The Value of OpenNotes for Pediatric Patients, Their Families and Impact on the Patient-Physician Relationship

Exploring potential drivers of patient engagement with their health data through digital platforms: A scoping review

BACKGROUND

Patient engagement when providing patient access to health data results from an interaction between the available tools and individual capabilities. The recent digital advancements of the healthcare field have altered the manifestation and importance of patient engagement. However, a comprehensive assessment of what factors contribute to patient engagement remain absent. In this review article, we synthesised the most frequently discussed factors that can foster patient engagement with their health data.

METHODS

A scoping review was conducted in MEDLINE, Embase, and Google Scholar. Relevant data were synthesized within 7 layers using a thematic analysis: (1) social and demographic factors, (2) patient ability factors, (3) patient motivation factors, (4) factors related to healthcare professionals' attitudes and skills, (5) health system factors, (6) technological factors, and (7) policy factors.

RESULTS

We identified 5801 academic and 200 Gy literature records, and included 292 (4.83%) in this review. Overall, 44 factors that can affect patient engagement with their health data were extracted. We extracted 6 social and demographic factors, 6 patient ability factors, 12 patient motivation factors, 7 factors related to healthcare professionals' attitudes and skills, 4 health system factors, 6 technological factors, and 3 policy factors.

CONCLUSIONS

Improving patient engagement with their health data enables the development of patient-centered healthcare, though it can also exacerbate existing inequities. While expanding patient access to health data is an important step towards fostering shared decision-making in healthcare and subsequently empowering patients, it is important to ensure that these developments reach all sectors of the community.

Improving Sexual History Documentation in Teenagers

BACKGROUND AND OBJECTIVES

Teen access to sexual health care is essential. The 21st Century Cures Act mandates that most electronic health information be shared with patients; no standard exists for how to meet this mandate for teens and their proxy caregivers. Our confidential shared teen sexual history (SexHx) section, which is not note-based, allows clinicians to easily find information, promotes clinical decision support, and protects privacy. Nevertheless, significant variability existed in SexHx section usage, SexHx documentation, and teen note-sharing practices. For teens (aged 12-17) admitted to the Pediatric Hospital Medicine service, we aim to increase the use of the SexHx section by 10% and increase History and Physical notes (H&Ps) shared with teens by 5% over 12 months.

METHODS

Quality improvement methodology and tools were used to conduct a barrier analysis and implement a series of interventions, which included education, training, and electronic health record clinical decision support. Statistical process control charts were used to examine the impact of the interventions.

RESULTS

At baseline, from April to July 2021, sexual activity was documented or reviewed in the SexHx section for 56% of teen patients. Over the intervention period, the center line shifted to 72%. At baseline, 76% of teen H&Ps were shared with patients. The percentage of H&Ps shared revealed a center-line shift to 81% throughout the intervention period.

CONCLUSIONS

The shared teen SexHx section is an innovative tool for capturing sensitive patient history discretely. We demonstrated increased and sustained SexHx section use and H&P note-sharing in this quality improvement initiative.

Open Notes Experiences of Parents in the Pediatric ICU

OBJECTIVE

We examined how parents experience and navigate open access to clinical notes ("open notes") in their child's electronic health record and explored their interactions with clinicians during an ICU admission.

METHODS

We performed a qualitative analysis using semistructured interviews of English-speaking parents who accessed their child's clinical notes during a pediatric ICU (general or cardiac) admission. We included patient-parent dyads with an ICU admission ≥48 hours between April 2021 and December 2022, note access by proxy timestamp during the ICU course, and either patient age <12 years or incapacitated adolescent ages 12 to 21 years. Purposive sampling was based on sociodemographic and clinical characteristics. Phone interviews were audio-recorded, transcribed, and analyzed using inductive thematic codebook analysis.

