A patient and family reporting system for perceived ambulatory note mistakes: experience at 3 U.S. healthcare centers

Minors' and guardian access to and use of a national patient portal: A retrospective comparative case study of Sweden and Finland

BACKGROUND

Approaches to implementing online record access (ORA) via patient portals for minors and guardians vary internationally, as more countries continue to develop patient-accessible electronic health records (PAEHR) systems. Evidence of ORA usage and country-specific practices to allow or block minors' and guardians' access to minors' records during adolescence (i.e. access control practices) may provide a broader understanding of possible approaches and their implications for minors' confidentiality and guardian support.

AIM

To describe and compare minors' and guardian proxy users' PAEHR usage in Sweden and Finland. Furthermore, to investigate the use of country-specific access control practices.

METHODS

A retrospective, observational case study was conducted. Data were collected from PAEHR administration services in Sweden and Finland and proportional use was calculated based on population statistics. Descriptive statistics were used to analyze the results.

RESULTS

In both Sweden and Finland, the proportion of adolescents accessing their PAEHR increased from younger to older age-groups reaching the proportion of 59.9 % in Sweden and 84.8 % in Finland in the age-group of 17-year-olds. The PAEHR access gap during early adolescence in Sweden may explain the lower proportion of users among those who enter adulthood. Around half of guardians in Finland accessed their minor children's records in 2022 (46.1 %), while Swedish guardian use was the highest in 2022 for newborn children (41.8 %), and decreased thereafter. Few, mainly guardians, applied for extended access in Sweden. In Finland, where a case-by-case approach to access control relies on healthcare professionals' (HCPs) consideration of a minor's maturity, 95.8 % of minors chose to disclose prescription information to their guardians.

CONCLUSION

While age-based access control practices can hamper ORA for minors and guardians, case-by-case approach requires HCP resources and careful guidance to ensure equality between patients. Guardians primarily access minors' records during early childhood and adolescents show willingness to share their PAEHR with parents.

The Acceptance and Use of Digital Technologies for Self-Reporting Medication Safety Events After Care Transitions to Home in Patients With Cancer: Survey Study

BACKGROUND

Actively engaging patients with cancer and their families in monitoring and reporting medication safety events during care transitions is indispensable for achieving optimal patient safety outcomes. However, existing patient self-reporting systems often cannot address patients' various experiences and concerns regarding medication safety over time. In addition, these systems are usually not designed for patients' just-in-time reporting. There is a significant knowledge gap in understanding the nature, scope, and causes of medication safety events after patients' transition back home because of a lack of patient engagement in self-monitoring and reporting of safety events. The challenges for patients with cancer in adopting digital technologies and engaging in self-reporting medication safety events during transitions of care have not been fully understood.

OBJECTIVE

We aim to assess oncology patients' perceptions of medication and communication safety during care transitions and their willingness to use digital technologies for self-reporting medication safety events and to identify factors associated with their technology acceptance.

METHODS

A cross-sectional survey study was conducted with adult patients with breast, prostate, lung, or colorectal cancer (N=204) who had experienced care transitions from hospitals or clinics to home in the past 1 year. Surveys were conducted via phone, the internet, or email between December 2021 and August 2022. Participants' perceptions of medication and communication safety and perceived usefulness, ease of use, attitude toward use, and intention to use a technology system to report their medication safety events from home were assessed as outcomes. Potential personal, clinical, and psychosocial factors were analyzed for their associations with participants' technology acceptance through bivariate correlation analyses and multiple logistic regressions.

RESULTS

Participants reported strong perceptions of medication and communication safety, positively correlated with medication self-management ability and patient activation. Although most participants perceived a medication safety self-reporting system as useful (158/204, 77.5%) and easy to use (157/204, 77%), had a positive attitude toward use (162/204, 79.4%), and were willing to use such a system (129/204, 63.2%), their technology acceptance was associated with their activation levels (odds ratio [OR] 1.83, 95% CI 1.12-2.98), their perceptions of communication safety (OR 1.64, 95% CI 1.08-2.47), and whether they could receive feedback after self-reporting (OR 3.27, 95% CI 1.37-7.78).

CONCLUSIONS

In general, oncology patients were willing to use digital technologies to report their medication events after care transitions back home because of their high concerns regarding medication safety. As informed and activated patients are more likely to have the knowledge and capability to initiate and engage in self-reporting, developing a patient-centered reporting system to empower patients and their families and facilitate safety health communications will help oncology patients in addressing their medication safety concerns, meeting their care needs, and holding promise to improve the quality of cancer care.

