accessible EHRs (PAEHRs) in 2012. By the summer of 2016, 17 of 21 county councils had given citizens Web-based access to their medical information. Studies on the effect of PAEHRs on the work environment of health care professionals have been conducted, but up until now, few extensive studies have been conducted regarding patients’ experiences of using PAEHRs in Sweden or Europe, more generally.

Objective

The objective of our study was to investigate patients’ experiences of accessing their EHRs through the Swedish national patient portal. In this study, we have focused on describing user characteristics, usage, and attitudes toward the system.

Methods

A national patient survey was designed, based on previous interview and survey studies with patients and health care professionals. Data were collected during a 5-month period in 2016. The survey was made available through the PAEHR system, called Journalen, in Sweden. The total number of patients that logged in and could access the survey during the study period was 423,141. In addition to descriptive statistics reporting response frequencies on Likert scale questions, Mann-Whitney tests, Kruskal-Wallis tests, and chi-square tests were used to compare answers between different county councils as well as between respondents working in health care and all other respondents.

Results

Overall, 2587 users completed the survey with a response rate of 0.61% (2587/423,141). Two participants were excluded from the analysis because they had only received care in a county council that did not yet show any information in Journalen. The results showed that 62.97% (1629/2587) of respondents were women and 39.81% (1030/2587) were working or had been working in health care. In addition, 72.08% (1794/2489) of respondents used Journalen about once a month, and the main reason for use was to gain an overview of one’s health status. Furthermore, respondents reported that lab results were the most important information for them to access; 68.41% (1737/2539) of respondents wanted access to new information within a day, and 96.58% (2454/2541) of users reported that they are positive toward Journalen.

Conclusions

In this study, respondents provided several important reasons for why they use Journalen and why it is important for them to be able to access information in this way—several related to patient empowerment, involvement, and security. Considering the overall positive attitude, PAEHRs seem to fill important needs for patients.

Impact of Open Access to Physician Notes on Radiation Oncology Patients: Results from an Exploratory Survey

PURPOSE

There is an increasing effort to allow patients open access to their physician notes through electronic medical record portals. However, limited data exist on the impact of such access on oncology patients, and concerns remain regarding potential harms. Therefore, we determined the baseline perceptions and impact of open access to oncology notes on radiation oncology patients.

METHODS AND MATERIALS

Patients receiving radiation therapy were provided instructional materials on accessing oncology notes at the time of their initial evaluation. Patients were prospectively surveyed to evaluate baseline interest and expectations before access and to determine the actual usage and impact at the end of their radiation treatment course.

RESULTS

A total of 220 patients were surveyed; 136 (62%) completed the baseline survey, of which 88 (40%) completed the final survey. The majority of participants were age >60 years (n = 83; 61%), and 70 were male (51%). Before accessing the notes, the majority of patients agreed that open access to oncology notes would improve understanding of diagnosis (99%), understanding of treatment side effects (98%), reassurance about treatment goals (96%), and communication with family (99%). All patients who accessed the notes found them to be useful. After accessing the notes, approximately 96%, 94%, and 96% of patients reported an improved understanding of their diagnosis, an improved understanding of treatment side effects, and feeling more reassured about their treatment, respectively. Approximately 11%, 6%, and 4% of patients noted increased worry, increased confusion, and finding information they now regret reading, respectively. Patient age, sex, and specific cancer diagnoses were not predictive of experiencing negative effects from accessing the notes.

CONCLUSIONS

Radiation oncology patients have a strong interest in open access to their physician notes, and the majority of patients expect and actually report meaningful benefits. These data support strategies to allow more patients with cancer access to their physicians' notes.

Assessment of US Hospital Compliance With Regulations for Patients' Requests for Medical Records

IMPORTANCE

Although federal law has long promoted patients' access to their protected health information, this access remains limited. Previous studies have demonstrated some issues in requesting release of medical records, but, to date, there has been no comprehensive review of the challenges that exist in all aspects of the request process.

OBJECTIVE

To evaluate the current state of medical records request processes of US hospitals in terms of compliance with federal and state regulations and ease of patient access.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study of medical records request processes was conducted between August 1 and December 7, 2017, in 83 top-ranked US hospitals with independent medical records request processes and medical records departments reachable by telephone. Hospitals were ranked as the top 20 hospitals for each of the 16 adult specialties in the 2016-2017 US News & World Report Best Hospitals National Rankings.