RESULTS

We interviewed 20 parents and identified 2 thematic categories, outcomes and interactions, in parents accessing clinical notes. Themes of outcomes included applied benefits, psychosocial and emotional value, and negative consequences. Themes of interactions included practical limitations and parental approach and appraisal. The ICU context and power dynamics were a meta-theme, influencing multiple themes. All parents reported positive qualities of note access despite negative consequences related to content, language, burdens, and lack of support. Parents suggested practice and design improvements surrounding open note access.

CONCLUSIONS

Parental experiences with open notes reveal new, unaddressed considerations for documentation access, practices, and purpose. Parents leverage open notes by negotiating between the power dynamics in the ICU and the uncertain boundaries of their role and authority in the electronic health record.

Perception of Physicians' Notes Among Parents of Different Health Literacy Levels

OBJECTIVES

To explore the benefits and challenges of accessing physicians' notes during pediatric hospitalization across parents of different health literacy levels.

METHODS

For this secondary analysis, we used semi-structured interviews conducted with 28 parents on their impressions of having access to their child's care team notes on a bedside table. Three researchers used thematic analysis to develop a codebook, coded interview data, and identified themes. Parent interviews and respective themes were then dichotomized into proficient or limited health literacy groups and compared.

RESULTS

Nine themes were identified in this secondary analysis: 6 benefits and 3 challenges. All parents identified more benefits than challenges, including that the notes served as a recap of information and memory aid and increased autonomy, empowerment, and advocacy for their child. Both groups disliked receiving bad news in notes before face-to-face communication. Parents with proficient literacy reported that notes allowed them to check information accuracy, but that notes may not be as beneficial for parents with lower health literacy. Parents with limited literacy uniquely identified limited comprehension of medical terms but indicated that notes facilitated their understanding of their child's condition, increased their appreciation for their health care team, and decreased their anxiety, stress, and worry.

CONCLUSIONS

Parents with limited health literacy uniquely reported that notes improved their understanding of their child's care and decreased (rather than increased) worry. Reducing medical terminology may be one equitable way to increase note accessibility for parents across the health literacy spectrum.

Family Perception of OpenNotes in the Neonatal Intensive Care Unit

BACKGROUND

 OpenNotes, or sharing of medical notes via a patient portal, has been studied extensively in the adult population, but less in pediatric populations, and even more rarely in inpatient pediatric or intensive care settings.

OBJECTIVES

 This study aimed to understand families' interaction with and perception of inpatient hospital notes shared via patient portal in a community Neonatal Intensive Care Unit (NICU).

METHODS

 At the end of the NICU discharge education, completed in the patient portal before discharge, families were offered an anonymous survey on OpenNotes.

RESULTS

 Out of 446 NICU patients from March 16, 2022 to March 16, 2023, there were 59 respondents (13%). Race was primarily Asian (48%), and English was the predominant language (93%). Most families indicated that the notes were "very or somewhat easy to understand" (93%). Seventy-three percent of respondents felt much better about the doctor(s) after reading the notes, and 53% contacted the physicians about something in the notes. Six (16%) felt that OpenNotes were more confusing than helpful.

CONCLUSION

 To the authors' knowledge, this is the first study on NICU families' perceptions of OpenNotes, which indicated positive interactions with the doctors' daily progress notes and gave important suggestions for improvement.

Adolescent Access to Clinicians' Notes: Adolescent, Parent, and Clinician Perspectives

PURPOSE

In 2021, federal guidelines mandated that health-care organizations share clinicians' notes with patients to increase information transparency. While findings indicate advantages for adult patients, less is known about note-sharing from the viewpoint of adolescents. This study aims to identify adolescent, parent, and clinician perspectives on the anticipated benefits and concerns of giving adolescents access to clinicians' notes and strategies to support note-sharing in this population.

METHODS

We conducted six focus groups with adolescents, parents, and clinicians at a children's hospital from May to October 2021. A semistructured facilitator guide captured participant perspectives of note-sharing benefits, concerns, and strategies. Two researchers independently coded and analyzed transcript data using thematic analysis; a third researcher reconciled discrepancies.

