VA OpenNotes: exploring the experiences of early patient adopters with access to clinical notes

A Patient-Centered Documentation Skills Curriculum for Preclerkship Medical Students in an Open Notes Era

Introduction

New legislation allows patients (with permitted exceptions) to read their clinical notes, leading to both benefits and ethical dilemmas. Medical students need a robust curriculum to learn documentation skills within this challenging context. We aimed to teach note-writing skills through a patient-centered lens with special consideration for the impact on patients and providers. We developed this session for first-year medical students within their foundational clinical skills course to place bias-free language at the forefront of how they learn to construct a medical note.

Methods

One hundred seventy-three first-year medical and dental students participated in this curriculum. They completed an asynchronous presession module first, followed by a 2-hour synchronous workshop including a didactic, student-led discussion and sample patient note exercise. Students were subsequently responsible throughout the year for constructing patient-centered notes, graded by faculty with a newly developed rubric and checklist of best practices.

Results

On postworkshop surveys, learners reported increased preparedness in their ability to document in a patient-centered manner (presession M = 2.2, midyear M = 3.9, p < .001), as rated on a 5-point Likert scale (1 = not prepared at all, 5 = very prepared), and also found this topic valuable to learn early in their training.

Discussion

This curriculum utilizes a multipart approach to prepare learners to employ clinical notes to communicate with patients and providers, with special attention to how patients and their care partners receive a note. Future directions include expanding the curriculum to higher levels of learning and validating the developed materials.

People with diabetes who read their clinicians' visit notes: Behaviors and attitudes

OBJECTIVES

To understand behaviors and attitudes of adults with diabetes who read their clinicians' visit notes.

METHODS

By linking a large 2017 patient survey involving three institutions with administrative and portal use data, we identified patients with diabetes mellitus from outpatient records and examined reading behaviors related to eligible notes-initial, follow-up, history and physical, and progress notes. We analyzed patients' perceived benefits of reading notes.

RESULTS

2104 respondents had diagnoses of diabetes mellitus and had read ≥1 note in the 12-month period. Patients had an average of 8.7 eligible notes available and read 59% of them. The strongest predictor of reading more notes was having more notes available; the specialties of the authoring clinicians were not correlated with note reading rates. Patients reported understanding notes by primary care clinicians and specialists equally well; more than 90% of patients reported understanding everything or almost everything in a self-selected note. Across visit types, 73-80% of patients reported that note reading was extremely important for taking care of their health.

DISCUSSION

People with diabetes want to read their clinicians' notes, are accessing them at high rates, and report understanding the notes and benefiting from reading them.

Do patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests and referrals in primary care? A retrospective cohort study

OBJECTIVES

The 2021 US Cures Act may engage patients to help reduce diagnostic errors/delays. We examined the relationship between patient portal registration with/without note reading and test/referral completion in primary care.

MATERIALS AND METHODS

Retrospective cohort study of patients with visits from January 1, 2018 to December 31, 2021, and order for (1) colonoscopy, (2) dermatology referral for concerning lesions, or (3) cardiac stress test at 2 academic primary care clinics. We examined differences in timely completion ("loop closure") of tests/referrals for (1) patients who used the portal and read ≥1 note (Portal + Notes); (2) those with a portal account but who did not read notes (Portal Account Only); and (3) those who did not register for the portal (No Portal). We estimated the predictive probability of loop closure in each group after adjusting for socio-demographic and clinical factors using multivariable logistic regression.

RESULTS

Among 12 849 tests/referrals, loop closure was more common among Portal+Note-readers compared to their counterparts for all tests/referrals (54.2% No Portal, 57.4% Portal Account Only, 61.6% Portal+Notes, P < .001). In adjusted analysis, compared to the No Portal group, the odds of loop closure were significantly higher for Portal Account Only (OR 1.2; 95% CI, 1.1-1.4), and Portal+Notes (OR 1.4; 95% CI, 1.3-1.6) groups. Beyond portal registration, note reading was independently associated with loop closure (P = .002).

DISCUSSION AND CONCLUSION

Compared to no portal registration, the odds of loop closure were 20% higher in tests/referrals for patients with a portal account, and 40% higher in tests/referrals for note readers, after controlling for sociodemographic and clinical factors. However, important safety gaps from unclosed loops remain, requiring additional engagement strategies.

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.

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.

Evaluating a web-based personalized decision report for total knee or hip replacement: Lessons learned from patients

RATIONALE

Patient-reported outcomes (PROs) are increasingly used in the context of clinical care, but evaluation of patients' perspectives of PRO-based applications in routine care remains limited.

AIMS AND OBJECTIVES

This paper investigates patients' acceptability of a personalized web-based decision report for total knee or hip replacement and identifies opportunities to refine the report.

METHOD

This qualitative evaluation was embedded in a pragmatic cluster randomized trial of the report. We interviewed 25 patients with knee and hip osteoarthritis about their experiences using the personalized decision report in the context of a surgical consultation. The web-based report contained current descriptive PRO scores of pain, function and general physical health; tailored predicted postoperative PRO scores (i.e., personalized likely outcomes based on actual knee or hip replacement outcomes of similar patients in a national registry); and information about alternative nonoperative treatments. Two trained researchers analysed the interview data qualitatively using a combination of inductive and deductive coding.

RESULTS

We identified three major categories for evaluation: content of report, presentation of data in report and engagement with report. Patients generally liked the report overall but specifically valued different pages of the report based on where they were in the surgical decision-making process. Patients identified areas of confusion in data presentation related to graph orientation, terminology and interpretation of T-scores. Patients also highlighted support needs to meaningfully engage with the information in the report.

CONCLUSION

Our findings highlight areas of opportunity to further refine this personalized web-based decision report and similar patient-facing PRO applications for routine clinical care. Specific examples include additional tailoring of reports via filterable web-based dashboards and scalable educational supports to facilitate more independent patient understanding and use.

Clinical ethics consultation documentation in the era of open notes

BACKGROUND

In 2021, federal rules from the 21st Century Cures Act mandated most clinical notes be made available in real-time, online, and free of charge to patients, a practice often referred to as "open notes." This legislation was passed to support medical information transparency and reinforce trust in the clinician-patient relationship; however, it created additional complexities in that relationship and raises questions of what should be included in notes intended to be read by both clinicians and patients.

MAIN BODY

Even prior to open notes, how an ethics consultant should document a clinical ethics consultation was widely debated as there can be competing interests, differing moral values, and disagreement about pertinent medical information in any given encounter. Patients can now access documentation of these discussions through online portals which broach sensitive topics related to end-of-life care, autonomy, religious/cultural conflict, veracity, confidentiality, and many others. Clinical ethics consultation notes must be ethically robust, accurate, and helpful for healthcare workers and ethics committee members, but now also sensitive to the needs of patients and family members who can read them in real-time.