EXPOSURES

Scripted interview with medical records departments in a single-blind, simulated patient experience.

MAIN OUTCOMES AND MEASURES

Requestable information (entire medical record, laboratory test results, medical history and results of physical examination, discharge summaries, consultation reports, physician orders, and other), formats of release (pick up in person, mail, fax, email, CD, and online patient portal), costs, and request processing times, identified on medical records release authorization forms and through telephone calls with medical records departments.

RESULTS

Among the 83 top-ranked US hospitals representing 29 states, there was discordance between information provided on authorization forms and that obtained from the simulated patient telephone calls in terms of requestable information, formats of release, and costs. On the forms, as few as 9 hospitals (11%) provided the option of selecting 1 of the categories of information and only 44 hospitals (53%) provided patients the option to acquire the entire medical record. On telephone calls, all 83 hospitals stated that they were able to release entire medical records to patients. There were discrepancies in information given in telephone calls vs on the forms between the formats hospitals stated that they could use to release information (69 [83%] vs 40 [48%] for pick up in person, 20 [24%] vs 14 [17%] for fax, 39 [47%] vs 27 [33%] for email, 55 [66%] vs 35 [42%] for CD, and 21 [25%] vs 33 [40%] for online patient portals), additionally demonstrating noncompliance with federal regulations in refusing to provide records in the format requested by the patient. There were 48 hospitals that had costs of release (as much as $541.50 for a 200-page record) above the federal recommendation of $6.50 for electronically maintained records. At least 6 of the hospitals (7%) were noncompliant with state requirements for processing times.

CONCLUSIONS AND RELEVANCE

The study revealed that there are discrepancies in the information provided to patients regarding the medical records release processes and noncompliance with federal and state regulations and recommendations. Policies focused on improving patient access may require stricter enforcement to ensure more transparent and less burdensome medical records request processes for patients.

Communicating with Vulnerable Patient Populations: A Randomized Intervention to Teach Inpatients to Use the Electronic Patient Portal

BACKGROUND

Patient portals are expanding as a means to engage patients and have evidence for benefit in the outpatient setting. However, few studies have evaluated their use in the inpatient setting, or with vulnerable patient populations.

OBJECTIVE

This article assesses an intervention to teach hospitalized vulnerable patients to access their discharge summaries using electronic patient portals.

METHODS

Patients at a safety net hospital were randomly assigned to portal use education or usual care. Surveys assessed perceptions of discharge paperwork and the electronic portal.

RESULTS

Of the 202 prescreened eligible patients (e.g., deemed mentally competent, spoke English, and had a telephone), only 43% had working emails. Forty-four percent of participants did not remember receiving or reading discharge paperwork. Patients trained in portal use (n = 47) or receiving usual care (n = 23) preferred hospitals with online record access (85 and 83%, respectively), and felt that online access would increase their trust in doctors (85 and 87%) and satisfaction with care (91% each). Those who received training in portal use were more likely to register for the portal (48% vs. 11%; p < 0.01).

CONCLUSION

Patients had positive perceptions of portals, and education increased portal use. Lack of email access is a notable barrier to electronic communication with vulnerable patients.

The Role of PAEHRs in Patient Involvement

With increased patient access to data, healthcare services are experiencing change where patients are moving away from being mere passive actors towards becoming more active and involved participants. In this paper, we explore the role of patient accessible electronic health records (PAEHRs) with respect to this increase in patient involvement. The study was performed as a case study and included nine interviews with patients and a survey that was responded to by 56 patients. Our results show that PAEHRs have a role in the enhancement of patient involvement because PAEHRs (i) foster a more balanced relationship between patients and healthcare professionals and (ii) increase access to information.

Health care experiences of mothers of children with bronchiectasis in Counties Manukau, Auckland, New Zealand

BACKGROUND

Bronchiectasis is a worsening public health problem in New Zealand. This study aimed to explore the health care experiences of mothers of children with bronchiectasis in the Counties Manukau District Health Board area of Auckland, New Zealand.

METHODS

Semi-structured interviews were undertaken with ten mothers of children with bronchiectasis. Data were analysed using thematic analysis.

RESULTS

Five themes emerged: 1) Searching for answers, describing mothers' search for a diagnosis; 2) (Dis)empowerment, describing mothers' acquisition of knowledge, leading to empowerment; 3) Health care and relationships, describing the impact of relationships on the mother's health care experiences; 4) A juggling act, describing the challenges of juggling health care with school, work and family; 5) Making it work, describing how mothers overcome barriers to access health care for their child.