RESULTS

38 stakeholders (17 adolescents, 10 parents, and 11 clinicians) described four benefits, three concerns, and four implementation strategies regarding adolescent note-sharing. Potential benefits included adolescents using notes to remember and reinforce the visit, gaining knowledge about their health, strengthening the adolescent-clinician relationship, and increasing agency in health care decisions. Concerns included notes leading to a breach in confidentiality, causing negative emotions, and becoming less useful for clinicians. Strategies included making note-sharing more secure, optimizing note layout and content, setting clear expectations, and having a portion of the note for clinician use only.

DISCUSSION

Stakeholders suggest multiple strategies to optimize the implementation of note-sharing to support adolescent patients, parents, and clinicians as hospitals work to comply with federal regulations. These strategies may reinforce the potential benefits and mitigate the challenges of sharing notes with adolescent patients.

Perils of Auto-Population of Newborn EHR With Maternal Intimate Partner Violence History

In 2020, the 21st Century Cures Act was enacted, mandating that patients have access to their electronic health record. This has the potential to benefit both patients and clinicians by increasing communication, transparency, and patient autonomy. However, with the onset of the act, a number of unintended consequences of the act have been identified. Presently, we discuss a case where documentation of intimate partner violence and the safety plan documented in a mother's electronic health record automatically populated her newborn's admission note. This confidential information inadvertently became accessible to the perpetrator: the infant's father.

The State-of-the-Art of Patient Portals: Adapting to External Factors, Addressing Barriers, and Innovating

BACKGROUND AND OBJECTIVE

Recent external factors-the 21st Century Cures Act and the coronavirus disease 2019 (COVID-19) pandemic-have stimulated major changes in the patient portal landscape. The objective of this state-of-the-art review is to describe recent developments in the patient portal literature and to identify recommendations and future directions for the design, implementation, and evaluation of portals.

METHODS

To focus this review on salient contemporary issues, we elected to center it on four topics: (1) 21st Century Cures Act's impact on patient portals (e.g., Open Notes); (2) COVID-19's pandemic impact on portals; (3) proxy access to portals; and (4) disparities in portal adoption and use. We conducted targeted PubMed searches to identify recent empirical studies addressing these topics, used a two-part screening process to determine relevance, and conducted thematic analyses.

RESULTS

Our search identified 174 unique papers, 74 were relevant empirical studies and included in this review. Among these papers, we identified 10 themes within our four a priori topics, including preparing for and understanding the consequences of increased patient access to their electronic health information (Cures Act); developing, deploying, and evaluating new virtual care processes (COVID-19); understanding current barriers to formal proxy use (proxy access); and addressing disparities in portal adoption and use (disparities).

CONCLUSION

Our results suggest that the recent trends toward understanding the implications of immediate access to most test results, exploring ways to close gaps in portal adoption and use among different sub-populations, and finding ways to leverage portals to improve health and health care are the next steps in the maturation of patient portals and are key areas that require more research. It is important that health care organizations share their innovative portal efforts, so that successful measures can be tested in other contexts, and progress can continue.

Impact of a switch to immediate release on the patient viewing of diagnostic test results in an online portal at an academic medical center

Patient portals allow patients to access their personal health information. The 21st Century Cures Act in the United States sought to eliminate 'information blocking', requiring timely release upon request of electronic health information including diagnostic test results. Some health systems, including the one in the present study, chose a systematic switch to immediate release of all or nearly all diagnostic test results to patient portals as part of compliance with the Cures Act. Our primary objective was to study changes in the time to view test results by patients before and after implementation of Cures Act-related changes. This retrospective pre-post study included data from two 10-month time periods before and after implementation of Cures Act-related changes at an academic medical center. The study included all patients (adult and pediatric) with diagnostic testing (laboratory and imaging) performed in the outpatient, inpatient, or emergency department settings. Between February 9, 2020 and December 9, 2021, there was a total of 3 809 397 diagnostic tests from 204 605 unique patients (3 320 423 tests for adult patients; 488 974 for pediatric patients). Overall, 56.5% (115 627) of patients were female, 84.1% (172 048) white, and 96.5% (197 517) preferred English as primary language. The odds of viewing test results within 1 and 30 days after portal release increased monthly throughout both time periods before and after the Cures Act for all patients. The rate of increase was significantly higher after implementation only in the subgroup of tests belonging to adult patients with active MyChart accounts. Immediate release shifted a higher proportion of result/report release to weekends (3.2% pre-Cures vs 15.3% post-Cures), although patient viewing patterns by day of week and time of day were similar before and after immediate release changes. The switch to immediate release of diagnostic test results to the patient portal resulted in a higher fraction of results viewed within 1 day across outpatient, inpatient, and emergency department settings.

