Effect of Notes' Access and Complexity on OpenNotes' Utility

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Sharing a written medical summary with patients on the post-admission ward round: A qualitative study of clinician and patient experience

RATIONALE, AIMS AND OBJECTIVES

Sharing aspects of the traditional medical record with patients has been successful in primary and antenatal care, but has not been investigated in the UK inpatient setting. Our aim was to evaluate the impact on patient and clinician experience of providing patients with a written lay summary of their care-plan in the acute care setting.

METHOD

We carried out a qualitative interview study on two acute medicine wards in an NHS University Teaching Hospital for a 4-week period in 2019. A summary record, designed in response to suggestions from doctors and patients from a previous study, was distributed to patients on the first ward round after admission. Eligible participants included all doctors and nurses working on and all patients and their families attending the acute medical units; patients were excluded if they lacked capacity to consent or were under 18. We interviewed 20 patients, 10 relatives, 10 doctors and 7 nurses.

RESULTS

Patients felt that the summary improved their ability to remember details about their care so they could more accurately and easily update their relatives. They did not feel that the summary induced anxiety. Patient-doctor communication was improved: patients felt empowered to ask more questions and doctors felt that it solidified their plan and encouraged them to avoid medical jargon. Most patients felt the summary included the 'right' amount of information. Healthcare professionals were more concerned about the risk of breaching confidentiality than patients. Doctors felt that providing summaries was time-consuming; there were differing opinions about whether this was a worthwhile investment of time. Clinicians recognized that the traditional medical record has many roles.

CONCLUSIONS

A summary record could empower patients and improve patient-doctor communication but would require additional clinician and administrative time.

Disparities in Accessing and Reading Open Notes in the Emergency Department Upon Implementation of the 21st Century CURES Act

STUDY OBJECTIVE

There is a continued movement toward health data transparency, accelerated by the 21st Century CURES Act, which mandated the automatic and immediate release of clinical notes, often termed "open notes." Differences in utilization among different patient demographics and disproportionately affected populations within the emergency department (ED) are not yet known.

METHODS

This was an observational study of 10 EDs and 3 urgent care centers across a single health system over a 13-week period from February 1, 2021 to May 2, 2021. Primary outcomes included the proportion of patients with patient portal access to open notes at the time of encounter, the proportion of patients with access who opened the clinical note, and time from clinical note signing to patient read.

RESULTS

Among 98,725 patient visits, less than half (48.9%) had patient portal access, of which 13.7% read an open note. Access was less likely in patients who were under age 18 (odds ratio 0.10, 95% confidence interval 0.08 to 0.11), older than 65 (0.82, 0.73 to 0.93), Black non-Hispanic (0.66, 0.61 to 0.73), non-English speakers, and on public insurance. Patients were less likely to read open notes if they identified as Black non-Hispanic (0.61, 0.57 to 0.66), spoke Spanish (0.70, 0.60 to 0.81), or were on public insurance.

CONCLUSION

We identified substantial differences in digital access to clinical notes as well as patient utilization of open notes in a large, diverse sample. Health transparency initiatives must address not only technology adoption broadly but also the unique barriers faced by populations experiencing disadvantage to facilitate equitable access to and awareness about digital health tools without the unintended consequence of expanding disparities.

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.