CONCLUSIONS

The health provider-parent relationship was crucial for fostering positive health care experiences. Mothers' acquisition of knowledge facilitated empowerment within those relationships. Additionally, mothers' perceptions of the quality and benefit of health services motivated them to overcome barriers to accessing care. Study findings may help to improve health care experiences for parents of children with bronchiectasis if identified issues are addressed.

Monitoring for change: the role of family and friends in helping older adults manage personal health information

Objective

Although family and friends (FF) often play a significant support role in the health of older adults (OA), we know little about their role in personal health information management (PHIM). To address this gap and inform the design of PHIM tools, we describe the work, needs, and barriers of FF in the context of PHIM for OAs.

Methods

We conducted semi-structured telephone interviews with 52 FF identified by OA as being important in their health and PHIM. We analyzed interview transcripts for themes about FF information work, barriers, and support needs.

Results

FF play a supportive role in OA health maintenance, medical encounters, decision making, and daily activities. Monitoring, the ongoing process of seeking information related to the OA status, emerged as a key activity comprised of 3 phases: detection, interpretation, and action. Barriers to monitoring included OA choices and constraints, FF constraints, and difficulty with technological tools, resources, health information exchange between providers, social network dynamics, and physical distance.

Conclusions

FF frequently monitor for change in OA well-being, seeking up-to-date information to facilitate support of OA PHIM. Health information technology tools designed for FF can support all phases of monitoring by providing: (1) timely and granular levels of access to OA health information as the OA ages; (2) tailored health education for FF that is based on OA clinical data; and (3) networking platforms that integrate delegation, volunteering, and relevant resources, along with tools to facilitate support of OA appointment calendars and medication management. Such tools could reduce the burden of PHIM for OA and their loved ones.

Patient portal adoption and use by hospitalized cancer patients: a retrospective study of its impact on adverse events, utilization, and patient satisfaction

BACKGROUND

Portal use has been studied among outpatients, but its utility and impact on inpatients is unclear. This study describes portal adoption and use among hospitalized cancer patients and investigates associations with selected safety, utilization, and satisfaction measures.

METHODS

A retrospective review of 4594 adult hospitalized cancer patients was conducted between 2012 and 2014 at Mayo Clinic in Jacksonville, Florida, comparing portal adopters, who registered for a portal account prior to hospitalization, with nonadopters. Adopters were classified by their portal activity during hospitalization as active or inactive inpatient users. Univariate and several logistic and linear regression models were used for analysis.

RESULTS

Of total patients, 2352 (51.2%) were portal adopters, and of them, 632 (26.8%) were active inpatient users. Portal adoption was associated with patients who were young, female, married, with higher income, and had more frequent hospitalizations (P < .05). Active inpatient use was associated with patients who were young, married, nonlocals, with higher disease severity, and were hospitalized for medical treatment (P < .05). In univariate analyses, self-management knowledge scores were higher among adopters vs nonadopters (84.3 and 80.0, respectively; P = .01) and among active vs inactive inpatient users (87.0 and 83.3, respectively; P = .04). In regression models adjusted for age and disease severity, the association between portal behaviors and majority of measures were not significant (P > .05).

CONCLUSIONS

Over half of our cancer inpatients adopted a portal prior to hospitalization, with increased adoption associated with predisposing and enabling determinants (eg: age, sex, marital status, income), and increased inpatient use associated with need (eg: nonlocal residence and disease severity). Additional research and greater effort to expand the portal functionality is needed to impact inpatient outcomes.

Diabetes care providers' opinions and working methods after four years of experience with a diabetes patient web portal; a survey among health care providers in general practices and an outpatient clinic

BACKGROUND

To gain insight into the opinions and working methods of diabetes care providers after using a diabetes web portal for 4 years in order to understand the role of the provider in patients' web portal use.

METHODS

Survey among physicians and nurses from general practices and an outpatient clinic, correlated with data from the common web portal.