CONCLUSION

We explore implications of open notes for ethics consultation, review clinical ethics consultation documentation styles, and offer recommendations for documentation in this new era.

A Natural Language Processing Model to Identify Confidential Content in Adolescent Clinical Notes

BACKGROUND

The 21st Century Cures Act mandates the immediate, electronic release of health information to patients. However, in the case of adolescents, special consideration is required to ensure that confidentiality is maintained. The detection of confidential content in clinical notes may support operational efforts to preserve adolescent confidentiality while implementing information sharing.

OBJECTIVES

This study aimed to determine if a natural language processing (NLP) algorithm can identify confidential content in adolescent clinical progress notes.

METHODS

A total of 1,200 outpatient adolescent progress notes written between 2016 and 2019 were manually annotated to identify confidential content. Labeled sentences from this corpus were featurized and used to train a two-part logistic regression model, which provides both sentence-level and note-level probability estimates that a given text contains confidential content. This model was prospectively validated on a set of 240 progress notes written in May 2022. It was subsequently deployed in a pilot intervention to augment an ongoing operational effort to identify confidential content in progress notes. Note-level probability estimates were used to triage notes for review and sentence-level probability estimates were used to highlight high-risk portions of those notes to aid the manual reviewer.

RESULTS

The prevalence of notes containing confidential content was 21% (255/1,200) and 22% (53/240) in the train/test and validation cohorts, respectively. The ensemble logistic regression model achieved an area under the receiver operating characteristic of 90 and 88% in the test and validation cohorts, respectively. Its use in a pilot intervention identified outlier documentation practices and demonstrated efficiency gains over completely manual note review.

CONCLUSION

An NLP algorithm can identify confidential content in progress notes with high accuracy. Its human-in-the-loop deployment in clinical operations augmented an ongoing operational effort to identify confidential content in adolescent progress notes. These findings suggest NLP may be used to support efforts to preserve adolescent confidentiality in the wake of the information blocking mandate.

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.

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.

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.

Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes

BACKGROUND

The 21st Century Cures Act mandates patients' access to their electronic health record (EHR) notes. To our knowledge, no previous work has systematically invited patients to proactively report diagnostic concerns while documenting and tracking their diagnostic experiences through EHR-based clinician note review.

OBJECTIVE

To test if patients can identify concerns about their diagnosis through structured evaluation of their online visit notes.

METHODS

In a large integrated health system, patients aged 18-85 years actively using the patient portal and seen between October 2019 and February 2020 were invited to respond to an online questionnaire if an EHR algorithm detected any recent unexpected return visit following an initial primary care consultation ("at-risk" visit). We developed and tested an instrument (Safer Dx Patient Instrument) to help patients identify concerns related to several dimensions of the diagnostic process based on notes review and recall of recent "at-risk" visits. Additional questions assessed patients' trust in their providers and their general feelings about the visit. The primary outcome was a self-reported diagnostic concern. Multivariate logistic regression tested whether the primary outcome was predicted by instrument variables.

RESULTS

Of 293 566 visits, the algorithm identified 1282 eligible patients, of whom 486 responded. After applying exclusion criteria, 418 patients were included in the analysis. Fifty-one patients (12.2%) identified a diagnostic concern. Patients were more likely to report a concern if they disagreed with statements "the care plan the provider developed for me addressed all my medical concerns" [odds ratio (OR), 2.65; 95% confidence interval [CI], 1.45-4.87) and "I trust the provider that I saw during my visit" (OR, 2.10; 95% CI, 1.19-3.71) and agreed with the statement "I did not have a good feeling about my visit" (OR, 1.48; 95% CI, 1.09-2.01).

CONCLUSION

Patients can identify diagnostic concerns based on a proactive online structured evaluation of visit notes. This surveillance strategy could potentially improve transparency in the diagnostic process.

Can sharing clinic notes improve communication and promote self-management? A qualitative study of patients with COPD

OBJECTIVE

To understand the impact of sharing clinic notes on communication and self-management among patients with COPD and to develop recommendations for writing patient-centered notes.

METHODS

Thirty patients with COPD participated in 'think-aloud' interviews in which they reviewed their COPD-specific clinic note. Interviews were coded using conventional content analysis, organized by the six-function communication framework.

RESULTS

Participants were predominantly White (93.3%), with a mean age of 65.5 years. More than half had a high school degree or less, half reported difficulty understanding spoken information, and nearly half sometimes need help reading medical materials. Patients indicated notes provided an opportunity to learn details of their condition and facilitated information sharing - strengthening information exchange. Reading notes enabled self-management through motivation, prompting information seeking, and reminding them of action steps. Patients reacted positively to statements suggesting the provider listened to them, saw them as a person, and was attentive to details, which fostered the relationship. Most patients reacted negatively to medical terminology, incorrect information, and wording that was perceived as disparaging.

CONCLUSIONS

Sharing clinic notes with patients can promote information exchange, enable self-management, and strengthen the patient-provider relationship.

PRACTICE IMPLICATIONS

Incorporating patients' recommendations for writing notes could strengthen the benefits of sharing notes.

Patient and Provider Experience of Electronic Patient Portals and Secure Messaging in Mental Health Treatment

Objective: Electronic health record patient portals were promoted to enhance patient engagement. However, organizations often deny patient access to records of treatment for mental health disorders. This study explores patient and provider experience of patient electronic access to the mental health treatment record and the use of secure messaging. Materials and Methods: Online surveys of a sample of mental health patients (N = 168) and providers (N = 80) addressed their experience using patient portals and secure messaging. Results: Only 29 of the 80 providers (36%) worked at organizations which provided patients electronic access to mental health records. Of these 29 providers, 72% endorsed that patients requested a change in the provider note, 69% endorsed patients asked more questions, 55% endorsed patients reported they experienced significant distress after accessing portal, and 21% reported patients engaged in negative and/or self-destructive behavior toward themselves or others. Of patients with access to mental health notes (N = 37), 86% endorsed that they gained a better understanding of what was discussed in the appointment, 84% trusted their health care provider more, 76% felt comforted or relieved after reading their health information, and 57% reported they were better able to take medications as prescribed. Both patients and providers enjoyed the efficiency of secure messaging. Open-text responses are also presented. Conclusions: The implementation of electronic access to mental health notes requires a transition from viewing the medical record as the exclusive tool of providers to that of a collaborative tool for patients and providers to achieve treatment goals.

The Impact of Patient Access to Their Electronic Health Record on Medication Management Safety: A Narrative Review

Introduction

As the American’s Federal Health Insurance Portability and Accountability Act (HIPAA) stated that patients should be allowed to review their medical records, and as information technology is ever more widely used by healthcare professionals and patients, providing patients with online access to their own medical records through a patient portal is becoming increasingly popular. Previous research has been done regarding the impact on the quality and safety of patients’ care, rather than explicitly on medication safety, when providing those patients with access to their electronic health records (EHRs).