Implementation of EPR-Youth, a Client-Accessible and Multidisciplinary Health Record; A Mixed-Methods Process Evaluation

Introduction

Client-accessible interdisciplinary health records potentially contribute to integrated care by facilitating collaboration and enhancing clients' involvement in care. To achieve this, three Dutch organizations providing 'care for youth' developed a fully client-accessible electronic patient record (EPR-Youth).

Objective

To evaluate the implementation of EPR-Youth and to determine barriers and facilitators.

Methods

A mixed methods design combined system data, process observations, questionnaires and focus group interviews. Target groups were parents, adolescents, professionals using EPR-Youth, and implementation stakeholders.

Findings

Client-portal acceptability was high among all clients. Client-portal adoption rate was high and differed between age groups and educational levels. Professionals' doubts about acceptability, appropriateness and fidelity were partly due to lack of system knowledge. Implementation barriers were the complexity of co-creation, lack of clear leadership, and concerns about legal issues. Facilitators were clarifying vision and legal context, setting deadlines, and a pioneering spirit.

Conclusion

The early implementation of EPR-Youth, the first Dutch client-accessible interdisciplinary electronic health record in 'care for youth' was successful. To enhance adoption among clients, group-specific barriers for portal-use should be determined. Professionals need additional training. Further research is needed to gain insight into client-portal access barriers. To benefit more from co-creation, an organizational change towards situational leadership is necessary.

Perspectives of Patients About Immediate Access to Test Results Through an Online Patient Portal

Importance

The 21st Century Cures Act Final Rule mandates the immediate electronic availability of test results to patients, likely empowering them to better manage their health. Concerns remain about unintended effects of releasing abnormal test results to patients.

Objective

To assess patient and caregiver attitudes and preferences related to receiving immediately released test results through an online patient portal.

Design, Setting, and Participants

This large, multisite survey study was conducted at 4 geographically distributed academic medical centers in the US using an instrument adapted from validated surveys. The survey was delivered in May 2022 to adult patients and care partners who had accessed test results via an online patient portal account between April 5, 2021, and April 4, 2022.

Exposures

Access to test results via a patient portal between April 5, 2021, and April 4, 2022.

Main Outcomes and Measures

Responses to questions related to demographics, test type and result, reaction to result, notification experience and future preferences, and effect on health and well-being were aggregated. To evaluate characteristics associated with patient worry, logistic regression and pooled random-effects models were used to assess level of worry as a function of whether test results were perceived by patients as normal or not normal and whether patients were precounseled.

Results

Of 43 380 surveys delivered, there were 8139 respondents (18.8%). Most respondents were female (5129 [63.0%]) and spoke English as their primary language (7690 [94.5%]). The median age was 64 years (IQR, 50-72 years). Most respondents (7520 of 7859 [95.7%]), including 2337 of 2453 individuals (95.3%) who received nonnormal results, preferred to immediately receive test results through the portal. Few respondents (411 of 5473 [7.5%]) reported that reviewing results before they were contacted by a health care practitioner increased worry, though increased worry was more common among respondents who received abnormal results (403 of 2442 [16.5%]) than those whose results were normal (294 of 5918 [5.0%]). The result of the pooled model for worry as a function of test result normality was statistically significant (odds ratio [OR], 2.71; 99% CI, 1.96-3.74), suggesting an association between worry and nonnormal results. The result of the pooled model evaluating the association between worry and precounseling was not significant (OR, 0.70; 99% CI, 0.31-1.59).

