Opening Residents' Notes to Patients: A Qualitative Study of Resident and Faculty Physician Attitudes on Open Notes Implementation in Graduate Medical Education

Patient online access to medical records in general practice: Perceived effects after one year follow-up

OBJECTIVE

Online access to medical records is expected to foster patient empowerment and patient-centred healthcare. However, data on actual experienced effects remain limited. We aimed to examine the development of effects patients perceive from online access.

METHODS

A nationwide online survey (N = 1769) evaluated Dutch patients' use of online access and beliefs about its effects on 16 outcomes at baseline and one-year follow-up. Analyses of Variance (ANOVA) were used to examine within-person belief changes across three user groups: patients who 1) used online access before the study, 2) started use during the study, and 3) did not use it at all.

RESULTS

There was a small decline in five beliefs around online access facilitating patient empowerment and participation in participants who started using online access during the study compared to at least one other user group. Most changes in beliefs did not differ between groups.

CONCLUSION

No evidence of benefits from online access was found. The findings might indicate inadequacies in the current system of online access. Possibly, the benefits of online access are contingent upon portal improvements and changes in documentation practices.

PRACTICE IMPLICATION

Records need to be easily accessible and comprehensible for patients. Consultation practices should enable patient participation.

Attitudes and Experiences of Clinicians After Mandated Implementation of Open Notes by the 21st Century Cures Act: Survey Study

BACKGROUND

On December 13, 2016, the US Congress enacted the 21st Century Cures Act (hereafter the Cures Act), which contained the Final Rule mandate that took effect on April 5, 2021. Since then, health systems have been required to provide patients digital access to their eHealth information "without delay" and without charge.

OBJECTIVE

This study aimed to assess clinicians' initial experiences with, and attitudes toward, sharing visit notes with patients after being mandated to do so by the Cures Act and to determine clinician preferences regarding instant record release.

METHODS

This cross-sectional survey study was conducted between June 10, 2021, and August 15, 2021, at the University of Kansas Health System, a large academic medical center in Kansas City, Kansas, United States. Participants included clinicians currently employed by the health system, including resident and attending physicians, physician assistants, nurse practitioners, and critical care and emergency medicine registered nurses.

RESULTS

A total of 1574 attending physicians, physician assistants, and nurse practitioners, as well as 506 critical care and emergency medicine nurses, were sent invitations; 538 (34.18%) and 72 (14.2%), respectively, responded. Of 609 resident physicians, 4 (response rate not applicable because it was unknown how many residents viewed the website while the link was available) responded. The majority of respondents were attending physicians (402/614, 65.5%) and within the department of internal medicine (160/614, 26.1%). Most agreed that sharing visit notes was a good idea (355/613, 57.9%) and that it is important to speak with the patients before they accessed their records (431/613, 70.3%). Those who agreed that sharing visit notes is a good idea tended to view the practice as a useful tool for engaging patients ("Agree": 139/355, 39.2%; "Somewhat agree": 161/355, 45.4%; P<.001) and experience no change in the clinical value of their notes for other clinicians (326/355, 91.8%; P<.001). Those who disagreed (or were neutral) tended not to encourage patients to read their notes (235/258, 91.1%; P<.001) and were more likely to experience a change in their charting practice (168/257, 65.4%; P<.001) and increased time charting (99/258, 38.4%; P<.001).

CONCLUSIONS

The findings of this study may be generalizable to institutions similar to the University of Kansas Health System, and the clinician testimonies gathered in this study may provide valuable insight into the initial opinions and experiences of clinicians at these institutions. In addition, these clinician experiences collected early in the transition period may be used to guide future health policy implementation and to understand how best to prepare clinicians for these changes in practice.

Professionals as Change Agents or Instruments of Reproduction? Medical Residents’ Reasoning for Not Sharing the Electronic Health Record Screen with Patients

The stability of physicians’ authority over patients despite decades of changes in medicine conflicts with newer institutionalist accounts of professionals as change agents rather than instruments of reproduction. We analyzed whether the cultural scripts that twenty-one residents used to justify their approach to a new change, the electronic health record (EHR), signaled a leveling of the patient-physician hierarchy. Residents are intriguing because their position makes them open to change. Indeed, residents justified using the EHR in ways that level the patient-physician hierarchy, but also offered rationales that sustain it. For the latter, residents described using the EHR to substantiate their expertise, situate themselves as brokers between patients and the technology, and preserve the autonomy of clinicians. Our findings highlight how professionals with little direct experience before a change can selectively apply incumbent scripts to sustain extant structures, while informing newer institutionalist accounts of professionals and the design of EHR systems.