Aim

This narrative review aims to summarise the results from previous studies on the impact on medication management safety concepts of adult patients accessing information contained in their own EHRs.

Result

A total of 24 studies were included in this review. The most two commonly studied measures of safety in medication management were: (a) medication adherence and (b) patient-reported experience. Other measures, such as: discrepancies, medication errors, appropriateness and Adverse Drug Events (ADEs) were the least studied.

Conclusion

The results suggest that providing patients with access to their EHRs can improve medication management safety. Patients pointed out improvements to the safety of their medications and perceived stronger medication control. The data from these studies lay the foundation for future research.

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.

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.

The 21st Century Cures Act and Emergency Medicine - Part 1: Digitally Sharing Notes and Results

Among the provisions of the 21st Century Cures Act is the mandate for digital sharing of clinician notes and test results through the patient portal of the clinician's electronic health record system. Although there is considerable evidence of the benefit to clinic patients from open notes and minimal apparent additional burden to primary care clinicians, emergency department (ED) note sharing has not been studied. With easier access to notes and results, ED patients may have an enhanced understanding of their visit, findings, and clinician's medical decisionmaking, which may improve adherence to recommendations. Patients may also seek clarifications and request edits to their notes. EDs can develop workflows to address patient concerns without placing new undue burden on clinicians, helping to realize the benefits of sharing notes and test results digitally.

Challenges, Facilitators, and Recommendations for Implementation of Home Dialysis in the Veterans Health Administration: Patient, Caregiver, and Clinician Perceptions

Background

Home dialysis confers similar survival and greater quality of life than in-center hemodialysis for adults with ESKD but remains underutilized. We examined challenges and facilitators to implementation of home dialysis and identified stakeholder-centered strategies for improving it.

Methods

We conducted a qualitative, cross-sectional, multisite evaluation that included five geographically dispersed Veterans Health Administration (VHA) home dialysis programs. Participants included patients with ESKD receiving home dialysis, their informal caregivers, and home dialysis staff. Semistructured telephone interviews were conducted and audio-recorded from 2017 through 2018, to assess perceived barriers and facilitators to patient home dialysis use in VHA. Transcribed interviews were analyzed thematically by each participant group.

Results

Participants included 22 patients receiving home dialysis (18 on peritoneal dialysis [PD] and four hemodialysis [HD]); 20 informal caregivers, and 19 home dialysis program staff. Ten themes emerged as challenges to implementing home dialysis, of which six (60%) spanned all groups: need for sterility, burden of home dialysis tasks, lack of suitable home environment, physical side effects of home dialysis, negative psychosocial effects of home dialysis, and loss of freedom. Four themes (40%), identified only by staff, were insufficient self-efficacy, diminished peer socialization, geographic barriers, and challenging health status. Twelve themes emerged as facilitators to implementing home dialysis, of which seven (58%) spanned all groups: convenience, freedom, avoidance of in-center HD, preservation of autonomy, adequate support, favorable disposition, and perceptions of improved health. Two themes (17%) common among patients and staff were adequate training and resources, and physical and cognitive skills for home dialysis. Recommendations to promote implementation of home dialysis common to all participant groups entailed incorporating mental health care services, offering peer-to-peer coaching, increasing home visits, providing health data feedback, and reducing patient burden.

Conclusions

Stakeholder-centered challenges were rigorously identified. Facilitators and recommendations can inform efforts to support home dialysis implementation.

Do you want to receive bad news through your patient accessible electronic health record? A national survey on receiving bad news in an era of digital health

Despite the fact that patient accessible electronic health records (PAEHRs) have been around for many years in several countries, there is a lack of research investigating patient's preferences for receiving bad news, including through PAEHRs. Little is also known about the characteristics of the patients who prefer to receive bad news through the PAEHR in terms of, for example medical diagnosis, age and educational level. This study, based on a national patient survey in Sweden (N = 2587), investigated this. Results show that, generally, receiving bad news by reading in the PAEHR is still among the least preferred options. Additionally, a higher proportion of men want to receive bad news in the PAEHR compared to women (p = 0.001), and the same goes for those who are not working/have worked in healthcare (p = 0.007). An effect of disease groups was also found, showing that diabetes patients in particular, want to receive bad news through the PAEHR.

Words Matter: What Do Patients Find Judgmental or Offensive in Outpatient Notes?

BACKGROUND

Sharing outpatient notes with patients may bring clinically important benefits, but notes may sometimes cause patients to feel judged or offended, and thereby reduce trust.

OBJECTIVE

As part of a larger survey examining the effects of open notes, we sought to understand how many patients feel judged or offended due to something they read in outpatient notes, and why.

DESIGN

We analyzed responses from a large Internet survey of adult patients who used secure patient portals and had at least 1 visit note available in a 12-month period at 2 large academic medical systems in Boston and Seattle, and in a rural integrated health system in Pennsylvania.

PARTICIPANTS

Adult ambulatory patients with portal accounts in health systems that offered open notes for up to 7 years.

APPROACH

(1) Quantitative analysis of 2 dichotomous questions, and (2) qualitative thematic analysis of free-text responses on what patients found judgmental or offensive.

KEY RESULTS

Among 22,959 patient respondents who had read at least one note and answered the 2 questions, 2,411 (10.5%) reported feeling judged and/or offended by something they read in their note(s). Patients who reported poor health, unemployment, or inability to work were more likely to feel judged or offended. Among the 2,411 patients who felt judged and/or offended, 2,137 (84.5%) wrote about what prompted their feelings. Three thematic domains emerged: (1) errors and surprises, (2) labeling, and (3) disrespect.

CONCLUSIONS

One in 10 respondents reported feeling judged/offended by something they read in an outpatient note due to the perception that it contained errors, surprises, labeling, or evidence of disrespect. The content and tone may be particularly important to patients in poor health. Enhanced clinician awareness of the patient perspective may promote an improved medical lexicon, reduce the transmission of bias to other clinicians, and reinforce healing relationships.

Natural language processing for automated annotation of medication mentions in primary care visit conversations

OBJECTIVES

The objective of this study is to build and evaluate a natural language processing approach to identify medication mentions in primary care visit conversations between patients and physicians.

MATERIALS AND METHODS

Eight clinicians contributed to a data set of 85 clinic visit transcripts, and 10 transcripts were randomly selected from this data set as a development set. Our approach utilizes Apache cTAKES and Unified Medical Language System controlled vocabulary to generate a list of medication candidates in the transcribed text and then performs multiple customized filters to exclude common false positives from this list while including some additional common mentions of the supplements and immunizations.

RESULTS

Sixty-five transcripts with 1121 medication mentions were randomly selected as an evaluation set. Our proposed method achieved an F-score of 85.0% for identifying the medication mentions in the test set, significantly outperforming existing medication information extraction systems for medical records with F-scores ranging from 42.9% to 68.9% on the same test set.