Conclusions and Relevance

In this multisite survey study of patient attitudes and preferences toward receiving immediately released test results via a patient portal, most respondents preferred to receive test results via the patient portal despite viewing results prior to discussion with a health care professional. This preference persisted among patients with nonnormal results.

Experiences of Transgender People Reviewing Their Electronic Health Records, a Qualitative Study

BACKGROUND

The 21st Century Cures Act and the OpenNotes movement have brought patients immediate access to their electronic health records (EHRs). The experiences of marginalized people, including transgender people, accessing and reviewing their EHRs could inform documentation guidelines to improve patient-clinician rapport and reduce harm.

OBJECTIVE

To investigate the experiences of transgender people reviewing EHRs.

DESIGN

Qualitative study using community-engaged research and an interpretive description methodology. Participants were recruited via social media, snowball sampling was employed, and purposive sampling was used to ensure diversity in terms of age, race/ethnicity, and other factors. In focus groups, participants were asked to discuss their experiences reviewing their EHRs and, for those participants who were clinicians, their experiences reviewing other clinicians' documentation.

PARTICIPANTS

Thirty transgender adults aged 20 to 67 years, including 10 clinicians.

APPROACH

Digital audio-recordings of focus groups were transcribed verbatim. Content was analyzed to identify emerging essential elements and analysis was continued until no new themes emerged (i.e., saturation).

KEY RESULTS

Four themes were noted. (1) Using the wrong name, pronoun, or gender marker for patients is common in the EHR, erodes trust, and causes trauma. (2) Various aspects of clinicians' notes contradict, blame, or stigmatize patients, across multiple axes of oppression. (3) Limitations of EHR capabilities create barriers to quality care. (4) Certain medical customs set the stage for marginalizing, objectifying, and pathologizing transgender people.

CONCLUSIONS

Transgender people experience harm via various aspects of EHR documentation, suggesting that changes must be made to improve patient-clinician relationships and reduce ill-effects for patients.

Parent Perspectives on Sharing Pediatric Hospitalization Clinical Notes

BACKGROUND AND OBJECTIVES

Federal guidelines mandate that hospitals provide patients and caregivers with free, online access to their physician's clinical notes. This study sought to identify parent perceptions of the benefits and challenges of real-time note access during their child's hospitalization and strategies to optimize note-sharing at the bedside.

METHODS

This qualitative study was conducted with parents of children aged <12 years admitted to a pediatric hospitalist service in April 2019. Parents were given access to their child's admission and daily progress notes on a bedside tablet (iPad), and interviewed upon discharge. In-depth, 60-minute interviews were audio-recorded and transcribed. Two researchers developed and refined a codebook and coded data inductively and deductively with validation by a third researcher. Thematic analysis was used to identify emergent themes.

RESULTS

The 28 interviewed parents described 6 benefits of having note access, which: provided a recap and improved their knowledge about their child's care plan, enhanced communication, facilitated empowerment, increased autonomy, and incited positive emotions. Potential challenges included that notes: caused confusion, hindered communication with the health care team, highlighted problems with note content, and could incite negative emotions. Parents recommended 4 strategies to support sharing: provide preemptive communication about expectations, optimize the note release process, consider parent-friendly note template modifications, and offer informational resources for parents.

CONCLUSIONS

Findings provide a framework for operationalizing note-sharing with parents during hospitalization. These results have important implications for hospitals working to comply with federal regulations and researchers assessing the effects of increased information transparency in the inpatient setting.

Effect of Notes' Access and Complexity on OpenNotes' Utility

BACKGROUND

Health care providers are now required to provide their patients access to their consultation and progress notes. Early research of this concept, known as "OpenNotes," showed promising results in terms of provider acceptability and patient adoption, yet objective evaluations relating to patients' interactions with the notes are limited.