Changes in Clinician Attitudes Toward Sharing Visit Notes: Surveys Pre-and Post-Implementation

BACKGROUND

Clinician perceptions before and after inviting patients to read office notes (open notes) are unknown.

OBJECTIVE

To describe changes in clinicians' attitudes about sharing notes with patients.

DESIGN, PARTICIPANTS, AND MAIN MEASURE

Survey of outpatient primary and specialty care clinicians who were from a large group practice and had one or more patients who accessed notes. The main outcome was percent change (before vs. after implementation) in clinician perception that online visit notes are beneficial overall.

KEY RESULTS

Of the 563 invited clinicians, 400 (71%) took the baseline survey; 295 were eligible for a follow-up survey with 192 (65%) responding (119 primary care, 47 medical specialties, 26 surgical specialties). Before implementation, 29% agreed or somewhat agreed that visit notes online are beneficial overall, increasing to 71% following implementation (p<0.001); 44% switched beliefs from bad to good idea; and 2% reported the opposite change (p<0.001). This post-implementation change was observed in all clinician categories. Compared to pre-implementation, fewer clinicians had concerns about office visits taking longer (47% pre vs. 15% post) or requiring more time for questions (71% vs. 16%), or producing notes (57% vs. 28%). Before and after implementation, most clinicians reported being less candid in documentation (65% vs. 52%) and that patients would have more control of their care (72% vs. 78%) and worry more (72% vs. 65%).

CONCLUSIONS

Following implementation, more primary and specialty care clinicians agreed that sharing notes with patients online was beneficial overall. Fewer had concerns about more time needed for office visits or documentation. Most thought patients would worry more and reported being less candid in documentation.

Notes at your fingertips: Open note considerations regarding pediatric and adolescent care

The clinician's note serves an increasing number of audiences, the most recent addition being the patient and, in the case of pediatrics, the parent/guardian. The early work of the OpenNotes initiative followed by the recently enacted 21^st Century Cures Act Information Blocking Rule has mandated easy and timely electronic access to notes involving their clinical care. While many benefits have already been described and most drawbacks unrealized, the care of pediatric and adolescent patients brings unique challenges to enable this functionality while preserving patient, parent, and family confidentiality. Given statewide variability in affording these protections, there remains a technological gap in uniformly assisting clinicians to do the right thing while remaining compliant with the law. More research is needed on the impact and new workflow considerations for using an open notes approach across care settings and within academic institutions. Additional education and training are needed to adapt note writing to accommodate patient understanding and encourage patient engagement while conveying the complexity of medical decision making. As transparency and shared medical decision-making become more prevalent within medicine, clinicians' communication and documentation styles need to evolve to meet that challenge.

Beyond Known Barriers-Assessing Physician Perspectives and Attitudes Toward Introducing Open Health Records in Germany: Qualitative Study

Background

Giving patients access to their medical records (ie, open health records) can support doctor-patient communication and patient-centered care and can improve quality of care, patients’ health literacy, self-care, and treatment adherence. In Germany, patients are entitled by law to have access to their medical records. However, in practice doing so remains an exception in Germany. So far, research has been focused on organizational implementation barriers. Little is known about physicians’ attitudes and perspectives toward opening records in German primary care.

Objective

This qualitative study aims to provide a better understanding of physicians’ attitudes toward opening records in primary care in Germany. To expand the knowledge base that future implementation programs could draw from, this study focuses on professional self-conception as an influencing factor regarding the approval for open health records. Perspectives of practicing primary care physicians and advanced medical students were explored.

Methods

Data were collected through semistructured guide-based interviews with general practitioners (GPs) and advanced medical students. Participants were asked to share their perspectives on open health records in German general practices, as well as perceived implications, their expectations for future medical records, and the conditions for a potential implementation. Data were pseudonymized, audiotaped, and transcribed verbatim. Themes and subthemes were identified through thematic analysis.

