Patient experiences with full electronic access to health records and clinical notes through the My HealtheVet Personal Health Record Pilot: qualitative study

Promoting diversity, equity and inclusion awareness in clinical documentation through postgraduate year one training

BACKGROUND AND PURPOSE

As healthcare providers increasingly focus on emerging issues of diversity, equity and inclusion (DEI) in patient care, less is known about the training in postgraduate year one (PGY1) pharmacy residency on DEI clinical documentation considerations. This pilot project explored whether training, discussion and self-reflection within a peer review activity promoted DEI self-awareness in clinical documentation through a centralized curriculum of a multisite PGY1.

EDUCATIONAL ACTIVITY AND SETTING

Building upon an established peer review of clinical documentation activity, PGY1 pharmacy residents practicing in ambulatory care settings received training on DEI considerations and completed small and large group discussions, a post-activity mixed methods survey with self-reflection prompts, and a three-month follow-up survey.

FINDINGS

Twenty-two residents participated in the peer review of clinical documentation activity, DEI training and discussions. Twelve residents completed the post-activity survey with reflection prompts; 6 (50%) reported similar previous DEI training prior to residency. After the DEI training and discussions, 12 (100%) agreed or strongly agreed that their awareness of DEI documentation considerations increased; 10 (83%) would document their submitted notes differently, while one resident was unsure and one would not make changes. Twelve residents completed the follow-up survey three months following the activity. Themes from the free-text responses on key learnings collected post-activity and three-month post (respectively) included: 1) new knowledge, increased self-awareness, and intended action and 2) increased self-awareness and changes in note-making convention.

SUMMARY

Integrating DEI training, discussion, and self-reflection prompts into a peer review clinical documentation activity increased self-awareness and knowledge of DEI considerations and promoted intended changes in patient care documentation for pharmacy residents. Regardless of previous training, residents reported continued self-awareness and changes in documentation conventions continued three months later.

The Impact of Structural Integration on Clinical Outcomes among Individuals with Serious Mental Illness and Chronic Illness

Though considered a best practice, there is substantial variation in how integrated behavioral health (IBH) services are structured. This study examined the impact of IBH structure on health outcomes among individuals with serious mental illness (SMI) and chronic disease receiving care in community health centers (CHCs). Data from the ADVANCE network identified 8,548 individuals with co-occurring SMI diabetes and 16,600 with an SMI and hypertension. Logistic regression tested whether IBH type impacted disease specific health outcomes among these populations. Among those with diabetes or hypertension, colocated care was associated with better health outcomes related to HbA1c, blood pressure control, and BMI compared to less coordinated and unintegrated care, though there was significant variation in this relationship across SMI diagnoses. Results reflect that colocation of primary care and behavioral health may improve outcomes for individuals with bipolar disorder or major depression and chronic disease, but that CHC-based integrated care may not be optimized for individuals with schizophrenia.

[Attitudes and Expectations of Psychological and Medical Psychotherapists Towards Open Notes: Analysis of Qualitative Survey Responses]

OBJECTIVE

This study explores attitudes and expectations of psychotherapists (PT) towards the introduction of digital patient access to clinical notes ("Open Notes"; ON)), including the advantages and disadvantages in psychotherapeutic practice.

METHODS

As part of the PEPPPSY study, an online survey was conducted. Free text responses (n = 107) were qualitatively analysed using thematic analysis.

RESULTS

129 psychological and medical PT took part in the survey. PT saw advantages such as transparency and patient-centred documentation, but feared disadvantages for the therapeutic relationship and an increased workload through the implementation of ON. Concerns were raised about data security and negative effects on treatment. Recommendations for implementation include patient-specific access adaptations and guided access.

CONCLUSION

PT are ambivalent about ON. Further research and guidelines for the use of ON in psychotherapy are needed.

The relationship between patient experience and real-world digital health access in primary care: A population-based cross-sectional study

Implementing digital health technologies in primary care is anticipated to improve patient experience. We examined the relationships between patient experience and digital health access in primary care settings in Ontario, Canada. We conducted a retrospective cross-sectional study using patient responses to the Health Care Experience Survey linked to health and administrative data between April 2019-February 2020. We measured patient experience by summarizing HCES questions. We used multivariable logistic regression stratified by the number of primary care visits to investigate associations between patient experience with digital health access and moderating variables. Our cohort included 2,692 Ontario adults, of which 63.0% accessed telehealth, 2.6% viewed medical records online, and 3.6% booked appointments online. Although patients reported overwhelmingly positive experiences, we found no consistent relationship with digital health access. Online appointment booking access was associated with lower odds of poor experience for patients with three or more primary care visits in the past 12 months (adjusted odds ratio 0.16, 95% CI 0.02-0.56). Younger age, tight financial circumstances, English as a second language, and knowing their primary care provider for fewer years had greater odds of poor patient experience. In 2019/2020, we found limited uptake of digital health in primary care and no clear association between real-world digital health adoption and patient experience in Ontario. Our findings provide an essential context for ensuing rapid shifts in digital health adoption during the COVID-19 pandemic, serving as a baseline to reexamine subsequent improvements in patient experience.

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.

MiQuit: A Study Protocol to Link Low-Income Smokers to a State Tobacco Quitline

Purpose

To conduct a randomized controlled trial to compare 3 implementation strategies and the impact of facilitated referrals on linkage of Federally Qualified Health Center patients to the Illinois Tobacco Quitline (ITQL).

Methods

This study will be a hybrid type 3 implementation-effectiveness trial guided by 2 implementation science frameworks: reach, effectiveness, adoption, implementation, and maintenance and exploration preparation implementation sustainment. We will evaluate whether sending provider messages through the patient electronic health portal increases patient linkage to the ITQL. We will (1) randomly assign all eligible patients to receive 1 of 3 messages (information about quitting, advice to quit, and advice to quit or cut down), and (2) we will offer a facilitated linkage to the ITQL. For patients who opt into a facilitated referral, we will share their contact information with the ITQL, who will contact them. Four weeks after the initial message, patients who expressed interest in services but were not reached by the ITQL will be rerandomized to 1 of 2 arms, an offer to reconnect to the ITQL or an offer to engage a peer navigator who can help them reconnect to the ITQL. We will assess the implementation strategies' reach, adoption, linkage, and sustainability with the ITQL.

Discussion

This study will provide a new cost-effective and efficient model to link low-income smokers to state tobacco quitlines. Message delivery via patient health portals has important implications for addressing other tobacco-related morbidities.

Patient experience of imaging reports: A systematic literature review

Introduction

Written reports are often the sole form of communication from diagnostic imaging. Reports are increasingly being accessed by patients through electronic records. Experiencing medical terminology can be confusing and lead to miscommunication, a decrease in involvement and increased anxiety for patients.