RESULTS

One hundred twenty-eight questionnaires were analysed (response rate 56.6%). Responders' mean age was 46.2 ± 9.8 years and 43.8% were physicians. The majority was of opinion that the portal improves patients' diabetes knowledge (90.6%) and quality of care (72.7%). Although uploading glucose diary (93.6%) and patient access to laboratory and clinical notes (91.2 and 71.0%) were considered important, these features were recommended to patients in only 71.8 and 19.5% respectively. 64.8% declared they informed their patients about the portal and 45.3% handed-out the information leaflet and website address. The portal was especially recommended to type 1 diabetes patients (78.3%); those on insulin (84.3%) and patients aged< 65 years (72.4%). Few found it timesaving (21.9%). Diabetes care providers' opinions were not associated with patients' portal use.

CONCLUSIONS

Providers are positive about patients web portals but still not recommend or encourage the use to all patients. There seems room for improvement in their working methods.

Resident and Attending Physicians' Perceptions of Patient Access to Provider Notes: Comparison of Perceptions Prior to Pilot Implementation

BACKGROUND

As electronic health records have become a more integral part of a physician's daily life, new electronic health record tools will continue to be rolled out to trainees. Patient access to provider notes is becoming a more widespread practice because this has been shown to increase patient empowerment.

OBJECTIVE

In this analysis, we compared differences between resident and attending physicians' perceptions prior to implementation of patient access to provider notes to facilitate optimal use of electronic health record features and as a potential for patient empowerment.

METHODS

This was a single-site study within an academic internal medicine program. Prior to implementation of patient access to provider notes, we surveyed resident and attending physicians to assess differences in perceptions of this new electronic health record tool using an open access survey provided by OpenNotes.

RESULTS

We surveyed 37% (20/54 total) of resident physicians and obtained a 100% response rate and 72% (31/44 total) of attending physicians. Similarities between the groups included concerns about documenting sensitive topics and anticipation of improved patient engagement. Compared with attending physicians, resident physicians were more concerned about litigation, discussing weight, offending patients, and communicated less overall with patients through electronic health record.

CONCLUSIONS

Patient access to provider notes has the potential to empower patients but concerns of the resident physicians need to be validated and addressed prior to its utilization.

Same, same but different: Perceptions of patients’ online access to electronic health records among healthcare professionals

In this study, we explore how healthcare professionals in primary care and outpatient clinics perceive the outcomes of giving patients online access to their electronic health records. The study was carried out as a case study and included a workshop, six interviews and a survey that was answered by 146 healthcare professionals. The results indicate that professionals working in primary care perceive that an increase in information-sharing with patients can increase adherence, clarify important information to the patient and allow the patient to quality-control documented information. Professionals at outpatient clinics seem less convinced about the benefits of patient accessible electronic health records and have concerns about how patients manage the information that they are given access to. However, the patient accessible electronic health record has not led to a change in documentation procedures among the majority of the professionals. While the findings can be connected to the context of outpatient clinics and primary care units, other contextual factors might influence the results and more in-depth studies are therefore needed to clarify the concerns.

Predictors of viewing progress notes among users of VA's electronic health portal who receive mental health care

Objective

Consistent with the OpenNotes movement, the Veterans Health Administration (VHA) offers patients online access to their clinical notes through the Blue Button feature in its electronic patient health portal, My HealtheVet. We identified demographic, diagnostic, and knowledge-related predictors of viewing clinical notes among veterans receiving VHA mental health care who recently used My HealtheVet.

Materials and Methods

Three hundred and thirty-eight patients receiving mental health care from 1 VHA medical center who had logged into My HealtheVet in the prior 6 months completed self-report questionnaires assessing their viewing of clinical notes. Additional data were extracted from VHA's Patient Care Database. Multivariable logistic regression was used to examine predictors of viewing notes.

Results

Fifty percent of respondents reported having read their notes. In the final multivariable model, post-traumatic stress disorder (PTSD) diagnosis [odds ratio (OR) = 2.30 (1.31-4.07)], speaking with their mental health clinician about their ability to view notes [OR = 3.84 (1.69-8.72)], and being very or extremely confident in understanding the purpose and uses of Blue Button [OR = 9.80 (2.23-43.07) and OR = 13.36 (2.74-65.20), respectively] were associated with viewing notes.

Discussion

Patient recall of mental health clinicians speaking to them about their ability to view notes, and confidence in understanding the use and purposes of Blue Button, were stronger predictors of viewing notes than demographic variables. PTSD diagnosis was the only clinical characteristic associated with viewing notes.