DISCUSSION

Our medication information extraction approach for primary care visit conversations showed promising results, extracting about 27% more medication mentions from our evaluation set while eliminating many false positives in comparison to existing baseline systems. We made our approach publicly available on the web as an open-source software.

CONCLUSION

Integration of our annotation system with clinical recording applications has the potential to improve patients' understanding and recall of key information from their clinic visits, and, in turn, to positively impact health outcomes.

Anticipated Benefits and Concerns of Sharing Hospital Outpatient Visit Notes With Patients (Open Notes) in Dutch Hospitals: Mixed Methods Study

Background

The past few years have seen an increase in interest in sharing visit notes with patients. Sharing visit notes with patients is also known as “open notes.” Shared notes are seen as beneficial for patient empowerment and communication, but concerns have also been raised about potential negative effects. Understanding barriers is essential to successful organizational change, but most published studies on the topic come from countries where shared notes are incentivized or legally required.

Objective

We aim to gather opinions about sharing outpatient clinic visit notes from patients and hospital physicians in the Netherlands, where there is currently no policy or incentive plan for shared visit notes.

Methods

This multimethodological study was conducted in an academic and a nonacademic hospital in the Netherlands. We conducted a survey of patients and doctors in March-April 2019. In addition to the survey, we conducted think-aloud interviews to gather more insight into the reasons behind participants’ answers. We surveyed 350 physicians and 99 patients, and think-aloud interviews were conducted with an additional 13 physicians and 6 patients.

Results

Most patients (81/98, 77%) were interested in viewing their visit notes, whereas most physicians (262/345, 75.9%) were opposed to allowing patients to view their visit notes. Most patients (54/90, 60%) expected the notes to be written in layman’s terms, but most physicians (193/321, 60.1%) did not want to change their writing style to make it more understandable for patients. Doctors raised concerns that reading the note would make patients feel confused and anxious, that the patient would not understand the note, and that shared notes would result in more documentation time or losing a way to communicate with colleagues. Interviews also revealed concerns about documenting sensitive topics such as suspected abuse and unlikely but worrisome differential diagnoses. Physicians also raised concerns that documenting worrisome thoughts elsewhere in the record would result in fragmentation of the patient record. Patients were uncertain if they would understand the notes (46/90, 51%) and, in interviews, raised questions about security and privacy. Physicians did anticipate some benefits, such as the patients remembering the visit better, shared decision-making, and keeping patients informed, but 24% (84/350) indicated that they saw no benefit. Patients anticipated that they would remember the visit better, feel more in control, and better understand their health.

Conclusions

Dutch patients are interested in shared visit notes, but physicians have many concerns that should be addressed if shared notes are pursued. Physicians’ concerns should be addressed before shared notes are implemented. In hospitals where shared notes are implemented, the effects should be monitored (objectively, if possible) to determine whether the concerns raised by our participants have actualized into problems and whether the anticipated benefits are being realized.

Cancer patients' information seeking behavior related to online electronic healthcare records

Patients' online access to their EHR together with the rapid proliferation of medical information on the Internet has changed how patients use information to learn about their health. Patients' tendency to turn to the Internet to find information about their health and care is well-documented. However, little is known about patients' information seeking behavior when using online EHRs. By using information horizons as an analytical tool this paper aims to investigate the information behavior of cancer patients who have chosen to view their EHRs (readers) and to those who have not made that option (non-readers). Thirty interviews were conducted with patients. Based on information horizons, it seems that non-reading is associated with living in a narrower information world in comparison to readers. The findings do not suggest that the smallness would be a result of active avoidance of information, or that it would be counterproductive for the patients. The findings suggest, however, that EHRs would benefit from comprehensive linking to authoritative health information sources to help users to understand their contents. In parallel, healthcare professionals should be more aware of their personal role as a key source of health information to those who choose not to read their EHRs.

BedsideNotes: Sharing Physicians' Notes With Parents During Hospitalization

OBJECTIVES

Physicians increasingly share ambulatory visit notes with patients to meet new federal requirements, and evidence suggests patient experiences improve without overburdening physicians. Whether sharing inpatient notes with parents of hospitalized children yields similar outcomes is unknown. In this pilot study, we evaluated parent and physician perceptions of sharing notes with parents during hospitalization.

METHODS

Parents of children aged <12 years admitted to a hospitalist service at a tertiary children's hospital in April 2019 were offered real-time access to their child's admission and daily progress notes on a bedside inpatient portal (MyChart Bedside). Upon discharge, ambulatory OpenNotes survey items assessed parent and physician (attendings and interns) perceptions of note sharing.

RESULTS

In all, 25 parents and their children's discharging attending and intern physicians participated. Parents agreed that the information in notes was useful and helped them remember their child's care plan (100%), prepare for rounds (96%), and feel in control (91%). Although many physicians (34%) expressed concern that notes would confuse parents, no parent reported that notes were confusing. Some physicians perceived that they spent more time writing and/or editing notes (28%) or that their job was more difficult (15%). Satisfaction with sharing was highest among parents (100%), followed by attendings (81%) and interns (35%).

CONCLUSIONS

Parents all valued having access to physicians' notes during their child's hospital stay; however, some physicians remained concerned about the potential negative consequences of sharing. Comparative effectiveness studies are needed to evaluate the effect of note sharing on outcomes for hospitalized children, families, and staff.

Racial differences in patient consent policy preferences for electronic health information exchange

OBJECTIVE

This study aimed to explore the association between demographic variables, such as race and gender, and patient consent policy preferences for health information exchange as well as self-report by VHA enrollees of information continuity between Veterans Health Administration (VHA) and community non-VHA heath care providers.

MATERIALS AND METHODS

Data were collected between March 25, 2016 and August 22, 2016 in an online survey of 19 567 veterans. Three questions from the 2016 Commonwealth Fund International Health Policy Survey, which addressed care continuity, were included. The survey also included questions about consent policy preference regarding opt-out, opt-in, and "break the glass" consent policies.

RESULTS

VHA enrollees had comparable proportions of unnecessary laboratory testing and conflicting information from providers when compared with the United States sample in the Commonwealth Survey. However, they endorsed medical record information being unavailable between organizations more highly. Demographic variables were associated with gaps in care continuity as well as consent policy preferences, with 56.8% of Whites preferring an opt-out policy as compared with 40.3% of Blacks, 44.9% of Hispanic Latinos, 48.3% of Asian/Pacific Islanders, and 38.3% of Native Americans (P < .001).

DISCUSSION

Observed large differences by race and ethnicity in privacy preferences for electronic health information exchange should inform implementation of these programs to ensure cultural sensitivity. Veterans experienced care continuity comparable to a general United States sample, except for less effective exchange of health records between heath care organizations. VHA followed an opt-in consent policy at the time of this survey which may underlie this gap.