Methods

This systematic review was designed to include predefined study selection criteria and was registered prospectively on PROSPERO (CRD42020221734). MEDLINE, CINAHL, Academic Search Complete (EBSCOhost), EMBASE, Scopus and EThOS were searched to identify articles meeting the inclusion criteria. Studies were assessed against the Mixed-Methods Appraisal Tool version 2018 for quality. A segregated approach was used to synthesise data. A thematic synthesis of the qualitative data and a narrative review of the quantitative data were performed, and findings of both syntheses were then integrated.

Findings

Twelve articles reporting 13 studies were included. This review found that patients' experiences of imaging reports included positive and negative aspects. The study identified two main themes encompassing both qualitative and quantitative findings. Patients reported their experiences regarding their understanding of reports and self-management.

Discussion

Patient understanding of imaging reports is multi factorial including medical terminology, communication aids and errors. Self-management through direct access is important to patients. While receiving bad news is a concern, responsibility for accessing this is accepted.

Conclusion

A patient-centred approach to writing imaging reports may help to improve the quality of service, patient experience and wider health outcomes.

Adolescent patient portals and concerns about confidentiality

PURPOSE OF REVIEW

To better understand confidentiality issues that arise from adolescent access to patient portals.

RECENT FINDINGS

Studies have evaluated the views of teens, parents, providers, and institutional leadership on adolescent patient portals and the risks they pose to adolescent privacy. Additional investigations have shown that teen portal accounts are often inappropriately accessed by parents. Guidelines are needed to better inform the creation of secure teen patient portals. Adolescent providers and other medical staff should be aware of the information available on portals, how to ensure portals are being accessed appropriately, and the potential for confidentiality breaches that come with portal use. Medical organizations that offer portal access need to provide resources to adolescents and their families to improve understanding around the importance of confidential care and how to maintain confidentiality while still engaging meaningfully with the healthcare system through patient portals.

SUMMARY

Adolescents realize the benefits portals may offer regarding improved understanding of their health conditions, communication with their providers, and autonomy in their healthcare decisions. However, confidentiality of patient portals is a major concern and a potential barrier to adolescent portal utilization. Adolescent providers should be aware of the limitations of portal systems and advocate for improved confidentiality functionality to ensure teens can access the benefits of patient portals without any harm.

Patient and provider perspectives of personal health record use: a multisite qualitative study in HIV care settings

Use of tethered personal health records (PHRs) can streamline care, reduce unnecessary care utilization, and improve health outcomes for people living with human immunodeficiency virus (HIV). Providers play a role in influencing patients' decision to adopt and use PHRs. To explore patient and provider acceptance and use of PHRs in an HIV care setting. We used a qualitative study design guided by the Unified Theory of Acceptance and Use of Technology. Participants included providers of HIV care, patients living with HIV, and PHR coordinating and support staff in the Veterans Health Administration (VA). Interviews were analyzed using directed content analysis. We interviewed providers (n = 41), patients living with HIV (n = 60), and PHR coordinating and support staff (n = 16) at six VA Medical Centers between June and December 2019. Providers perceived PHR use could enhance care continuity, appointment efficiency, and patient engagement. Yet, some expressed concerns that patient PHR use would increase provider workload and detract from clinical care. Concerns about poor PHR interoperability with existing clinical tools further eroded acceptance and use of PHRs. PHR use can enhance care for patients with HIV and other complex, chronic conditions. Negative provider attitudes toward PHRs may impact providers' encouragement of use among patients, consequently limiting patient uptake. Multipronged interventions at the individual, institutional, and system level are needed to enhance PHR engagement among both providers and patients.

Factors associated with the download and use of mobile personal health record applications in Korean hospitals

The use of mobile personal health records (m-PHR) has been little studied at the organizational level. This study was to investigate the relationships of various hospital-related factors with m-PHR use in Korean hospitals. Downloads of m-PHR applications for 101 hospitals were examined from May 26 to 30 June 2022. The dependent variable was the number of m-PHR downloads, and the major independent variables included six technological, organizational, and environmental factors. As technological factors, the number of computed tomography and magnetic resonance imagery devices were significantly associated with downloads (RR = 1.119, CI = 1.022-1.226, p = 0.016; and RR = 1.155; 95% CI = 1.024-1.302, p = 0.019, respectively). At the organizational level, the number of physicians, adjusting for the number of beds, and the number of medical information management staff showed significant associations (RR = 1.059, CI = 1.019-1.100, p = 0.004; and RR = 1.026, CI = 1.002-1.050, p = 0.033, respectively). From an environmental standpoint, downloads were positively associated with the proportion of the local population of working age (20-59 years) (RR = 1.102, CI 1.022-1.189, p = 0.012). Healthcare policymakers should pay close attention to these factors to advocate for the widespread use of m-PHR applications.

Decreasing Racial Disparities in Preventable Emergency Department Visits Through Hospital Health Information Technology Patient Engagement Functionalities

Introduction: Hospitals are a major source of care for underserved populations in the United States. However, little is known about how hospital-based health information technology (HIT) can improve the efficiency of care and reduce disparities. Objective: We examined the variation of preventable emergency department (ED) visits and associated racial disparities by hospital adoption of HIT patient engagement (HIT-PE) functionalities. Methods: This was an observational study of 6,543,514 non-Hispanic Black (Black) and non-Hispanic White (White) adult patients using 2019 datasets of seven states (Arizona, Florida, Kentucky, Maryland, North Carolina, Vermont, Wisconsin) from the State Emergency Department Databases, American Hospital Association Annual Survey & Information Technology Supplement, and Area Health Resources File. Results: High HIT-PE adoption was associated with lower rates of preventable ED (odds ratio [OR] = 0.992, p < 0.001). Specific HIT-PE functions such as importing medical records from other organizations into the patient portal (OR = 0.977, p < 0.001), electronically sending medical information to a third party (OR = 0.970, p < 0.001), and scheduling appointments online (OR = 0.987, p < 0.001) were also associated with reduced preventable ED rates. Black patients had higher rates of preventable ED compared with Whites (OR = 1.386, p < 0.001); however, the interaction of Black patients and high HIT-PE adoption was associated with lower rates of preventable ED (OR = 0.977, p < 0.001). Our results also showed that higher HIT-PE adoption was associated with a reduction in preventable ED visits among Black patients with comorbidities and Black patients living in low-income areas. Conclusions: The results of our study suggest that there is potential to reduce preventable ED rates and racial disparities through hospital-based HIT-PE functionalities.

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.