Conclusion

The findings support the value of mental health clinicians openly discussing the availability of notes with patients if they wish to help them take advantage of their potential benefits.

Balancing Health Information Exchange and Privacy Governance from a Patient-Centred Connected Health and Telehealth Perspective

Objectives:  Connected healthcare is an essential part of patient-centred care delivery. Technology such as telehealth is a critical part of connected healthcare. However, exchanging health information brings the risk of privacy issues. To better manage privacy risks we first need to understand the different patterns of patient-centred care in order to tailor solutions to address privacy risks.

Methods:  Drawing upon published literature, we develop a business model to enable patient-centred care via telehealth. The model identifies three patient-centred connected health patterns. We then use the patterns to analyse potential privacy risks and possible solutions from different types of telehealth delivery.

Results:  Connected healthcare raises the risk of unwarranted access to health data and related invasion of privacy. However, the risk and extent of privacy issues differ according to the pattern of patient-centred care delivery and the type of particular challenge as they enable the highest degree of connectivity and thus the greatest potential for privacy breaches.

Conclusion:  Privacy issues are a major concern in telehealth systems and patients, providers, and administrators need to be aware of these privacy issues and have guidance on how to manage them. This paper integrates patient-centred connected health care, telehealth, and privacy risks to provide an understanding of how risks vary across different patterns of patient-centred connected health and different types of telehealth delivery.

Open Oncology Notes: A Qualitative Study of Oncology Patients' Experiences Reading Their Cancer Care Notes

PURPOSE

Electronic medical records increasingly allow patients access to clinician notes. Although most believe that open notes benefits patients, some suggest negative consequences. Little is known about the experiences of patients with cancer reading their medical notes; thus we aimed to describe this qualitatively.

METHODS

We interviewed 20 adults with metastatic or incurable cancer receiving cancer treatment. The semistructured qualitative interviews included four segments: assessing their overall experience reading notes, discussing how notes affected their cancer care experiences, reading a real note with the interviewer, and making suggestions for improvement. We used a constant comparison approach to analyze these qualitative data.

RESULTS

We found four themes. Patients reported that notes resulted in the following: (1) increased comprehension; (2) ameliorated uncertainty, relieved anxiety, and facilitated control; (3) increased trust; and (4) for a subset of patients, increased anxiety. Patients described increased comprehension because notes refreshed their memory and clarified their understanding of visits. This helped mitigate the unfamiliarity of cancer, addressing uncertainty and relieving anxiety. Notes facilitated control, empowering patients to ask clinicians more questions. The transparency of notes also increased trust in clinicians. For a subset of patients, however, notes were emotionally difficult to read and raised concerns. Patients identified medical jargon and repetition in notes as areas for improvement.

CONCLUSION

Most patients thought that reading notes improved their care experiences. A small subset of patients experienced increased distress. As reading notes becomes a routine part of the patient experience, physicians might want to elicit and address concerns that arise from notes, thereby further engaging patients in their care.

Patterns in Patient Access and Utilization of Online Medical Records: Analysis of MyChart

BACKGROUND

Electronic patient portals provide a new method for sharing personal medical information with individual patients.

OBJECTIVE

Our aim was to review utilization patterns of the largest online patient portal in Canada's largest city.

METHODS

We conducted a 4-year time-trend analysis of aggregated anonymous utilization data of the MyChart patient portal at Sunnybrook Health Sciences Centre in Ontario, Canada, from January 1, 2012, through December 31, 2015. Prespecified analyses examined trends related to day (weekend vs weekday), season (July vs January), year (2012 vs 2015), and an extreme adverse weather event (ice storm of December 20-26, 2013). Primary endpoints included three measures of patient portal activity: registrations, logins, and pageviews.

RESULTS

We identified 32,325 patients who registered for a MyChart account during the study interval. Time-trend analysis showed no sign of attenuating registrations over time. Logins were frequent, averaged 734 total per day, and showed an increasing trend over time. Pageviews mirrored logins, averaged about 3029 total per day, and equated to about 5 pageviews during the average login. The most popular pageviews were clinical notes, followed by laboratory results and medical imaging reports. All measures of patient activity were lower on weekends compared to weekdays (P<.001) yet showed no significant changes related to seasons or extreme weather. No major security breach, malware attack, or software failure occurred during the study.

CONCLUSIONS

Online patient portals can provide a popular and reliable system for distributing personal medical information to active patients and may merit consideration for hospitals.