Biases in Electronic Health Records Data for Generating Real-World Evidence: An Overview

Electronic Health Records (EHR) are increasingly being perceived as a unique source of data for clinical research as they provide unprecedentedly large volumes of real-time data from real-world settings. In this review of the secondary uses of EHR, we identify the anticipated breadth of opportunities, pointing out the data deficiencies and potential biases that are likely to limit the search for true causal relationships. This paper provides a comprehensive overview of the types of biases that arise along the pathways that generate real-world evidence and the sources of these biases. We distinguish between two levels in the production of EHR data where biases are likely to arise: (i) at the healthcare system level, where the principal source of bias resides in access to, and provision of, medical care, and in the acquisition and documentation of medical and administrative data; and (ii) at the research level, where biases arise from the processes of extracting, analyzing, and interpreting these data. Due to the plethora of biases, mainly in the form of selection and information bias, we conclude with advising extreme caution about making causal inferences based on secondary uses of EHRs.

Utility of Family Reports in Predicting Emergency Department Patient Alcohol Use in Tanzania

OBJECTIVE

Myriad reasons, including stigma, may prevent patients from self-reporting harmful use of alcohol in Tanzania. Family members may be more forthright but might not know the extent of the patient's alcohol use or suffer alcohol-related stigma as well. Our study aims to compare the reporting of patient alcohol use by emergency department patients themselves and their family members in Tanzania in order to describe the potential use of family reports as a proxy for patient self-reports.

METHOD

We conducted a secondary descriptive analysis of a prospective cohort of adult patients seeking treatment for injury and their family members. We evaluated alcohol use behavior, alcohol-related consequences, and alcohol-related stigma reported by 231 patients and 231 family members (both majority male, ages 25-45 years), measured by the Alcohol Use Disorders Identification Test (AUDIT), Perceived Alcohol Stigma (PAS) scale, and the Drinker Inventory of Consequences (DrInC). Alcohol use behavior concordance/discordance between patients and families was established, and alcohol use and perceived stigma were analyzed.

RESULTS

More than 72% of patient-family pairs showed alcohol use (AUDIT) concordance. Receiver operating characteristic curve and regression analysis suggests family reports to be clinically relevant, significant, and potentially accurate markers of patient alcohol use (sensitivity: 95.10%, specificity: 69.77%). Findings support the existence of stigma toward alcohol in this context, with similar stigma levels of patients and family members.

CONCLUSIONS

Family-reported patient alcohol use may be an accurate proxy for patient self-reporting. Further research is needed into stigma toward alcohol that is culturally appropriate and adopted.

Open Notes, a digital transformation of pediatric inpatient care: Focus groups of parents and other stakeholders (Preprint)

Background

Patient portals are a health information technology that allows patients and their proxies, such as caregivers and family members, to access designated portions of their electronic health record using mobile devices and web browsers. The Open Notes initiative in the United States, which became federal law in April 2021, has redrawn and expanded the boundaries of medical records. Only a few studies have focused on sharing notes with parents or caregivers of pediatric patients.

Objective

This study aimed to investigate the anticipated impact of increasing the flow of electronic health record information, specifically physicians’ daily inpatient progress notes, via a patient portal to parents during their child’s acute hospital stay—an understudied population and an understudied setting.

Methods

A total of 5 in-person focus groups were conducted with 34 stakeholders most likely impacted by sharing of physicians’ inpatient notes with parents of hospitalized children: hospital administrators, hospitalist physicians, interns and resident physicians, nurses, and the parents themselves.

Results

Distinct themes identified as benefits of pediatric inpatient Open Notes for parents emerged from all the 5 focus groups. These themes were communication, recapitulation and reinforcement, education, stress reduction, quality control, and improving family-provider relationships. Challenges identified included burden on provider, medical jargon, communication, sensitive content, and decreasing trust.

Conclusions

Providing patients and, in the case of pediatrics, caregivers with access to medical records via patient portals increases the flow of information and, in turn, their ability to participate in the discourse of their care. Parents in this study demonstrated not only that they act as monitors and guardians of their children’s health but also that they are observers of the clinical processes taking place in the hospital and at their child’s bedside. This includes the clinical documentation process, from the creation of notes to the reading and sharing of the notes. Parents acknowledge not only the importance of notes in the clinicians’ workflow but also their collaboration with providers as part of the health care team.

Analysis of patient preferences on patient-provider interactions through the OpenNotes online portal in dermatology

Background: Many medical centers are beginning to use OpenNotes (ON) to empower patients. However, there is a lack of literature reviewing the ON system in dermatology and any differences in attitudes between men and women. If so, it is uncertain what concerns are more important to female patients. Given the complex lexicon of notes in dermatology, the outpatient setting of dermatology practices, and the often-complex nature of treatment regimens, investigation was merited.