Impact of Patient Access to Online VA Notes on Healthcare Utilization and Clinician Documentation: a Retrospective Cohort Study

BACKGROUND

In an effort to foster patient engagement, some healthcare systems provide their patients with open notes, enabling them to access their clinical notes online. In January 2013, the Veterans Health Administration (VA) implemented online access to clinical notes ("VA Notes") through the Blue Button feature of its patient portal.

OBJECTIVE

To measure the association of online patient access to clinical notes with changes in healthcare utilization and clinician documentation behaviors.

DESIGN

A retrospective cohort study.

PATIENTS

Patients accessing My HealtheVet (MHV), the VA's online patient portal, between July 2011 and January 2015.

MAIN MEASURES

Use of healthcare services (primary care clinic visits and online electronic secure messaging), and characteristics of physician clinical documentation (readability of notes).

KEY RESULTS

Among 882,575 unique portal users, those who accessed clinical notes (16.2%; N = 122,972) were younger, more racially homogenous (white), and less likely to be financially vulnerable. Compared with non-users, Notes users more frequently used the secure messaging feature on the portal (mean of 2.6 messages (SD 7.0) v. 0.87 messages (SD 3.3) in January-July 2013), but their higher use of secure messaging began prior to VA Notes implementation, and thus was not temporally related to the implementation. When comparing clinic visit rates pre- and post-implementation, Notes users had a small but significant increase in rate of 0.36 primary care clinic visits (2012 v. 2013) compared to portal users who did not view their Notes (p = 0.01). At baseline, the mean reading ease of primary care clinical notes was 53.8 (SD 10.1) and did not improve after implementation of VA Notes.

CONCLUSIONS

VA Notes users were different than patients with portal access who did not view their notes online, and they had higher rates of healthcare service use prior to and after VA Notes implementation. Opportunities exist to improve clinical note access and readability.

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

OBJECTIVE

The study sought to test a patient and family online reporting system for perceived ambulatory visit note inaccuracies.

MATERIALS AND METHODS

We implemented a patient and family electronic reporting system at 3 U.S. healthcare centers: a northeast urban academic adult medical center (AD), a northeast urban academic pediatric medical center (PED), and a southeast nonprofit hospital network (NET). Patients and families reported potential documentation inaccuracies after reading primary care and subspecialty visit notes. Results were characterized using descriptive statistics and coded for clinical relevance.

RESULTS

We received 1440 patient and family reports (780 AD, 402 PED, and 258 NET), and 27% of the reports identified a potential inaccuracy (25% AD, 35% PED, 28% NET). Among these, patients and families indicated that the potential inaccuracy was important or very important in 58% of reports (55% AD, 55% PED, 71% NET). The most common types of potential inaccuracies included description of symptoms (21%), past medical problems (21%), medications (18%), and important information that was missing (15%). Most patient- and family-reported inaccuracies resulted in a change to care or to the medical record (55% AD, 67% PED, data not available at NET).

DISCUSSION

About one-quarter of patients and families using an online reporting system identified potential documentation inaccuracies in visit notes and more than half were considered important by patients and clinicians, underscoring the potential role of patients and families as ambulatory safety partners.

CONCLUSIONS

Partnering with patients and families to obtain reports on inaccuracies in visit notes may contribute to safer care. Mechanisms to encourage greater use of patient and family reporting systems are needed.

How the Use of a Patient-Accessible Health Record Contributes to Patient-Centered Care: Scoping Review

BACKGROUND

Worldwide, patient-centered care is becoming a widely used concept in medical practice, getting more and more attention because of its proven ability to improve quality of care and reduce costs. Although several studies show that patient-accessible electronic health records (PAEHRs) influence certain aspects of patient-centered care, the possible contribution of PAEHR implementation to patient-centered care as a comprehensive concept has not, to our knowledge, been structurally evaluated to date.

OBJECTIVE

The objective of this study is to review whether and how the use of PAEHRs contributes to patient-centered care both in general and among specific population groups.

METHODS

We followed PRISMA Extension for Scoping Reviews reporting guidelines. We identified literature in 5 databases, using the terms "patient-accessible medical records," "patient experiences," and "professional experiences" as key concepts. A total of 49 articles were included and analyzed with a charting code list containing 10 elements of patient-centered care.

RESULTS

Studies were diverse in design, country of origin, functionalities of the investigated PAEHR, and target population. Participants in all studies were adults. Most studies reported positive influence of PAEHR use on patient-centered care; patient accessible health records were appreciated for their opportunity to empower patients, inform patients about their health, and involve patients in their own care. There were mixed results for the extent to which PAEHRs affected the relation between patients and clinicians. Professionals and patients in mental health care held opposing views concerning the impact of transparency, where professionals appeared more worried about potential negative impact of PAEHRs on the patient-clinician relationship. Their worries seemed to be influenced by a reluctant attitude toward patient-centered care. Disadvantaged groups appeared to have less access to and make less use of patient-accessible records than the average population but experienced more benefits than the average population when they actually used PAEHRs.

CONCLUSIONS

The review indicates that PAEHRs bear the potential to positively contribute to patient-centered care. However, concerns from professionals about the impact of transparency on the patient-clinician relationship as well as the importance of a patient-centered attitude need to be addressed. Potentially significant benefits for disadvantaged groups will be achieved only through easily accessible and user-friendly PAEHRs.

Patients Evaluate Visit Notes Written by Their Clinicians: a Mixed Methods Investigation

BACKGROUND

Patients actively involved in their care demonstrate better health outcomes. Using secure internet portals, clinicians are increasingly offering patients access to their narrative visit notes (open notes), but we know little about their understanding of notes written by clinicians.

OBJECTIVE

We examined patients' views on the clarity, accuracy, and thoroughness of notes, their suggestions for improvement, and associations between their perceptions and willingness to recommend clinicians to others.

DESIGN

We conducted an online survey of patients in 3 large health systems, June-October 2017. We performed a mixed methods analysis of survey responses regarding a self-selected note.

PARTICIPANTS

Respondents were 21,664 patients aged 18 years or older who had read at least 1 open note in the previous 12 months.

MAIN MEASURES

We asked to what degree the patient recalled understanding the note, whether it described the visit accurately, whether anything important was missing, for suggestions to improve the note, and whether they would recommend the authoring clinician to others.

KEY RESULTS

Nearly all patients (96%) reported they understood all or nearly all of the self-selected note, with few differences by clinician type or specialty. Overall, 93% agreed or somewhat agreed the note accurately described the visit, and 6% reported something important missing from the note. The most common suggestions for improvement related to structure and content, jargon, and accuracy. Patients who reported understanding only some or very little of the note, or found inaccuracies or omissions, were much less likely to recommend the clinician to family and friends.