From passive passenger to participating co-pilot - Pregnant women's expectations of being able to access their online journal from antenatal care

OBJECTIVE

The aim of the study was to describe pregnant women's expectations of being able to access their electronic health records from antenatal care.

METHODS

Nine pregnant women passing 25 full gestational weeks were interviewed individually. Collected data were analysed with an inductive approach using content analysis. The study was performed in antenatal care units in southern Sweden.

RESULTS

The following five categories emerged from the analysis: Being able to achieve increased participation, being able to have more control, being more knowledgeable about the pregnancy, identification of possible risks, and perceptions of one's own well-being can predict usage. The five categories led to one main category: 'Shift in power - from passive passenger to participating co-pilot'.

CONCLUSION

The pregnant women expected that having access to electronic health records would give them more control, make them more knowledgeable and increase their participation. Access to electronic health records may empower pregnant women and contribute to a more person-centred approach. This could provide greater knowledge for the woman and her partner about her health, thus, allowing them to make evidence-based choices in relation to the newborn baby and the woman's health.

"Why Do They Need to Check Me?" Patient Participation Through eHealth and the Doctor-Patient Relationship: Qualitative Study

BACKGROUND

Roles in the doctor-patient relationship are changing and patient participation in health care is increasingly emphasized. Electronic health (eHealth) services such as patient accessible electronic health records (PAEHRs) have been implemented to support patient participation. Little is known about practical use of PAEHR and its effect on roles of doctors and patients.

OBJECTIVE

This qualitative study aimed to investigate how physicians view the idea of patient participation, in particular in relation to the PAEHR system. Hereby, the paper aims to contribute to a deeper understanding of physicians' constructions of PAEHR, roles in the doctor-patient relationship, and levels and limits of involvement.

METHODS

A total of 12 semistructured interviews were conducted with physicians in different fields. Interviews were transcribed, translated, and a theoretically informed thematic analysis was performed.

RESULTS

Two important aspects were identified that are related to the doctor-patient relationship: roles and involvement. The physicians viewed their role as being the ones to take on the responsibility, determining treatment options, and to be someone who should be trusted. In relation to the patient's role, lack of skills (technical or regarding medical jargon), motives to read, and patients' characteristics were aspects identified in the interviews. Patients were often referred to as static entities disregarding their potential to develop skills and knowledge over time. Involvement captures aspects that support or hinder patients to take an active role in their care.

CONCLUSIONS

Literature of at least two decades suggests an overall agreement that the paternalistic approach in health care is inappropriate, and a collaborative process with patients should be adopted. Although the physicians in this study stated that they, in principle, were in favor of patient participation, the analysis found little support in their descriptions of their daily practice that participation is actualized. As seen from the results, paternalistic practices are still present, even if professionals might not be aware of this. This can create a conflict between patients who strive to become more informed and their questions being interpreted as signs of critique and mistrust toward the physician. We thus believe that the full potential of PAEHRs is not reached yet and argue that the concept of patient empowerment is problematic as it triggers an interpretation of "power" in health care as a zero-sum, which is not helpful for the maintenance of the relationship between the actors. Patient involvement is often discussed merely in relation to decision making; however, this study emphasizes the need to include also sensemaking and learning activities. This would provide an alternative understanding of patients asking questions, not in terms of "monitoring the doctor" but to make sense of the situation.

What is eHealth (6)? Development of a Conceptual Model for eHealth: Qualitative Study with Key Informants

Background

Despite rapid growth in eHealth research, there remains a lack of consistency in defining and using terms related to eHealth. More widely cited definitions provide broad understanding of eHealth but lack sufficient conceptual clarity to operationalize eHealth and enable its implementation in health care practice, research, education, and policy. Definitions that are more detailed are often context or discipline specific, limiting ease of translation of these definitions across the breadth of eHealth perspectives and situations. A conceptual model of eHealth that adequately captures its complexity and potential overlaps is required. This model must also be sufficiently detailed to enable eHealth operationalization and hypothesis testing.

Objective

This study aimed to develop a conceptual practice-based model of eHealth to support health professionals in applying eHealth to their particular professional or discipline contexts.

Methods

We conducted semistructured interviews with key informants (N=25) from organizations involved in health care delivery, research, education, practice, governance, and policy to explore their perspectives on and experiences with eHealth. We used purposeful sampling for maximum diversity. Interviews were coded and thematically analyzed for emergent domains.