Objective: This paper aimed to evaluate a survey of dermatologic patients on their attitudes toward the ON system.

Methods: From July through October 2015, 333 dermatologic patients at the Beth Israel Deaconess Medical Center completed an anonymous, voluntary, 25-question survey of the ON system while in the waiting room. Approximately 60% of respondents were female and 40% were male. Respondents were older, with 27% age >65 years, 21% between 56 and 65 years, 16% between 46 and 55 years, 17% between 36 and 45 years, 14% between 26 and 35 years, and 4% between 18 and 25 years. Eighty-five percent of respondents were white, and 73% had, at minimum, graduated from college.

Results: Patient response to ON was positive, with 93% agreeing ON is a good idea. Of the patients who accessed their own notes (69% of respondents), 99.6% desired continued access. In addition, 85.6% of patients felt ON allowed them to control their own health, and 70% reported increased confidence in their dermatologist. Nineteen percent of respondents thought ON presented a privacy concern.

Conclusion: The results showed that female patients strongly desire access to their medical records, but concerns about privacy and security exist. Preliminary analysis by a statistician did not find any statistically significant variations between men and women within the results of the survey. Due to the wide agreement in responses, it is unlikely that there are significant differences in opinion on ON between men and women.

Characteristics of Critical Incident Reporting Systems in Primary Care: An International Survey

OBJECTIVE

The aim of the study was to support the development of future critical incident reporting systems (CIRS) in primary care by collecting information on existing systems. Our focus was on processes used to report and analyze incidents, as well as strategies used to overcome difficulties.

METHODS

Based on literature from throughout the world, we identified existing CIRS in primary care. We developed a questionnaire and sent it to operators of a purposeful sample of 17 CIRS in primary care. We used cross-case analysis to compare the answers and pinpoint important similarities and differences in the CIRS in our sample.

RESULTS

Ten CIRS operators filled out the questionnaire, and 9 systems met our inclusion criteria. The sample of CIRS came from 8 different countries and was rather heterogeneous. The reporting systems invited a broad range of professions to report, with some also including reports by patients. In most cases, reporting was voluntary and conducted via an online reporting form. Reports were analyzed locally, centrally, or both. The various CIRS used interesting ideas to deal with barriers. Some, for example, used confidential reporting modes as a compromise between anonymity and the need for follow-up investigations, whereas others used smartphone applications and call centers to speed up the reporting process.

CONCLUSIONS

We found multiple CIRS that have operated in primary care for many years and have received a high number of reports. They were largely developed in accordance with recommendations found in literature. Developers of future systems may find this overview useful.

Attitudes, experiences, and safety behaviours of adolescents and young adults who read visit notes: Opportunities to engage patients early in their care

The Cures Act made access to electronic visit notes ('open notes') nearly universal across the USA, and efforts to share open notes with patients are underway worldwide. This landmark policy change provides an opportunity to engage adolescents and young adults (AYA) early in their care, yet little is known about their attitudes related to reading notes. We compared the responses of 332 AYA (13-25 years old) and 6,914 adults (>25 years old) in a 2016 survey at two USA academic adult and paediatric hospitals. Over 85% of AYA and adults with available notes reported reading at least one note in the prior year. AYA reported similar benefits from note-reading to adults in 15 outcomes related to engagement, relational effects and safety behaviours, supporting efforts to engage AYA as partners in their care using open notes.

Patients Contributing to Visit Notes: Mixed Methods Evaluation of OurNotes

Background

Secure patient portals are widely available, and patients use them to view their electronic health records, including their clinical notes. We conducted experiments asking them to cogenerate notes with their clinicians, an intervention called OurNotes.

Objective

This study aims to assess patient and provider experiences and attitudes after 12 months of a pilot intervention.

Methods

Before scheduled primary care visits, patients were asked to submit a word-constrained, unstructured interval history and an agenda for what they would like to discuss at the visit. Using site-specific methods, their providers were invited to incorporate the submissions into notes documenting the visits. Sites served urban, suburban, and rural patients in primary care practices in 4 academic health centers in Boston (Massachusetts), Lebanon (New Hampshire), Denver (Colorado), and Seattle (Washington). Each practice offered electronic access to visit notes (open notes) to its patients for several years. A mixed methods evaluation used tracking data and electronic survey responses from patients and clinicians. Participants were 174 providers and 1962 patients who submitted at least 1 previsit form. We asked providers about the usefulness of the submissions, effects on workflow, and ideas for the future. We asked patients about difficulties and benefits of providing the requested information and ideas for future improvements.