User Testing of the Veteran Delegation Tool: Qualitative Inquiry

BACKGROUND

Informal caregivers, or care partners, provide critical support to care recipients when managing health care. Veterans Health Administration (VHA) priorities identify care partners as vital in supporting veterans' care management. The Veteran Delegation Tool (VDT) is VHA's Health Insurance Portability and Accountability Act-compliant solution for care partners to comanage veterans' care through VHA's electronic health portal. Human-centered design approaches in VDT development are needed to inform enhancements aimed at promoting uptake and sustained use.

OBJECTIVE

The objective of this prospective descriptive quality improvement project was to use a human-centered design approach to examine VDT use perceptions and practical experiences.

METHODS

This project was conducted using a 4-phase approach: frame, discover, design, and deliver. The frame phase designed the protocol and prepared the VDT system for testing. This paper reports on the discover phase, which used semistructured and follow-up interviews and user testing to examine VDT's benefits, facilitators, and barriers. The discover phase data informed the design and deliver phases, which are underway.

RESULTS

Veterans (24/54, 44%), care partners (21/54, 39%), and individuals who represented dual roles (9/54, 17%)-namely veteran care partner (4/54, 7%), veteran clinical provider (2/54, 4%), and care partner provider (3/54, 6%)-participated in semistructured interviews in the discover phase. A subsample of these participants (3/54, 6%) participated in the follow-up interviews and user testing. Analysis of the semistructured interviews indicated convergence on the respondents' perceptions of VDT's benefits, facilitators, and barriers and recommendations for improving VDT. The perceived benefits were authorized access, comanagement of care needs on the web, communication with the clinical team, access to resources, and ease of burden. Perceived barriers were nonrecognition of the benefits of VDT, technical literacy access issues, increased stress in or burden on care partners, and personal health information security. Participant experiences across 4 VDT activity domains were upgrade to My HealtheVet Premium account, registration, sign-in, and use. User testing demonstrated users' challenges to register, navigate, and use VDT. Findings informed VDT development enhancements and recommendations.

CONCLUSIONS

Care partners need Health Insurance Portability and Accountability Act-compliant access to electronic health portals to assist with care management. VDT is VHA's solution, allowing communication among delegates, veterans, and clinical care teams. Users value VDT's potential use and benefits, while access and navigation improvements to ensure uptake and sustained use are needed. Future efforts need to iteratively evaluate the human-centered phases, design and deliver, of VDT to target audiences. Continued efforts to understand and respond to care partners' needs are warranted.

Electronic Medical Record-Based Electronic Messaging Among Patients with Breast Cancer: A Systematic Review

BACKGROUND

Electronic medical record (EMR) systems and electronic messages are an increasingly common conduit between physicians and patients. Clear benefits of this type of communication have been established, especially among cancer patients. Studies suggest that patient portals and electronic messaging platforms can help with care coordination between oncology providers and facilitate asynchronous patient-provider communication. Despite the many benefits, there is little research regarding EMR and secure messaging use, particularly among patients with breast cancer.

OBJECTIVES

The objective of this systematic review was to examine the evidence supporting the use of EMR-based messaging systems in patients with breast cancer.

METHODS

A systematic literature search of Ovid MEDLINE, PubMed, Scopus, Web of Science CINAHL, and Cochrane Library was conducted. Studies were required to be published between 2005 and 2022 and report data on demographic information and electronic messaging between patients and providers. Studies were excluded if they reported insufficient data, did not include breast cancer patients, or were not published in English.

RESULTS

This study identified 10 articles that met inclusion criteria. The resulting studies investigated topics such as: patterns of messaging and medication adherence, cancer screening, messaging as a predictor of behavior or outcomes, and symptom management. The literature indicates that electronic messaging with providers was associated with clinical benefits for breast cancer patients and improved screening behaviors.

CONCLUSION

This review uncovered multiple areas to focus future research on, including ideal volume of electronic messages sent and their relation to prescription adherence, studies focusing solely on the breast cancer population, racial disparities in electronic messaging, and provider perceptions of electronic messaging. It is vital that more work be done to understand barriers and gaps in EMR usage to ensure that all individuals can access this increasingly essential medical service while minimizing physician workload and burnout.

A Process Related View on the Usage of Electronic Health Records from the Patients' Perspective: A Systematic Review

BACKGROUND

In recent years, there has been an increasing interest in electronic health record (EHR) systems and various approaches of encouraging acceptance. Multiple methods of EHR acceptance have been proposed. However, a systematic review of patient's perspectives of their role and challenges in processing EHR remains lacking. Moreover, so far, there has been little discussion about barriers and facilitators of EHR system acceptance and usage from the patients' perspective.

METHODS

The study was reported according to the PRISMA statement. Six databases were systematically searched using keywords for articles from 2002-2020. We reviewed these data and used an inductive approach to analyse findings.

RESULTS

A total of 36 studies met the inclusion criteria. Our systematic literature review results reveal a wide range of barriers and facilitators assigned to four distinct stages of EHR system usage: awareness, adoption, behaviour and perception, and consequences. Results were described in a narrative synthesis of the included empirical studies.

DISCUSSION

Results underline the necessity to put a particular emphasis - but not exclusively - on the initial stage of awareness in the future. Further research in the field is therefore strongly recommended in order to develop tailored mediated communication to foster EHR system usage in the long run.

Proposed Questions to Assess the Extent of Knowledge in Understanding the Radiology Report Language

Radiotherapy and diagnostic imaging play a significant role in medical care. The amount of patient participation and communication can be increased by helping patients understand radiology reports. There is insufficient information on how to measure a patient's knowledge of a written radiology report. The goal of this study is to design a tool that will measure patient literacy of radiology reports. A radiological literacy tool was created and evaluated as part of the project. There were two groups of patients: control and intervention. A sample radiological report was provided to each group for reading. After reading the report, the groups were quizzed to see how well they understood the report. The participants answered the questions and the correlation between the understanding of the radiology report and the radiology report literacy questions was calculated. The correlations between radiology report literacy questions and radiology report understanding for the intervention and control groups were 0.522, p < 0.001, and 0.536, p < 0.001, respectively. Our radiology literacy tool demonstrated a good ability to measure the awareness of radiology report understanding (area under the receiver operator curve in control group (95% CI: 0.77 (0.71-0.81)) and intervention group (95% CI: 0.79 (0.74-0.84))). We successfully designed a tool that can measure the radiology literacy of patients. This tool is one of the first to measure the level of patient knowledge in the field of radiology understanding.

Mobile Access to Medical Records in Heart Transplantation Aftercare: Mixed-Methods Study Assessing Usability, Feasibility and Effects of a Mobile Application

BACKGROUND

Patient access to medical records can improve quality of care. The phellow application (app) was developed to provide patients access to selected content of their medical record. It was tested at a heart transplantation (HTx) outpatient clinic. The aims of this study were (1) to assess usability of phellow, (2) to determine feasibility of implementation in routine care, and (3) to study the effects app use had on patients' self-management.