Results

Thematic analyses revealed 3 prominent but overlapping domains of eHealth: (1) health in our hands (using eHealth technologies to monitor, track, and inform health), (2) interacting for health (using digital technologies to enable health communication among practitioners and between health professionals and clients or patients), and (3) data enabling health (collecting, managing, and using health data). These domains formed a model of eHealth that addresses the need for clear definitions and a taxonomy of eHealth while acknowledging the fluidity of this area and the strengths of initiatives that span multiple eHealth domains.

Conclusions

This model extends current understanding of eHealth by providing clearly defined domains of eHealth while highlighting the benefits of using digital technologies in ways that cross several domains. It provides the depth of perspectives and examples of eHealth use that are lacking in previous research. On the basis of this model, we suggest that eHealth initiatives that are most impactful would include elements from all 3 domains.

Sharing clinical notes with patients

Patient portals are access points to patient information, meeting Centers for Medicare and Medicaid Services incentives. Providing patients with access to clinical notes has garnered positive feedback with few concerns. This article addresses the latest literature on patient access to clinical notes and offers suggestions for NPs in their use.

Crossing the health IT chasm: considerations and policy recommendations to overcome current challenges and enable value-based care

While great progress has been made in digitizing the US health care system, today's health information technology (IT) infrastructure remains largely a collection of systems that are not designed to support a transition to value-based care. In addition, the pursuit of value-based care, in which we deliver better care with better outcomes at lower cost, places new demands on the health care system that our IT infrastructure needs to be able to support. Provider organizations pursuing new models of health care delivery and payment are finding that their electronic systems lack the capabilities needed to succeed. The result is a chasm between the current health IT ecosystem and the health IT ecosystem that is desperately needed.In this paper, we identify a set of focal goals and associated near-term achievable actions that are critical to pursue in order to enable the health IT ecosystem to meet the acute needs of modern health care delivery. These ideas emerged from discussions that occurred during the 2015 American Medical Informatics Association Policy Invitational Meeting. To illustrate the chasm and motivate our recommendations, we created a vignette from the multistakeholder perspectives of a patient, his provider, and researchers/innovators. It describes an idealized scenario in which each stakeholder's needs are supported by an integrated health IT environment. We identify the gaps preventing such a reality today and present associated policy recommendations that serve as a blueprint for critical actions that would enable us to cross the current health IT chasm by leveraging systems and information to routinely deliver high-value care.

Exploring patients' perceptions of accessing electronic health records: Innovation in healthcare

The more widespread implementation of electronic health records has led to new ways of providing access to healthcare information, allowing patients to view their medical notes, test results, medicines and so on. In this article, we explore how patients perceive the possibility to access their electronic health record online and whether this influences patient involvement. The study includes interviews with nine patients and a survey answered by 56 patients. Our results show that patients perceive healthcare information to be more accessible and that electronic health record accessibility improves recall, understanding and patient involvement. However, to achieve the goal of involving patients as active decision-makers in their own treatment, electronic health records need to be fully available and test results, referrals and information on drug interactions need to be offered. As patient access to electronic health records spreads, it is important to gain a deeper understanding of how documentation practices can be changed to serve healthcare professionals and patients.

When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient-doctor relationship

BACKGROUND

Patient advocates and safety experts encourage adoption of transparent health records, but sceptics worry that shared notes may offend patients, erode trust or promote defensive medicine. As electronic health records disseminate, such disparate views fuel policy debates about risks and benefits of sharing visit notes with patients through portals.

METHODS

Presurveys and postsurveys from 99 volunteer doctors at three US sites who participated in OpenNotes and postsurveys from 4592 patients who read at least one note and submitted a survey.

RESULTS

Patients read notes to be better informed and because they were curious; about a third read them to check accuracy. In total, 7% (331) of patients reported contacting their doctor's office about their note. Of these, 29% perceived an error, and 85% were satisfied with its resolution. Nearly all patients reported feeling better (37%) or the same (62%) about their doctor. Patients who were older (>63), male, non-white, had fair/poor self-reported health or had less formal education were more likely to report feeling better about their doctor. Among doctors, 26% anticipated documentation errors, and 44% thought patients would disagree with notes. After a year, 53% believed patient satisfaction increased, and 51% thought patients trusted them more. None reported ordering more tests or referrals.