Results

Barriers and potential advantages were reported by 7 GPs and 7 medical students (N=14). The following barriers were identified: (1) data security, (2) increased workload, (3) costs, (4) the patients’ limited capabilities, and (5) the physicians’ concerns. The following advantages were reported: (1) patient education and empowerment, (2) positive impact on the practice, and (3) improved quality of care. GPs’ professional self-conception influenced their approval for open records: GPs considered their aspiration for professional autonomy and freedom from external control to be threatened and their knowledge-based support of patients to be obstructed by open records. Medical students emphasized the chance to achieve shared decision making through open records and expected the implementation to be realistic in the near future. GPs were more hesitant and voiced a strong resistance toward sharing notes on perceptions that go beyond clinical data. Reliable technical conditions, the participants’ consent, and a joint development of the implementation project to meet the GPs’ interests were requested.

Conclusions

Open health record concepts can be seen as a chance to increase transparency in health care. For a potential future implementation in Germany, thorough consideration regarding the compatibility of GPs’ professional values would be warranted. However, the medical students’ positive attitude provides an optimistic perspective. Further research and a broad support from decision makers would be crucial to establish open records in Germany.

Perception versus reality: Does provider documentation behavior change when clinic notes are shared electronically with patients?

INTRODUCTION

Secure patient portals have improved patient access to information, including provider notes. Although there is evidence suggesting that electronic note sharing improves communication and care quality, some studies have reported provider concerns regarding note sharing.

MATERIAL AND METHODS

This mixed-methods single site study utilized survey questions from a previously published landmark study to assess provider perceptions of electronic note sharing as well as objective EHR data. Surveys were sent to 628 providers in 34 primary and specialty care clinics approximately 12 weeks after the implementation of phase 1 (April 1, 2018) and phase 2 (July 1, 2018). EHR data were extracted from three months pre- and three months post-implementation of note sharing to determine whether or not note authoring times were affected.

RESULTS

Nearly one-quarter (n = 150) of the responses sent to 628 providers were retained for analysis (23.9 % response rate). A majority (84.7 %) of respondents believed notes were useful vehicles for communication and 73.3 % agreed that making notes available to patients was a good idea. Additionally, 16.0 % of respondents (14.0 % for primary care and 17.0 % for specialists) believed they "spent more time writing/dictating/editing their notes." A comparison of pre-post note authoring time revealed the aggregated primary care median increased 0.14 min (7.93-8.07 min) while aggregated specialty care median was identical (11.6 min).

DISCUSSION

The EHR comparison of note authoring time pre-post did not reflect provider concerns identified in the survey regarding electronic note sharing.

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.

Open Notes in Teaching Clinics: A Multisite Survey of Residents to Identify Anticipated Attitudes and Guidance for Programs

BACKGROUND

Clinicians are increasingly sharing outpatient visit notes with patients through electronic portals. These open notes may bring about new educational opportunities as well as concerns to physicians-in-training and residency programs.

OBJECTIVE

We assessed anticipatory attitudes about open notes and explored factors influencing residents' propensity toward note transparency.

METHODS

Residents in primary care clinics at 4 teaching hospitals were surveyed prior to implementation of open notes. Main measures included resident attitudes toward open notes and the anticipated effect on patients, resident workload, and education. Data were stratified by site.

RESULTS

A total of 176 of 418 (42%) residents responded. Most residents indicated open notes would improve patient engagement, trust, and education but worried about overwhelming patients, residents being less candid, and workload. More than half of residents thought open notes were a good idea, and 32% (56 of 176) indicated they would encourage patients to read these notes. More than half wanted note-writing education and more feedback, and 72% (126 of 175) indicated patient feedback on residents' notes could improve communication skills. Attitudes about effects of open notes on safety, quality, trust, and medical education varied by site.

CONCLUSIONS

Residents reported mixed feelings about the anticipated effects of sharing clinical notes with patients. They advocate for patient feedback on notes, yet worry about workload, supervision, and errors. Training site was correlated with many attitudes, suggesting local culture drives resident support for open notes. Strategies that address resident concerns and promote teaching and feedback related to notes may be helpful.