Results

Forms were submitted before 9.15% (5365/58,652) eligible visits, and 43.7% (76/174) providers and 26.76% (525/1962) patients responded to the postintervention evaluation surveys; 74 providers and 321 patients remembered receiving and completing the forms and answered the survey questions. Most clinicians thought interim patient histories (69/74, 93%) and patient agendas (72/74, 97%) as good ideas, 70% (52/74) usually or always incorporated them into visit notes, 54% (40/74) reported no change in visit length, and 35% (26/74) thought they saved time. Their most common suggestions related to improving notifications when patient forms were received, making it easier to find the form and insert it into the note, and educating patients about how best to prepare their submissions. Patient respondents were generally well educated, most found the history (259/321, 80.7%) and agenda (286/321, 89.1%) questions not difficult to answer; more than 92.2% (296/321) thought sending answers before the visit a good idea; 68.8% (221/321) thought the questions helped them prepare for the visit. Common suggestions by patients included learning to write better answers and wanting to know that their submissions were read by their clinicians. At the end of the pilot, all participating providers chose to continue the OurNotes previsit form, and sites considered expanding the intervention to more clinicians and adapting it for telemedicine visits.

Conclusions

OurNotes interests patients, and providers experience it as a positive intervention. Participation by patients, care partners, clinicians, and electronic health record experts will facilitate further development.

Speaking up about patient-perceived serious visit note errors: Patient and family experiences and recommendations

BACKGROUND

Open notes invite patients and families to read ambulatory visit notes through the patient portal. Little is known about the extent to which they identify and speak up about perceived errors. Understanding the barriers to speaking up can inform quality improvements.

OBJECTIVE

To describe patient and family attitudes, experiences, and barriers related to speaking up about perceived serious note errors.

METHODS

Mixed method analysis of a 2016 electronic survey of patients and families at 2 northeast US academic medical centers. Participants had active patient portal accounts and at least 1 note available in the preceding 12 months.

RESULTS

6913 adult patients (response rate 28%) and 3672 pediatric families (response rate 17%) completed the survey. In total, 8724/9392 (93%) agreed that reporting mistakes improves patient safety. Among 8648 participants who read a note, 1434 (17%) perceived ≥1 mistake. 627/1434 (44%) reported the mistake was serious and 342/627 (56%) contacted their provider. Participants who self-identified as Black or African American, Asian, "other," or "multiple" race(s) (OR 0.50; 95% CI (0.26,0.97)) or those who reported poorer health (OR 0.58; 95% CI (0.37,0.90)) were each less likely to speak up than white or healthier respondents, respectively. The most common barriers to speaking up were not knowing how to report a mistake (61%) and avoiding perception as a "troublemaker" (34%). Qualitative analysis of 476 free-text suggestions revealed practical recommendations and proposed innovations for partnering with patients and families.

CONCLUSIONS

About half of patients and families who perceived a serious mistake in their notes reported it. Identified barriers demonstrate modifiable issues such as establishing clear mechanisms for reporting and more challenging issues such as creating a supportive culture. Respondents offered new ideas for engaging patients and families in improving note accuracy.

Augmenting patient safety through participation by design - An assessment of dual monitors for patients in the outpatient clinic

BACKGROUND

Patients and physicians engaging together in the electronic health record (EHR) during clinical visits may provide opportunities to both improve patient understanding and reduce medical errors.

OBJECTIVE

To assess the potential impact of a patient EHR display intervention on patient quality and safety. We hypothesized that if patients had a dedicated display with an explicit invitation to follow clinicians in the EHR that this would identify several opportunities to engage patients in their care quality and safety.

MATERIAL AND METHODS

Physician-patient outpatient encounters (24 patients and 8 physicians) were videotaped. Encounters took place in a hospital-based general internal medicine outpatient clinic where physicians and patients had their respective EHR monitors. Following the visits, each patient and physician was interviewed for 30 min to understand their perception of the mirrored-screen setting.

RESULTS

The following 7 themes were identified (a) curiosity, (b) opportunity to ask questions, (c) error identification, (d) control over medications, (e) awareness, (f) shared understanding & decision-making, (g) data privacy. These themes collectively comprised a conceptual model for how patient engagement in electronic health record use, through a dedicated second screen or an explicitly shared screen, relates to safety and quality opportunities. Therefore, the double EHR screen provides an explicit invitation for patients to join the process to influence safety.

CONCLUSION

Desired outcomes include real-time error identification and better-shared understanding and decision-making, leading to better downstream follow-through with care plans.