CONCLUSIONS

Despite concerns about errors, offending language or defensive practice, transparent notes overall did not harm the patient-doctor relationship. Rather, doctors and patients perceived relational benefits. Traditionally more vulnerable populations-non-white, those with poorer self-reported health and those with fewer years of formal education-may be particularly likely to feel better about their doctor after reading their notes. Further informing debate about OpenNotes, the findings suggest transparent records may improve patient satisfaction, trust and safety.

An Approach for All in Pharmacy Informatics Education

Computerization is transforming health care. All clinicians are users of health information technology (HIT). Understanding fundamental principles of informatics, the field focused on information needs and uses, is essential if HIT is going to support improved patient outcomes. Informatics education for clinicians is a national priority. Additionally, some informatics experts are needed to bring about innovations in HIT. A common approach to pharmacy informatics education has been slow to develop. Meanwhile, accreditation standards for informatics in pharmacy education continue to evolve. A gap remains in the implementation of informatics education for all pharmacy students and it is unclear what expert informatics training should cover. In this article, we propose the first of two complementary approaches to informatics education in pharmacy: to incorporate fundamental informatics education into pharmacy curricula for all students. The second approach, to train those students interested in becoming informatics experts to design, develop, implement, and evaluate HIT, will be presented in a subsequent issue of the Journal.

DERBI: A Digital Method to Help Researchers Offer "Right-to-Know" Personal Exposure Results

Researchers and clinicians in environmental health and medicine increasingly show respect for participants and patients by involving them in decision-making. In this context, the return of personal results to study participants is becoming ethical best practice, and many participants now expect to see their data. However, researchers often lack the time and expertise required for report-back, especially as studies measure greater numbers of analytes, including many without clear health guidelines. In this article, our goal is to demonstrate how a prototype digital method, the Digital Exposure Report-Back Interface (DERBI), can reduce practical barriers to high-quality report-back. DERBI uses decision rules to automate the production of personalized summaries of notable results and generates graphs of individual results with comparisons to the study group and benchmark populations. Reports discuss potential sources of chemical exposure, what is known and unknown about health effects, strategies for exposure reduction, and study-wide findings. Researcher tools promote discovery by drawing attention to patterns of high exposure and offer novel ways to increase participant engagement. DERBI reports have been field tested in two studies. Digital methods like DERBI reduce practical barriers to report-back thus enabling researchers to meet their ethical obligations and participants to get knowledge they can use to make informed choices.

Sharing notes with patients: A review of current practice and considerations for neurologists

Improved patient engagement is a critical consideration in the new payment climate. Releasing progress notes for patients to view may improve patient involvement and engagement in their care. Patients perceive benefit from viewing physician progress notes. As initial studies involved only primary care physicians, specialist physicians may have specific considerations when releasing notes to patients. This article provides a framework for neurologists to implement a note release policy in their practice.

The Veteran-Initiated Electronic Care Coordination: A Multisite Initiative to Promote and Evaluate Consumer-Mediated Health Information Exchange

INTRODUCTION

Information continuity is critical to person-centered care when patients receive care from multiple healthcare systems. Patients can access their electronic health record data through patient portals to facilitate information exchange. This pilot was developed to improve care continuity for rural Veterans by (1) promoting the use of the Department of Veterans Affairs (VA) patient portal to share health information with non-VA providers, and (2) evaluating the impact of health information sharing at a community appointment.

MATERIALS AND METHODS

Veterans from nine VA healthcare systems were trained to access and share their VA Continuity of Care Document (CCD) with their non-VA providers. Patients and non-VA providers completed surveys on their experiences.

RESULTS

Participants (n = 620) were primarily older, white, and Vietnam era Veterans. After training, 78% reported the CCD would help them be more involved in their healthcare and 86% planned to share it regularly with non-VA providers. Veterans (n = 256) then attended 277 community appointments. Provider responses from these appointments (n = 133) indicated they were confident in the accuracy of the information (97%) and wanted to continue to receive the CCD (96%). Ninety percent of providers reported the CCD improved their ability to have an accurate medication list and helped them make medication treatment decisions. Fifty percent reported they did not order a laboratory test or another procedure because of information available in the CCD.

CONCLUSIONS

This pilot demonstrates feasibility and value of patient access to a CCD to facilitate information sharing between VA and non-VA providers. Outreach and targeted education are needed to promote consumer-mediated health information exchange.