OBJECTIVES

To assess the effect of the complexity level of notes and number of accesses (initial read vs. continuous access) on the user's performance, perceived usability, cognitive workload, and satisfaction with the notes.

METHODS

We used a 2*2 mixed subjects experimental design with two independent variables: (1) note's complexity at two levels (simple vs. complex) and (2) number of accesses to notes at two levels (initial vs. continuous). Fifty-three participants were randomly assigned to receive a simple versus complex radiation oncology clinical note and were tested on their performance for understanding the note content after an initial read, and then with continuous access to the note. Performance was quantified by comparing each participant's answers to the ones developed by the research team and assigning a score of 0 to 100 based on participants' understanding of the notes. Usability, cognitive workload, and satisfaction scores of the notes were quantified using validated tools.

RESULTS

Performance for understanding was significantly better in simple versus complex notes with continuous access (p = 0.001). Continuous access to the notes was also positively associated with satisfaction scores (p = 0.03). The overall perceived usability, cognitive workload, and satisfaction scores were considered low for both simple and complex notes.

CONCLUSION

Simplifying notes can improve understanding of notes for patients/families. However, perceived usability, cognitive workload, and satisfaction with even the simplified notes were still low. To make notes more useful for patients and their families, there is a need for dramatic improvements to the overall usability and content of the notes.

Experiences of stigma in hospitals with addiction consultation services: A qualitative analysis of patients' and hospital-based providers' perspectives

BACKGROUND

Addiction consultation services (ACS) provide evidence-based treatment to hospitalized patients with substance use disorders (SUD). Expansion of hospital-based addiction care may help to counteract the stigma that patients with SUD experience within the health care system. Stigma is among the most impactful barriers to seeking care and adhering to medical advice among people with SUD. We aimed to understand how the presence of an ACS affected patients' and hospital-based providers' experiences with stigma in the hospital setting.

METHODS

We conducted a qualitative study utilizing focus groups and key informant interviews with hospital-based providers (hospitalists and hospital-based nurses, social workers, pharmacists). We also conducted key informant interviews with patients who received care from an ACS during their hospitalization. An interprofessional team coded and analyzed transcripts using a thematic analysis approach to identify emergent themes.

RESULTS

Sixty-two hospital-based providers participated in six focus groups or eight interviews. Twenty patients participated in interviews. Four themes emerged relating to the experiences of stigma reported by hospital-based providers and hospitalized patients with SUD: (1) past experiences in the health care system propagate a cycle of stigmatization between hospital-based providers and patients; (2) documentation in medical charts unintentionally or intentionally perpetuates enacted stigma among hospital-based providers resulting in anticipated stigma among patients; (3) the presence of an ACS reduces enacted stigma among hospital-based providers through expanding the use of evidenced-based SUD treatment and reframing the SUD narrative; (4) ACS team members combat the effects of internalized stigma by promoting feelings of self-worth, self-efficacy, and mutual respect among patients with SUD.

CONCLUSIONS

An ACS can facilitate destigmatization of hospitalized patients with SUD by incorporating evidence-based SUD treatment into routine hospital care, by providing and modeling compassionate care, and by reframing addiction as a chronic condition to be treated alongside other medical conditions. Future reductions of stigma in hospital settings may result from promoting greater use of evidence-based treatment for SUD and expanded education for health care providers on the use of non-stigmatizing language and medical terminology when documenting SUD in the medical chart.

Lessons Learned from OpenNotes Learning Mode and Subsequent Implementation across a Pediatric Health System

BACKGROUND

The 21st Century Cures Act has accelerated adoption of OpenNotes, providing new opportunities for patient and family engagement in their care. However, these regulations present new challenges, particularly for pediatric health systems aiming to improve information sharing while minimizing risks associated with adolescent confidentiality and safety.

OBJECTIVE

Describe lessons learned preparing for OpenNotes across a pediatric health system during a 4-month trial period (referred to as "Learning Mode") in which clinical notes were not shared by default but decision support was present describing the upcoming change and physicians could request feedback on complex cases from a multidisciplinary team.