CONCLUSIONS

Patients overwhelmingly report understanding their visit notes and usually find them accurate, with few disparities according to sociodemographic or health characteristics. They have many suggestions for improving their quality, and if they understand a note poorly or find inaccuracies, they often have less confidence in their clinicians.

Helpfulness of Clinical Visit Summary Content From Multi-Specialty Care: A Mixed-Methods Assessment

Objective:

We surveyed patients who visited multiple outpatient specialty practices to understand what summary content was most helpful with the goal of optimizing meaningful outpatient clinical visit summary content.

Materials and Methods:

We constructed a survey instrument to measure delivery, use, and contents of clinical visit summaries. We surveyed patients who visited with at least 2 different outpatient medical specialties to understand preferences.

Results:

Most patients in our sample valued the summary information they received, and retained it as healthcare documentation (84%) and/or quick reference in supporting self-care (70%). Patients most commonly reported that information on results of completed tests (91%) and treatment plan instructions (89%) were very helpful. Additionally, patients expressed the importance of online access to clinical visit summary information.

Discussion:

Most patients used the clinical visit summary as healthcare documentation, and valued online availability of their summary information. Patients most often reported that information on results of recently completed tests and specific instructions on treatment plan were very helpful. Patients who sought further information after their visit most often looked to a provider and/or online.

Conclusions:

Patients valued clinical visit summary accessibility and as a reference tool to summarize care and provide next steps. Optimal clinical visit summaries might collate and integrate assessments and recommendations from multiple specialties into coherent care plans for patients.

Electronic Patient Portal Use in Orthopaedic Surgery Is Associated with Disparities, Improved Satisfaction, and Lower No-Show Rates

BACKGROUND

Electronic patient portal (EPP) use has been associated with a number of benefits in the internal medicine setting. Few studies have examined the disparities in and the benefits of EPP utilization among surgical patients. The purposes of this study were to examine factors associated with EPP use among patients undergoing an orthopaedic surgical procedure and to determine if EPP use is associated with improved outcomes or satisfaction after orthopaedic surgical procedures.

METHODS

We queried all patients undergoing an orthopaedic surgical procedure from May 2015 to December 2018 at 2 academic medical centers in an integrated hospital system. Patient demographic characteristics, operative characteristics, satisfaction scores, and patient-reported outcome measures (PROMs) were collected. Multivariable logistic regression was used to identify disparities in EPP use. Adjusted logistic and linear regressions were then used to assess the association between EPP use and the various outcome metrics while controlling for confounders identified in the previous analysis.

RESULTS

Numerous demographic factors were independently associated with EPP use among patients undergoing an orthopaedic surgical procedure, including English speakers compared with non-English speakers (odds ratio [OR], 2.37 [95% confidence interval (CI), 2.01 to 2.79]); African-American or black race (OR, 0.42 [95% CI, 0.36 to 0.48]) and Hispanic race (OR, 0.52 [95% CI, 0.44 to 0.61]) compared with white race; college education compared with high school education (OR, 2.30 [95% CI, 2.12 to 2.49]); and a surgical procedure for orthopaedic trauma compared with that for the hand or upper extremity (OR, 0.51 [95% CI, 0.45 to 0.58]) (p < 0.001 for all), among others. EPP use was independently associated with the increased likelihood of completing a PROM (OR, 1.57 [95% CI, 1.45 to 1.7]) and a satisfaction survey (OR, 2.38 [95% CI, 2.17 to 2.61]) and improved overall patient satisfaction (mean difference, 2.61 points [95% CI, 1.79 to 3.43 points]) (p < 0.001 for all). Finally, EPP use was independently associated with lower mean no-show rates (6.8% [95% CI, 6.4% to 7.2%] compared with 9.3% [95% CI, 8.9% to 9.7%]). The lower no-show rate for EPP users corresponded to an estimated $218,225 in savings for our institution within the first postoperative year.

CONCLUSIONS

This study identified significant disparities in EPP use among patients undergoing an orthopaedic surgical procedure. Given that EPP use was independently associated with lower no-show rates and improved patient satisfaction among patients undergoing an orthopaedic procedure, efforts to reduce these disparities are warranted.

CLINICAL RELEVANCE

EPPs are increasingly being used by health-care systems to improve communication between providers and patients; however, providers should be aware of and strive to eliminate disparities in EPP utilization among orthopaedic patients. Within orthopaedic surgery, EPPs are associated with a number of benefits, including lower no-show rates and increased patient satisfaction.

How much can we trust electronic health record data?

Trust in EHR data is becoming increasingly important as a greater share of clinical and health services research use EHR data. We discuss reasons for distrust and acknowledge limitations. Researchers continue to use EHR data because of strengths including greater clinical detail than sources like administrative billing claims. Further, many limitations are addressable with existing methods including data quality checks and common data frameworks. We discuss how to build greater trust in the use of EHR data for research, including additional transparency and research priority areas that will both enhance existing strengths of the EHR and mitigate its limitations.

Electronic Documentation in Pediatrics: The Rationale and Functionality Requirements

Clinical documentation has dramatically changed since the implementation and use of electronic health records and electronic provider documentation. The purpose of this report is to review these changes and promote the development of standards and best practices for electronic documentation for pediatric patients. In this report, we evaluate the unique aspects of clinical documentation for pediatric care, including specialized information needs and stakeholders specific to the care of children. Additionally, we explore new models of documentation, such as shared documentation, in which patients may be both authors and consumers, and among care teams while still maintaining the ability to clearly define care and services provided to patients in a given day or encounter. Finally, we describe alternative documentation techniques and newer technologies that could improve provider efficiency and the reuse of clinical data.

Frequency and Types of Patient-Reported Errors in Electronic Health Record Ambulatory Care Notes

Importance

As health information transparency increases, patients more often seek their health data. More than 44 million patients in the US can now readily access their ambulatory visit notes online, and the practice is increasing abroad. Few studies have assessed documentation errors that patients identify in their notes and how these may inform patient engagement and safety strategies.

Objective

To assess the frequency and types of errors identified by patients who read open ambulatory visit notes.

Design, Setting, and Participants

In this survey study, a total of 136 815 patients at 3 US health care organizations with open notes, including 79 academic and community ambulatory care practices, received invitations to an online survey from June 5 to October 20, 2017. Patients who had at least 1 ambulatory note and had logged onto the portal at least once in the past 12 months were included. Data analysis was performed from July 3, 2018, to April 27, 2020.

Exposures

Access to ambulatory care open notes through patient portals for up to 7 years (2010-2017).

Main Outcomes and Measures

Proportion of patients reporting a mistake and how serious they perceived the mistake to be, factors associated with finding errors characterized by patients as serious, and categories of patient-reported errors.