METHODS

Usability was measured quantitatively through the System Usability Scale (SUS). Furthermore, usability, feasibility, and effects on self-management were qualitatively assessed through interviews with users, non-users, and health care providers.

RESULTS

The SUS rating (n = 31) was 79.9, indicating good usability. Twenty-three interviews were conducted. Although appreciation and willingness-to-use were high, usability problems such as incompleteness of record, technical issues, and complex registration procedures were reported. Improved technical support infrastructure, clearly defined responsibilities, and app-specific trainings were suggested for further implementation. Patients described positive effects on their self-management.

CONCLUSIONS

To be feasible for implementation in routine care, usability problems should be addressed. Feedback on the effect of app use was encouraging. Accompanying research is crucial to monitor usability improvements and to further assess effects of app use on patients.

Impact on patient-provider relationship and documentation practices when mental health patients access their electronic health records online: a qualitative study among health professionals in an outpatient setting

BACKGROUND

Patient accessible electronic health records (PAEHR) hold the potential to increase patient empowerment, especially for patients with complex, long-term or chronic conditions. However, evidence of its benefits for patients who undergo mental health treatment is unclear and inconsistent, and several concerns towards use of PAEHR emerged among health professionals. This study aimed at exploring the impact of PAEHR among mental health professionals in terms of patient-provider relationship, changes in the way of writing in the electronic health records and reasons for denying access to information.

METHODS

In-depth qualitative interviews with health professionals working in two mental health outpatient clinics at Helgelandssykehuset in Northern Norway, one of the first hospitals in Norway to implement the PAEHR in 2015. The interviews were conducted by phone or videoconferencing, audio recorded and transcribed verbatim. Data were analyzed by a multidisciplinary research team using the Framework Method.

RESULTS

A total of 16 in-depth qualitative interviews were conducted in April and May 2020. The PAEHR implemented in Norway was seen as a tool to increase transparency and improve the patient-provider relationship. The PAEHR was seen to have negative consequences only in limited situations, such as for patients with severe mental conditions, for child protective services when parents access their children's journal, or for patients with abusive partners. The functionality to deny access to the journal was used rarely. A more common practice for making information not immediately available was to delay the final approval of the notes. The documentation practices changed over the years, but it was not clear to what extent the changes were attributable to the introduction of the PAEHR. Health professionals write their notes keeping in mind that patients might read them, and they try to avoid unclear language, information about third parties, and hypotheses that might create confusion.

CONCLUSIONS

The concerns voiced by mental health professionals regarding the impact of the PAEHR on the patient-provider relationship and practices to deny access to information were not supported by the results of this study. Future research should explore changes in documentation practices by analysing the content of the electronic health records.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

The Influence of the Electronic Health Record on Achieving Equity and Eliminating Health Disparities for Children

The electronic health record (EHR) has been heralded as a transformative approach to modernizing health care and advancing health equity. Access to the EHR can facilitate shared clinical decision-making and improved communication with patients, families, and among health care providers. Recent legislative and regulatory efforts have been passed to increase the transparency as well as the initiatives to increase the meaningful use of the EHR. Yet despite these well-intended efforts, challenges to addressing health equity through the EHR persist. This article reviews three distinct challenges to addressing health equity related to the EHR. We discuss (1) both the implicit and explicit bias that exist in EHR documentation, (2) the gaps that remain between screening for social determinants of health and the effective inclusion and billing of that screening into the EHR, and (3) the disparities that exist with the use of patient portals. Addressing these three areas will enhance the opportunities to advance health equity through the use of the EHR and bring us one step closer to eliminating health disparities in pediatric health care. [Pediatr Ann. 2022;51(3):e112-e117.].

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.

Sharing Clinical Notes and Electronic Health Records With People Affected by Mental Health Conditions: Scoping Review

BACKGROUND

Electronic health records (EHRs) are increasingly implemented internationally, whereas digital sharing of EHRs with service users (SUs) is a relatively new practice. Studies of patient-accessible EHRs (PAEHRs)-often referred to as open notes-have revealed promising results within general medicine settings. However, studies carried out in mental health care (MHC) settings highlight several ethical and practical challenges that require further exploration.

OBJECTIVE

This scoping review aims to map available evidence on PAEHRs in MHC. We seek to relate findings with research from other health contexts, to compare different stakeholders' perspectives, expectations, actual experiences with PAEHRs, and identify potential research gaps.

METHODS

A systematic scoping review was performed using 6 electronic databases. Studies that focused on the digital sharing of clinical notes or EHRs with people affected by mental health conditions up to September 2021 were included. The Mixed Methods Appraisal Tool was used to assess the quality of the studies. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Extension for Scoping Reviews guided narrative synthesis and reporting of findings.

RESULTS

Of the 1034 papers screened, 31 were included in this review. The studies used mostly qualitative methods or surveys and were predominantly published after 2018 in the United States. PAEHRs were examined in outpatient (n=29) and inpatient settings (n=11), and a third of all research was conducted in Veterans Affairs Mental Health. Narrative synthesis allowed the integration of findings according to the different stakeholders. First, SUs reported mainly positive experiences with PAEHRs, such as increased trust in their clinician, health literacy, and empowerment. Negative experiences were related to inaccurate notes, disrespectful language use, or uncovering of undiscussed diagnoses. Second, for health care professionals, concerns outweigh the benefits of sharing EHRs, including an increased clinical burden owing to more documentation efforts and possible harm triggered by reading the notes. Third, care partners gained a better understanding of their family members' mental problems and were able to better support them when they had access to their EHR. Finally, policy stakeholders and experts addressed ethical challenges and recommended the development of guidelines and trainings to better prepare both clinicians and SUs on how to write and read notes.

CONCLUSIONS

PAEHRs in MHC may strengthen user involvement, patients' autonomy, and shift medical treatment to a coproduced process. Acceptance issues among health care professionals align with the findings from general health settings. However, the corpus of evidence on digital sharing of EHRs with people affected by mental health conditions is limited. Above all, further research is needed to examine the clinical effectiveness, efficiency, and implementation of this sociotechnical intervention.

Security Engineering of Patient-Centered Health Care Information Systems in Peer-to-Peer Environments: Systematic Review

Background

Patient-centered health care information systems (PHSs) enable patients to take control and become knowledgeable about their own health, preferably in a secure environment. Current and emerging PHSs use either a centralized database, peer-to-peer (P2P) technology, or distributed ledger technology for PHS deployment. The evolving COVID-19 decentralized Bluetooth-based tracing systems are examples of disease-centric P2P PHSs. Although using P2P technology for the provision of PHSs can be flexible, scalable, resilient to a single point of failure, and inexpensive for patients, the use of health information on P2P networks poses major security issues as users must manage information security largely by themselves.