METHODS

During Learning Mode (December 3, 2020-March 9, 2021), implementation included (1) educational text at the top of commonly used note types indicating that notes would soon be shared and providing guidance, (2) a new confidential note type, and (3) a mechanism for physicians to elicit feedback from a multidisciplinary OpenNotes working group for complex cases with questions related to OpenNotes. The working group reviewed lessons learned from this period, as well as implementation of OpenNotes from March 10, 2021 to June 30, 2021.

RESULTS

During Learning Mode, 779 confidential notes were written across the system. The working group provided feedback on 14 complex cases and also reviewed 7 randomly selected confidential notes. The proportion of physician notes shared with patients increased from 1.3% to 88.4% after default sharing of notes to the patient portal. Key lessons learned included (1) sensitive information was often present in autopopulated elements, differential diagnoses, and supervising physician note attestations; and (2) incorrect reasons were often selected by clinicians for withholding notes but this accuracy improved with new designs.

CONCLUSION

While OpenNotes provides an unprecedented opportunity to engage pediatric patients and their families, targeted education and electronic health record designs are needed to mitigate potential harms of inappropriate disclosures.

Patient Perceptions of Receiving COVID-19 Test Results via an Online Patient Portal: An Open Results Survey

BACKGROUND

In the United States, attention has been focused on "open notes" and "open results" since the Office of the National Coordinator for Health Information Technology implemented the 21st Century Cures Act Final Rule on information blocking. Open notes is an established best practice, but open results remains controversial, especially for diseases associated with stigma, morbidity, and mortality. Coronavirus disease 2019 (COVID-19) is associated with all three of these effects and represents an ideal disease for the study of open results for sensitive test results.

OBJECTIVES

This study evaluates patient perspectives related to receiving COVID-19 test results via an online patient portal prior to discussion with a clinician.

METHODS

We surveyed adults who underwent COVID-19 testing between March 1, 2020 and October 21, 2020 who agreed to be directly contacted about COVID-19-related research about their perspectives on receiving test results via a patient portal. We evaluated user roles (i.e., patient vs. care partner), demographic information, ease of use, impact of immediate release, notification of results, impact of viewing results on health management, and importance of sharing results with others.

RESULTS

Users were mostly patients themselves. Users found the portal easy to use but expressed mixed preferences about the means of notification of result availability (e.g., email, text, or phone call). Users found immediate access to results useful for managing their health, employment, and family/childcare. Many users shared their results and encouraged others to get tested. Our cohort consisted mostly of non-Hispanic white, highly educated, English-speaking patients.

CONCLUSION

Overall, patients found open results useful for COVID-19 testing and few expressed increased worries from receiving their results via the patient portal. The demographics of our cohort highlight the need for further research in patient portal equity in the age of open results.

The 21st Century Cures Act and Challenges to Adolescent Confidentiality

Confidentiality is an important part of adolescent health care, providing a safe arena for young people to address sensitive health concerns and develop independent relationships with their providers. State and federal laws support a range of adolescent confidentiality protections. However, the full implementation of the 21st Century Cures Act, with the release of all medical records to patients and caregivers, may endanger this expectation of privacy. This policy brief reviews implications of the open notes requirement of the Cures Act, suggests strategies to improve care for adolescent patients, and recommends advocacy to improve the 2020 Final Rule implementation.

Current Grief Support in Pediatric Palliative Care

Grief support changes as more is learned from current grief theory and research. The authors provide a comprehensive overview of current grief support as it relates to Pediatric Palliative Care (PPC). The following aspects of grief are addressed: (1) anticipatory grief: the nondeath losses that occur with a complex and chronic illness, as well as the time leading up to death; (2) grief around the time of death: the intense and sacred experience of companioning with a dying child; (3) grief after death: supporting bereavement and mourning through programing and other methods; (4) innovative approaches: the future of grief support. The contents of this article are meant to support and educate programs currently providing grief services and those aiming to begin the meaningful work of grief support.