Results

Of 136 815 patients who received survey invitations, 29 656 (21.7%) responded and 22 889 patients (mean [SD] age, 55.16 [15.96] years; 14 447 [63.1%] female; 18 301 [80.0%] white) read 1 or more notes in the past 12 months and completed error questions. Of these patients, 4830 (21.1%) reported a perceived mistake and 2043 (42.3%) reported that the mistake was serious (somewhat serious: 1563 [32.4%]; very serious: 480 [9.9%]). In multivariable analysis, female patients (relative risk [RR], 1.79; 95% CI, 1.72-1.85), more educated patients (RR, 1.38; 95% CI, 1.29-1.48), sicker patients (RR, 1.89; 95% CI, 1.84-1.94), those aged 45 to 64 years (RR, 2.23; 95% CI, 2.06-2.42), those 65 years or older (RR, 2.00; 95% CI, 1.73-2.32), and those who read more than 1 note (2-3 notes: RR, 1.82; 95% CI, 1.34-2.47; ≥4 notes: RR, 3.09; 95% CI, 2.02-4.73) were more likely to report a mistake that they found to be serious compared with their reference groups. After categorization of patient-reported very serious mistakes, those specifically mentioning the word diagnosis or describing a specific error in current or past diagnoses were most common (98 of 356 [27.5%]), followed by inaccurate medical history (85 of 356 [23.9%]), medications or allergies (50 of 356 [14.0%]), and tests, procedures, or results (30 of 356 [8.4%]). A total of 23 (6.5%) reflected notes reportedly written on the wrong patient. Of 433 very serious errors, 255 (58.9%) included at least 1 perceived error potentially associated with the diagnostic process (eg, history, physical examination, tests, referrals, and communication).

Conclusions and Relevance

In this study, patients who read ambulatory notes online perceived mistakes, a substantial proportion of which they found to be serious. Older and sicker patients were twice as likely to report a serious error compared with younger and healthier patients, indicating important safety and quality implications. Sharing notes with patients may help engage them to improve record accuracy and health care safety together with practitioners.

Full Radiology Report through Patient Web Portal: A Literature Review

The aim of this study discusses the gap between the patient web portal and providing a full radiology report. A literature review was conducted to examine radiologists, physicians, and patients’ opinions and preferences of providing patients with online access radiology reports. The databases searched were Pubmed and Google Scholar and the initial search included 927 studies. After review, 47 studies were included in the study. We identified several themes, including patients’ understanding of radiology reports and radiological images, as well as the need for decreasing the turnaround time for reports availability. The existing radiology reports written for physicians are not suited for patients. Further studies are needed to guide and inform the design of patient friendly radiology reports. One of the ways that can be used to fill the gap between patients and radiology reports is using social media sites.

Veterans Universal Passport: a pilot of a health and social care record for UK ex-service personnel

BACKGROUND

The transfer of care between different health and social care systems are often associated with poor outcomes and disengagement. Indeed, following the transition from military to civilian life, ex-service personnel report difficulties in navigating civilian health and social care services. Personal healthcare records are associated with a number of benefits, including improved continuity of care and patient empowerment. As such, this pilot project aimed to assess the benefits of the Veterans Universal Passport (VUP) in supporting UK ex-service personnel accessing NHS services.

METHODS

In-depth semi-structured interviews were carried out with eight participants (three ex-service personnel, two carers, three health and social care professionals) who had used the VUP. Interviews explored the benefits, challenges and unmet needs associated with the VUP. A thematic analysis was used to identify themes within this framework.

RESULTS

Participants felt that the VUP improved continuity of care and promoted a feeling of control over care. The military-specific nature of the VUP promoted a sense of identity and provided a 'support scaffold' for navigating the complexities of the civilian healthcare system. Challenges included awareness among health and social care professionals, and engagement of users. All participants suggested development into a digital application.

CONCLUSIONS

Findings suggest that the VUP had a positive impact on veterans' access to civilian health and social care services, highlighting that it provided a much-needed structure to their journey through treatment. Considering the parallels with other health and social care transitions, translation for other populations may be beneficial.

Envisioning a Better U.S. Health Care System for All: Health Care Delivery and Payment System Reforms

The American College of Physicians (ACP) has long advocated for universal access to high-quality health care in the United States. Yet, it is essential that the U.S. health system goes beyond ensuring coverage, efficient delivery systems, and affordability. Fundamental restructuring of payment policies and delivery systems is required to achieve a health care system that puts patients' interests first and supports physicians and their care teams to deliver high-value, patient- and family-centered care. The ACP calls for reform of U.S. payment, delivery, and information technology systems to achieve this vision. The ACP's recommendations include increased investment in primary care; alignment of financial incentives to achieve better patient outcomes, lower costs, reduce inequities in health care, and facilitate team-based care; freeing patients and physicians of inefficient administrative and billing tasks and documentation requirements; and development of health information technologies that enhance the patient-physician relationship.

The future state of patient engagement? Personal health information use, attitudes towards health, and health behavior

The past decade has given rise to interest in the effects of health care information on personal well-being. However, investigations to-date typically centered on mass communication programs in health rather than on individuals’ psychosocial characteristics, agency, and behaviors associated with their engagement with this information. Considering this gap, we examined whether the availability of personal health information is associated with health prevention behaviors in the United States. Using multivariable path analysis and data from the 2017 Health Information National Trends Survey, we investigate whether the use of personal health information is associated with positive, preventative health behaviors (healthy eating, tobacco smoking, and exercise), and if this relationship is mediated by patient confidence in their ability to care for themselves and by their self-perceived health status. Findings indicate that the use of health information, at low levels, is important for improving patient attitudes regarding their health status and confidence in caring for themselves. Perceived health-status and patient confidence, in turn, are associated with preventative health behaviors. Notably, too much information does not necessarily result in positive health behaviors among patients. Organizations may wish to critically assess how much information they make readily available to the populations they serve.

Patient access to clinical notes in oncology: A mixed method analysis of oncologists' attitudes and linguistic characteristics towards notes

BACKGROUND

Providers have expressed concern about patient access to clinical notes. There is the possibility that providers may linguistically censor notes knowing that patients have access.

PURPOSE

Qualitative interviews and a pre- and post- linguistic analysis of the implementation of OpenNotes was performed to determine whether oncologists changed the content and style of their notes.

METHODS

Mixed methods were utilized, including 13 semi-structured interviews with oncologists and random effects modeling of over 500 clinical notes. The Linguistic Inquiry and Word Count program was used to evaluate notes for emotions, thinking styles, and social concerns.

RESULTS

No significant differences from pre- and post-implementation of OpenNotes was found. Thematic analysis revealed that oncologists were concerned that changing their notes would negatively impact multidisciplinary communication. However, oncologists acknowledged that notes could be more patient-friendly and may stimulate patient-provider communication.