Objective

This study aims to identify the inherent security issues for PHS deployment in P2P networks and how they can be overcome. In addition, this study reviews different P2P architectures and proposes a suitable architecture for P2P PHS deployment.

Methods

A systematic literature review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines. Thematic analysis was used for data analysis. We searched the following databases: IEEE Digital Library, PubMed, Science Direct, ACM Digital Library, Scopus, and Semantic Scholar. The search was conducted on articles published between 2008 and 2020. The Common Vulnerability Scoring System was used as a guide for rating security issues.

Results

Our findings are consolidated into 8 key security issues associated with PHS implementation and deployment on P2P networks and 7 factors promoting them. Moreover, we propose a suitable architecture for P2P PHSs and guidelines for the provision of PHSs while maintaining information security.

Conclusions

Despite the clear advantages of P2P PHSs, the absence of centralized controls and inconsistent views of the network on some P2P systems have profound adverse impacts in terms of security. The security issues identified in this study need to be addressed to increase patients’ intention to use PHSs on P2P networks by making them safe to use.

Human-Technology Interaction Factors Associated With the Use of Electronic Personal Health Records Among Younger and Older Adults: Secondary Data Analysis

BACKGROUND

An electronic personal health record (ePHR), also known as a personal health record (PHR), has been broadly defined as an electronic application through which individuals can access, manage, and share their health information in a secure and confidential environment. Although ePHRs can benefit individuals as well as caregivers and health care providers, the use of ePHRs among individuals continues to remain low.

OBJECTIVE

The current study aims to examine the relationship between human-technology interaction factors and ePHR use among adults and then to compare the different effects of human-technology interaction factors on ePHR use between younger adults (18-54 years old) and older adults (55 years of age and over).

METHODS

We analyzed data from the Health Information National Trends Survey (HINTS 5 cycle 3) collected from US adults aged 18 years old and over in 2019. Descriptive analysis was conducted for all variables and each item of ePHR use. Bivariate tests (Pearson correlation coefficient for categorical variable and F test for continuous variables) were conducted over 2 age groups. Finally, after adjustments were made for sociodemographics and health care resources, a weighted multiple linear regression was conducted to examine the relationship between human-technology interaction factors and ePHR use.

RESULTS

The final sample size of 1363 (average age 51.19) was divided into 2 age groups: 18 to 54 years old and 55 years old and older. The average level of ePHR use was low (mean 2.76, range 0-8). There was no significant difference in average ePHR use between the 2 age groups. Including clinical notes was positively related to ePHR use in both groups: 18 to 54 years old (β=.28, P=.005), 55 years old and older (β=.15, P=.006). Although accessing ePHRs using a smartphone app was only associated with ePHR use among younger adults (β=.29; P<.001), ease of understanding health information in ePHRs was positively linked to ePHR use only among older adults (β=.13; P=.003).

CONCLUSIONS

This study found that including clinical notes was positively related to ePHR use in both age groups, which suggested that including clinical notes as a part of ePHRs might improve the effective use of ePHRs among patients. Moreover, accessing ePHRs using a smartphone app was associated with higher ePHR use among younger adults while ease of understanding health information in ePHRs was linked to higher ePHR use among older adults. The design of ePHRs should provide the option of being accessible through mobile devices to promote greater ePHR use among young people. For older adults, providers could add additional notes to explain the health information recorded in the ePHRs.

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.

Patients' E-Readiness to use E-Health technologies for oral health

Introduction

Scientific evidence highlights the importance of E-Readiness in the adoption and implementation of E-Oral Health technologies. However, to our knowledge, there is no study investigating the perspective of patients in this regard. Therefore, the objective of this study was to explore patients’ E-Readiness in the field of dentistry.

Materials and methods

A qualitative study was conducted using interpretive descriptive methodology. Purposeful sampling with maximum variation and snowball techniques were used to recruit the study participants via McGill University dental clinics and affiliated hospitals, as well as private or public dental care organizations. A total of 15 face-to-face, semi-structured and 60 to 90-minute audio recorded interviews were conducted. Data collection and analyses were performed concurrently, and interviews were continued until saturation was reached. Activity theory was used as the conceptual framework, and thematic analysis was used to analyze data. Data analysis was conducted both manually and with the use of “ATLAS-ti” software.

Results

Four major themes emerged from the study; unlocking barriers, E-Oral Health awareness, inquisitiveness for E-Oral Health technology and enduring oral health benefits. These themes correspond with all three types of readiness (core, engagement and structural).

Conclusion

The study results suggest that dental patients consider E-Oral Health as a facilitator to access to care, and they are ready to learn and use E-Oral Health technology. There is a need to implement and support E-Oral Health technologies to improve patient care.

Personal Health Information Management Among Older Adults: Scoping Review

Background

Older adults face growing health care needs and could potentially benefit from personal health information management (PHIM) and PHIM technology. To ensure effective PHIM and to provide supportive tools, it is crucial to investigate the needs, challenges, processes, and tools used by this subpopulation. The literature on PHIM by older adults, however, remains scattered and has not provided a clear picture of what we know about the elements that play a role in older adults’ PHIM.

Objective

The goal of our review was to provide a comprehensive overview of extant knowledge on PHIM by older adults, establish the status quo of research on this topic, and identify research gaps.

Methods

We carried out a scoping review of the literature from 1998 to 2020, which followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) framework. First, we executed a broad and structured search. We then carried out a qualitative analysis of papers pertinent to the topic taking into consideration the five elements of the patient work system as follows: (1) personal-level factors, (2) PHIM tasks, (3) tools used, (4) physical settings of PHIM activities, and (5) socio-organizational aspects.

Results

The review included 22 studies. Consolidated empirical evidence was related to all elements of the patient work system. Multiple personal factors affected PHIM. Various types of personal health information were managed (clinical, patient-generated, and general) and tools were used (electronic, paper-based, and others). Older adults’ PHIM was intertwined with their surroundings, and various individuals participated. The largest body of evidence concerned personal factors, while findings regarding the physical environment of PHIM were scarce. Most research has thus far examined older adults as a single group, and scant attention has been paid to age subgroups.

Conclusions

Opportunities for further PHIM studies remain across all elements of the patient work system in terms of empirical, design science, or review work.

Leveraging electronic health records to improve management of noncommunicable diseases at primary healthcare centres in Saudi Arabia: a qualitative study

Background

Electronic Health Records (EHRs) can contribute to the earlier detection and better treatment of chronic diseases by improving accuracy and accessibility of patient data. The Saudi Ministry of Health (MOH) implemented an EHR system in all primary health care clinics (PHCs) as part of measures to improve their performance in managing chronic disease. This study examined the perspective of physicians on the current scope and content of NCDs management at PHCs including the contribution of the EHR system.