Potential of personal health record portals in the care of individuals with spinal cord injuries and disorders: Provider perspectives

CONTEXT/OBJECTIVE

Although personal health record (PHR) portals are designed for patients, healthcare providers are a key influence in how patients use their features and realize benefits from them. A few studies have examined provider attitudes toward PHR portals, but none have focused on those who care for individuals with spinal cord injuries and disorders (SCI/D). We characterize SCI/D provider perspectives of PHR portals, including perceived advantages and disadvantages of PHR portal use in SCI/D care.

DESIGN

Cross-sectional; semi-structured interviews.

SETTING

Spinal Cord Injury (SCI) Centers in the Veterans Health Administration.

PARTICIPANTS

Twenty-six SCI/D healthcare providers.

INTERVENTIONS

None.

OUTCOME MEASURES

Perceived advantages and disadvantages of PHR portals.

RESULTS

The complex situations of individuals with SCI/D shaped provider perspectives of PHR portals and their potential role in practice. Perceived advantages of PHR portal use in SCI/D care included the ability to coordinate information and care, monitor and respond to outpatient requests, support patient self-management activities, and provide reliable health information to patients. Perceived disadvantages of PHR portal use in SCI/D care included concerns about the quality of patient-generated health data, other potential liabilities for providers and workload burden, and the ability of individuals with SCI/D to understand clinical information accessed through a portal.

CONCLUSION

Our study highlights advantages and disadvantages that should be considered when promoting engagement of SCI/D healthcare providers in use of PHR portals, and portal features that may have the most utility in SCI/D care.

The electronic health record as a patient engagement tool: mirroring clinicians' screen to create a shared mental model

Objective

Electronic health records (EHRs) in physician offices can both enhance and detract from the patient experience. Best practices have emerged focusing on screen sharing. We sought to determine if adding a second monitor, mirroring the EHR for patients, would be welcome and useful for patients and clinicians.

Materials and Methods

This mixed-method study was conducted in a general medicine clinic from March to June 2016. Clinicians and patients met in a specially equipped exam room with a patient-facing monitor. Visits were video-recorded to assess time spent viewing the EHR and followed by interviews, which were transcribed and analyzed using established qualitative methods.

Results

Eight clinicians and 24 patients participated. Main themes included the second screen serving as a catalyst for patient engagement, augmenting the clinic visit in a meaningful way, improving transparency of the care process and documentation, and providing a substantially different experience for patients than a shared single screen. Concerns and suggestions for improvement were also reported. Quantitative results showed high patient engagement times with the EHR (25% of the visit length) compared to reports in previous studies. The median satisfaction score was 5 out of 5 for patients and 3.3 out of 5 for clinicians.

Discussion and Conclusion

Providing patient access to the EHRs with this design was linked with several benefits including improved patient engagement, education, transparency, comprehension, and trust. Future studies should explore how best to display information in such screens for patients and identify impact on care, safety, and quality.

Patient-centric medical notes: Identifying areas for improvement in the age of open medical records

OBJECTIVE

Patients are increasingly provided facilitated access to their medical notes. Physicians have reported concerns that patients will find notes confusing and offensive, and that typographical errors will appear unprofessional. This exploratory study quantifies the prevalence of potentially confusing or offensive medical language and typographic errors within notes.

METHODS

The authors performed a retrospective, cross-sectional review of 400 inpatient History and Physical notes from a tertiary care center. All notes were from admissions to general internal medicine services. Words and phrases of interest were codified into five pre-established categories and subdivisions.

RESULTS

Of 400 notes, 337 notes written by residents and hospitalists were analyzed. The most prevalent characteristics identified per note were General Medical Acronyms (99.1%), Medical Jargon (96.7%), and Typographical Errors (49%). Residents used a greater number of acronyms and abbreviations (p<0.01). All subdivisions within Subjective Descriptors and Mental and Personal Health appeared in less than 20% of notes.

CONCLUSION

While the place of medical shorthand, jargon, and sensitive history in the note is unlikely to change in the near future, this study identifies typographical errors as a modifiable area for improvement. The examination of medical note language may prove beneficial to the patient-physician relationship in the digital era.

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.