CONCLUSIONS

Although oncologists were aware that patients could have access, they felt strongly about not changing the content of notes. A comparison between pre- and post-implementation confirmed this view and found that notes did not change.

PRACTICE IMPLICATIONS

Patient access to oncologist's notes may serve as an opportunity to reinforce important aspects of the consultation.

An Opportunity to Engage Obstetrics and Gynecology Patients Through Shared Visit Notes

OBJECTIVE

To assess obstetrics and gynecology patients' interest in reading their ambulatory visit notes, identification of documentation errors, and perceptions of sensitive language through a quality improvement (QI) initiative.

METHODS

Beginning April 2016, as part of a QI project all obstetrics and gynecology patients (except family planning) were invited to read their ambulatory visit notes and provide feedback using a patient reporting tool codeveloped with patients. Two physicians with safety expertise reviewed all patient-reported errors over the first 16 months.

RESULTS

Among obstetrics and gynecology patients with an active portal account and an available note, 6,594 of 9,550 (69%) read at least one note. Two hundred twelve (3.2%) patients used the electronic reporting tool, submitting a total of 232 reports, in a "natural" environment with no advertisement, incentives, or clinician encouragement. In total, 94% felt they understood the notes, 95% understood the next steps in the care plan, and 92% felt the notes accurately described their visit. Of all reports, 27% of patients identified inaccuracies in the notes, including descriptions of symptoms (29%); family history (21%); medications (15%); health problems (15%); social history and physical examination, including elements that were reportedly documented but not performed (each 11%). Patients rated inaccuracies as important in 58% of reports, and, on clinician review, 75% of patient-reported mistakes had the potential to affect care. Among all reports, 7% of patients indicated bothersome words. More than half (56%) of patients included voluntary positive feedback such as appreciation for the health care provider, reassurance from notes, greater visit recall and care plan adherence, and positive effects on the patient-doctor relationship.

DISCUSSION

Obstetrics and gynecology patients are interested in reading notes, which can promote engagement and safety. Few patients provided feedback, but those who did identified documentation inaccuracies in about one quarter of reports; the majority were relevant to care. Greater outreach and patient encouragement are needed to further engage patients in safety.

Determinants and outcomes of patient access to medical records: Systematic review of systematic reviews

BACKGROUND

Patient access to electronic health records (EHRs) is associated with several determinants and outcomes, which are interrelated. However, individual studies and the reviews summarizing them have only addressed particular aspects, such as policy, usability or health outcomes of adoption. Therefore, no comprehensive overview exists. Additionally, reviews used different theoretical frameworks, which makes results difficult to compare.

OBJECTIVE

We aimed to systematically review recent systematic reviews on determinants and outcomes of patient access to EHRs to create a comprehensive overview and inform policy-makers and EHR implementers about the available literature, and to identify knowledge gaps in the literature reviews.

METHODS

We searched MEDLINE, EMBASE and PsycINFO for systematic reviews on patient portals, personal health records, and patient access to records that addressed determinants and outcomes of adoption. We synthesized the results from these reviews into the Clinical Adoption Framework (CAF), by mapping quotes from the reviews to categories and dimensions of the CAF, starting with the most recent ones until saturation of the CAF had been reached. The risk of bias in the reviews was assessed using the AMSTAR2 checklist.

RESULTS

We included nineteen reviews from 8871 records that were retrieved until February 19^th, 2018. The reviews had a median of 4 (IQR: 4-4) critical flaws according to the AMSTAR2 checklist. The reviews contained a total of 1054 quotes that were mapped to the CAF. All reviews reported on the dimension 'People' that can affect adoption (e.g. personal characteristics such as age) and the dimension 'HIS use' (health information system use). Most reviews reported the dimensions 'Organisation', 'Implementation', HIS 'System quality', and outcomes of HIS use. However, gaps in knowledge might exist on macro-level determinants and outcomes, such as healthcare standards, funding, and incentives, because few reviews addressed these aspects.

CONCLUSIONS

No review covered all aspects of the CAF and there was a large variety in aspects that were addressed, but all dimensions of the CAF were addressed by at least two reviews. Although reviews had critical flaws according to the AMSTAR2 checklist, almost half of the reviews did use methods to assess bias in primary studies. Implementers can use the synthesized results from this study as a reference for implementation and development when taking quality restrictions into account. Researchers should address the risk of bias in primary studies in future reviews and use a framework such as CAF to make results more comparable and reusable.

OpenNotes After 7 Years: Patient Experiences With Ongoing Access to Their Clinicians' Outpatient Visit Notes

Background

Following a 2010-2011 pilot intervention in which a limited sample of primary care doctors offered their patients secure Web-based portal access to their office visit notes, the participating sites expanded OpenNotes to nearly all clinicians in primary care, medical, and surgical specialty practices.

Objective

The aim of this study was to examine the ongoing experiences and perceptions of patients who read ambulatory visit notes written by a broad range of doctors, nurses, and other clinicians.

Methods

A total of 3 large US health systems in Boston, Seattle, and rural Pennsylvania conducted a Web-based survey of adult patients who used portal accounts and had at least 1 visit note available in a recent 12-month period. The main outcome measures included patient-reported behaviors and their perceptions concerning benefits versus risks.

Results

Among 136,815 patients who received invitations, 21.68% (29,656/136,815) responded. Of the 28,782 patient respondents, 62.82% (18,081/28,782) were female, 72.90% (20,982/28,782) were aged 45 years or older, 76.94% (22,146/28,782) were white, and 14.30% (4115/28,782) reported fair or poor health. Among the 22,947 who reported reading 1 or more notes, 3 out of 4 reported reading them for 1 year or longer, half reported reading at least 4 notes, and 37.74% (8588/22,753) shared a note with someone else. Patients rated note reading as very important for helping take care of their health (16,354/22,520, 72.62%), feeling in control of their care (15,726/22,515, 69.85%), and remembering the plan of care (14,821/22,516, 65.82%). Few were very confused (737/22,304, 3.3%) or more worried (1078/22,303, 4.83%) after reading notes. About a third reported being encouraged by their clinicians to read notes and a third told their clinicians they had read them. Less educated, nonwhite, older, and Hispanic patients, and individuals who usually did not speak English at home, were those most likely to report major benefits from note reading. Nearly all respondents (22,593/22,947, 98.46%) thought Web-based access to visit notes a good idea, and 62.38% (13,427/21,525) rated this practice as very important for choosing a future provider.

Conclusions

In this first large-scale survey of patient experiences with a broad range of clinicians working in practices in which shared notes are well established, patients find note reading very important for their health management and share their notes frequently with others. Patients are rarely troubled by what they read, and those traditionally underserved in the United States report particular benefit. However, fewer than half of clinicians and patients actively address their shared notes during visits. As the practice continues to spread rapidly in the United States and internationally, our findings indicate that OpenNotes brings benefits to patients that largely outweigh the risks.