Methods

Semi-structured interviews were conducted with 22 physicians working in chronic disease clinics at PHCs covering a range of locations and clinic sizes. The participants were selected based on their expertise using a combination of purposive and convenience sampling. The interviews were transcribed, analyzed and coded into the key themes.

Results

Physicians indicated that the availability of the EHR helped organise their work and positively influenced NCDs patient encounters in their PHCs. They emphasised the multiple benefits of EHR in terms of efficiency, including the accuracy of patient documentation and the availability of patient information. Shortcomings identified included the lack of a patient portal to allow patients to access information about their health and lack of capacity to facilitate multi-disciplinary care for example through referral to allied health services. Access to the EHR was limited to MOH primary healthcare centres and clinicians noted that patients also received care in private clinics and hospitals.

Conclusion

While well regarded by clinicians, the EHR system impact on patient care at chronic disease clinics is not being fully realised. Enabling patient access to their EHR would be help promote self-management, a core attribute of effective NCD management. Co-ordination of care is another core attribute and in the Saudi health system with multiple public and private providers, this may be substantially improved if the patients EHR was accessible wherever care was provided. There is also a need for enhanced capacity to support improving patient’s nutrition and physical activity.

Evaluating the Effectiveness of NoteAid in a Community Hospital Setting: Randomized Trial of Electronic Health Record Note Comprehension Interventions With Patients

Background

Interventions to define medical jargon have been shown to improve electronic health record (EHR) note comprehension among crowdsourced participants on Amazon Mechanical Turk (AMT). However, AMT participants may not be representative of the general population or patients who are most at-risk for low health literacy.

Objective

In this work, we assessed the efficacy of an intervention (NoteAid) for EHR note comprehension among participants in a community hospital setting.

Methods

Participants were recruited from Lowell General Hospital (LGH), a community hospital in Massachusetts, to take the ComprehENotes test, a web-based test of EHR note comprehension. Participants were randomly assigned to control (n=85) or intervention (n=89) groups to take the test without or with NoteAid, respectively. For comparison, we used a sample of 200 participants recruited from AMT to take the ComprehENotes test (100 in the control group and 100 in the intervention group).

Results

A total of 174 participants were recruited from LGH, and 200 participants were recruited from AMT. Participants in both intervention groups (community hospital and AMT) scored significantly higher than participants in the control groups (P<.001). The average score for the community hospital participants was significantly lower than the average score for the AMT participants (P<.001), consistent with the lower education levels in the community hospital sample. Education level had a significant effect on scores for the community hospital participants (P<.001).

Conclusions

Use of NoteAid was associated with significantly improved EHR note comprehension in both community hospital and AMT samples. Our results demonstrate the generalizability of ComprehENotes as a test of EHR note comprehension and the effectiveness of NoteAid for improving EHR note comprehension.

Utility, Value, and Benefits of Contemporary Personal Health Records: Integrative Review and Conceptual Synthesis

Background

Contemporary personal health record (PHR) technologies offer a useful platform for individuals to maintain a lifelong record of personally reported and clinically sourced data from various points of medical care.

Objective

This paper presents an integrative review and synthesis of the extant literature on PHRs. This review draws upon multiple lenses of analysis and deliberates value perspectives of PHRs at the product, consumer, and industry levels.

Methods

Academic databases were searched using multiple keywords related to PHRs for the years 2001-2020. Three research questions were formulated and used as selection criteria in our review of the extant literature relevant to our study.

Results

We offer a high-level functional utility model of PHR features and functions. We also conceptualize a consumer value framework of PHRs, highlighting the applications of these technologies across various health care delivery activities. Finally, we provide a summary of the benefits of PHRs for various health care constituents, including consumers, providers, payors, and public health agencies.

Conclusions

PHR products offer a myriad of content-, connectivity-, and collaboration-based features and functions for their users. Although consumers benefit from the tools provided by PHR technologies, their overall value extends across the constituents of the health care delivery chain. Despite advances in technology, our literature review identifies a shortfall in the research addressing consumer value enabled by PHR tools. In addition to scholars and researchers, our literature review and proposed framework may be especially helpful for value analysis committees in the health care sector that are commissioned for the appraisal of innovative health information technologies such as PHRs.

Impact of patient access to their electronic health record: systematic review

Patient access to their own electronic health records (EHRs) is likely to become an integral part of healthcare systems worldwide. It has the potential to decrease the healthcare provision costs, improve access to healthcare data, self-care, quality of care, and health and patient-centered outcomes. This systematic literature review is aimed at identifying the impact in terms of benefits and issues that have so far been demonstrated by providing patients access to their own EHRs, via providers' secure patient portals from primary healthcare centers and hospitals. Searches were conducted in PubMed, MEDLINE, CINHAL, and Google scholar. Over 2000 papers were screened and were filtered based on duplicates, then by reading the titles and finally based on their abstracts or full text. In total, 74 papers were retained, analyzed, and summarized. Papers were included if providing patient access to their own EHRs was the primary intervention used in the study and its impact or outcome was evaluated. The search technique used to identify relevant literature for this paper involved input from five experts. While findings from 54 of the 74 papers showed positive outcome or benefits of patient access to their EHRs via patient portals, 10 papers have highlighted concerns, 8 papers have highlighted both and 2 have highlighted absence of negative outcomes. The benefits range from re-assurance, reduced anxiety, positive impact on consultations, better doctor-patient relationship, increased awareness and adherence to medication, and improved patient outcomes (e.g., improving blood pressure and glycemic control in a range of study populations). In addition, patient access to their health information was found to improve self-reported levels of engagement or activation related to self-management, enhanced knowledge, and improve recovery scores, and organizational efficiencies in a tertiary level mental health care facility. However, three studies did not find any statistically significant effect of patient portals on health outcomes. The main concerns have been around security, privacy and confidentiality of the health records, and the anxiety it may cause amongst patients. This literature review identified some benefits, concerns, and attitudes demonstrated by providing patients' access to their own EHRs. This access is often part of government strategies when developing patient-centric self-management elements of a sustainable healthcare system. The findings of this review will give healthcare providers a framework to analyze the benefits offered by promoting patient access to EHRs and decide on the best approach for their own specialties and clinical setup. A robust cost-benefit evaluation of such initiatives along with its impact on major stakeholders within the healthcare system would be essential in understanding the overall impact of such initiatives. Implementation of patient access to their EHRs could help governments to appropriately prioritize the development or adoption of national standards, whilst taking care of local variations and fulfilling the healthcare needs of the population, e.g., UK Government is aiming to make full primary care records available online to every patient. Ultimately, increasing transparency and promoting personal responsibility are key elements of a sustainable healthcare system for future generations.

Perspectives on team communication challenges in caring for children with medical complexity

BACKGROUND

Children with medical complexity (CMC) require the expertise of many care providers spanning different disciplines, institutions, and settings of care. This leads to duplicate health records, breakdowns in communication, and limited opportunities to provide comprehensive, collaborative care. The objectives of this study were to explore communication challenges and solutions/recommendations from multiple perspectives including (i) parents, (ii) HCPs - hospital and community providers, and (iii) teachers of CMC with a goal of informing patient care.

METHODS

This qualitative study utilized an interpretive description methodology. In-depth semi-structured interviews were conducted with parents and care team members of CMC. The interview guides targeted questions surrounding communication, coordination, access to information and roles in the health system. Interviews were conducted until thematic saturation was reached. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed using thematic analysis.

RESULTS

Thirty-two individual interviews were conducted involving parents (n = 16) and care team members (n = 16). Interviews revealed 2 main themes and several associated subthemes (in parentheses): (1) Communication challenges in the care of CMC (organizational policy and technology systems barriers, inadequate access to health information, and lack of partnership in care) (2) Communication solutions (shared systems that can be accessed in real-time, universal access to health information, and partnered contribution to care).

CONCLUSION

Parents, HCPs, and teachers face multiple barriers to communication and information accessibility in their efforts to care for CMC. Parents and care providers in this study suggested potential strategies to improve communication including facilitating communication in real-time, universal access to health information and meaningful partnerships.

Post-9/11 Veteran Satisfaction With the VA eScreening Program

INTRODUCTION

eScreening is a mobile health technology resource for veterans and staff to support Veterans Health Administration initiatives such as early identification of health problems, shared decision-making, and measurement-based care.

METHODS

We conducted an exploratory mixed methods retrospective study with newly enrolling post-9/11 veterans to (1) understand eScreening user experience and obtain practical feedback on the technology to guide improvements, (2) assess veteran satisfaction with eScreening following improvements to the technology, and (3) examine veteran characteristics associated with eScreening satisfaction. Focus group data were collected on user experience with eScreening from a sample of veterans who participated in an eScreening pilot. Guided by a user-centered design approach, findings informed improvements to the technology. Survey data were subsequently collected from a large cohort of veterans to assess satisfaction with the improved program. Questionnaire data were also collected to examine variables associated with eScreening satisfaction. Qualitative focus group data were analyzed using content analysis. Descriptive statistics were used to characterize sociodemographic variables, questionnaires, and satisfaction ratings. Correlations were run to examine the relationship between certain veteran characteristics (eg, age, resiliency, anxiety, insomnia, post-traumatic stress disorder, somatic symptoms, depression, pain) and satisfaction with eScreening. All research activities were conducted at VA San Diego Healthcare System and approved by the Institutional Review Board.

RESULTS

Focus group data revealed that veterans were largely satisfied with eScreening, but they suggested some improvements (eg, to interface functionality), which were integrated into an updated version of eScreening. Following these changes, survey data revealed that veterans were highly satisfied with eScreening, including its usability, information security, and impact on health services. There were statistically significant, though not clinically meaningful relationships between health-related characteristics and satisfaction with eScreening. However, millennials showed significantly higher satisfaction ratings compared with non-millennials.

CONCLUSIONS

These findings support the use of patient experiences and feedback to aide product development. In addition, post-9/11 veterans support the use of eScreening to assist health screening. However, evaluating the eScreening program in more diverse veteran groups and Veterans Affairs settings is needed to improve the generalizability of these findings to the larger veteran population.

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.

Stakeholder Perspectives in Anticipation of Sharing Physicians' Notes With Parents of Hospitalized Children

OBJECTIVE

Elicit stakeholder perspectives on the anticipated benefits and challenges of sharing hospital physicians' admission and daily progress notes with parents at the bedside during their child's hospitalization and identify strategies to aid implementation of inpatient note sharing.

METHODS

Five semistructured focus groups were conducted with 34 stakeholders (8 parents, 8 nurses, 5 residents, 7 hospitalists, 6 administrators) at a tertiary children's hospital from October to November 2018 to identify anticipated benefits, challenges, and implementation strategies prior to sharing inpatient physicians' notes. A facilitator guide elicited participants' perspectives about the idea of sharing notes with parents during their child's hospitalization. Three researchers used content analysis to analyze qualitative data inductively.

RESULTS

Anticipated benefits of sharing inpatient notes included: Reinforcement of information, improved parental knowledge and empowerment, enhanced parent communication and partnership with providers, and increased provider accountability and documentation quality. Expected challenges included: Increased provider workload, heightened parental confusion, distress or anxiety, impaired parent relationship with providers, and compromised note quality and purpose. Suggested implementation strategies included: Setting staff and parent expectations upfront, providing tools to support parent education, and limiting shared note content and family eligibility.

CONCLUSIONS

Stakeholders anticipated multiple benefits and drawbacks of sharing notes with parents during their child's hospital stay and made practical suggestions for ways to implement inpatient note sharing to promote these benefits and mitigate challenges. Findings will inform the design and implementation of an intervention to share notes using an inpatient portal and evaluation of its effect on child, parent, and healthcare team outcomes.

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.

Interrelationships Between Patients' Data Tracking Practices, Data Sharing Practices, and Health Literacy: Onsite Survey Study

Background

Although the use of patient-generated data (PGD) in the optimization of patient care shows great promise, little is known about whether patients who track their PGD necessarily share the data with their clinicians. Meanwhile, health literacy—an important construct that captures an individual’s ability to manage their health and to engage with their health care providers—has often been neglected in prior studies focused on PGD tracking and sharing. To leverage the full potential of PGD, it is necessary to bridge the gap between patients’ data tracking and data sharing practices by first understanding the interrelationships between these practices and the factors contributing to these practices.

Objective

This study aims to systematically examine the interrelationships between PGD tracking practices, data sharing practices, and health literacy among individual patients.

Methods

We surveyed 109 patients at the time they met with a clinician at a university health center, unlike prior research that often examined patients’ retrospective experience after some time had passed since their clinic visit. The survey consisted of 39 questions asking patients about their PGD tracking and sharing practices based on their current clinical encounter. The survey also contained questions related to the participants’ health literacy. All the participants completed the survey on a tablet device. The onsite survey study enabled us to collect ecologically valid data based on patients’ immediate experiences situated within their clinic visit.

Results

We found no evidence that tracking PGD was related to self-reports of having sufficient information to manage one’s health; however, the number of data types participants tracked positively related to their self-assessed ability to actively engage with health care providers. Participants’ data tracking practices and their health literacy did not relate to their data sharing practices; however, their ability to engage with health care providers positively related to their willingness to share their data with clinicians in the future. Participants reported several benefits of, and barriers to, sharing their PGD with clinicians.

Conclusions

Although tracking PGD could help patients better engage with health care providers, it may not provide patients with sufficient information to manage their health. The gaps between tracking and sharing PGD with health care providers call for efforts to inform patients of how their data relate to their health and to facilitate efficient clinician-patient communication. To realize the full potential of PGD and to promote individuals’ health literacy, empowering patients to effectively track and share their PGD is important—both technologies and health care providers can play important roles.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

The impact of a comprehensive electronic patient portal on the health service use: an interrupted time-series analysis

BACKGROUND

There is little empirical research on the potential benefit that electronic patient portals (EPP) can have on the care quality and health outcomes of diverse multi-ethnic international populations. The purpose of this study is to determine the extent to which an EPP was associated with improvements in health service use.

METHODS

Using a quasi-experimental interrupted time-series approach, we assessed health service use before (April 2012-September 2015) and after (October 2015-December 2016) the implementation of a comprehensive EPP at four hospitals in Madrid, Spain. Primary outcomes were number of outpatient visits, any hospital admission, any 30-day all-cause readmission and any emergency department visit.

RESULTS

Implementation of the EPP was associated with a significant decline in readmissions. Among patients with chronic heart failure, EPP implementation was associated with a significant decline for all outcome measures, and among patients with COPD, a decline in all outcomes except readmissions. Among patients diagnosed with malignant hematological diseases, no significant changes were identified.

CONCLUSIONS

EPPs hold promise for reducing hospital readmissions. Certain patient populations with chronic conditions may differentially benefit from portal use depending on their needs for communication with their providers.

A Comparative Analysis of Online Medical Record Utilization and Perception by Cancer Survivorship

BACKGROUND

Cancer survivors face many challenges including coordinating care across multiple providers and maintaining medical records from multiple institutions. Access and utilization of online medical records could help cancer survivors manage this complexity. Here, we examined how cancer survivors differ from those without a history of cancer with regards to utilization and perception of medical records.

METHODS

We conducted a cross-sectional study of 3491 respondents, from the Health Information National Trends survey 5, cycle 2. The association of medical record utilization and perceptions with cancer survivorship was assessed using survey-weighted logistic regression.

RESULTS

Cancer survivors (n=593) were more likely to report that a provider maintains a computerized medical record [adjusted odds ratio (AOR)=2.05; 95% confidence (CI), 1.24-3.41] and were more likely to report confidence in medical record safeguards (AOR=1.44; 95% CI, 1.03-2.03). However, cancer survivors were no more likely to access online medical records than those without a history of cancer (AOR=1.13; 95% CI, 0.69-1.86). Cancer survivors were no more likely to report privacy concerns as a reason for not accessing online medical records, however, survivors were more likely to report a preference for speaking directly with a provider as a reason for not accessing online medical records (AOR=2.24; 95% CI, 0.99-5.05).

CONCLUSIONS

Although cancer survivors are more likely to trust medical record safe guards and do not express increased concerns about online medical record privacy, a preference to speak directly with provider is a barrier of use.

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.

Sociodemographic Differences and Factors Affecting Patient Portal Utilization

BACKGROUND

The primary function of the patient portal is to give patients greater access to their personal health information. Granting patients electronic access allows them to make well-informed health care decisions.

OBJECTIVE

This study aimed to identify sociodemographic differences in patient portal use and examine factors affecting patient portal utilization following the final stage of the Meaningful Use program which aimed to promote the use of certified electronic health record (EHR) technology.

RESEARCH DESIGN

Survey data from Health Information National Trends Survey (HINTS) 5, cycles 1, 2, and 3 were analyzed. The sample included 8291 completed surveys. Multivariable logistic regression on a selected response for each surveyed question was used to assess the racial and ethnic difference after controlling for age, sex, income, and education.

SUBJECTS

Subjects included English and Spanish speaking adults in the USA.

MEASURES

Measures included assessment of patient portal use, patient portal access, understanding health information, usefulness of health records, and privacy and security.

RESULTS

After adjusting for age, sex, income, and education, there was a significant association between race/ethnicity and patient portal non-users responding, "no need to use online medical record" as the reason for not using the patient portal (P = 0.005). Among the portal users, there were significant associations between race/ethnicity and health care provider maintaining an EHR (P = 0.006), being offered access to their portal (P < 0.001), understanding health information in the portal (P = 0.004), finding the portal useful for health monitoring (P < 0.001), reporting concern about unauthorized access (P = 0.017), and keeping information from health care providers (P = 0.012).

CONCLUSIONS

Race/ethnicity affects perceptions on the need for the patient portal, being offered access to a portal, and the reasons to access information online. Understanding the factors affecting patient portal use can inform future strategies aimed at increasing adoption.

An Untapped Potential in Primary Care: Semi-Structured Interviews with Clinicians on How Patient Portals Will Work for Caregivers in the Safety Net

Background

Patients within safety-net settings are less likely to access health information on patient portals, despite expressed interest. Family and friends are important resources to assist these patients (ie, Medicaid recipients, older patients, patients with limited English proficiency) in navigating health systems, and provider support of the use of patient portals among these groups may also facilitate caregivers’ use of their patients’ portal.

Objective

Because safety net providers work closely with caregivers to care for their patients, we used qualitative methods to explore safety net providers’ perspectives on portal use among caregivers for their patients, especially as there is limited literature about caregivers’ use of portals in the safety net.

Methods

We conducted 45- to 60-min semistructured telephone interviews with providers from three large California safety-net health systems. The interviews focused on providers’ experiences with caregivers, caregiver roles, and how the portal could be leveraged as a tool to support caregivers in their responsibilities. A total of three coders analyzed the interview transcripts using both deductive and inductive approaches and established a consensus regarding major themes.

Results

Of the 16 participants interviewed, 4 specialized in geriatrics, and all held a leadership or administrative role. We described themes highlighting providers’ recognition of potential benefits associated with caregiver portal use and specific challenges to caregiver engagement.

Conclusions

Providers recognized the potential for portals to improve information delivery and communication by helping caregivers assist socially and medically complex patients in the safety net. Providers in safety net sites also discussed a clear need for better ways to keep in touch with patients and connect with caregivers, yet security and privacy are perhaps of higher importance in these settings and may pose challenges to portal adoption. They noted that caregivers of patients in the safety net likely face similar communication barriers as patients, especially with respect to digital literacy, health literacy, and English proficiency. Further research is needed to assess and support caregivers’ interest and ability to access portals across barriers in health and digital literacy, and English proficiency. Portal platforms and health systems must also address specific strategies to uphold patient preferences while maintaining privacy and security.

Improving Self-Care in Patients With Coexisting Type 2 Diabetes and Hypertension by Technological Surrogate Nursing: Randomized Controlled Trial

BACKGROUND

Technological surrogate nursing (TSN) derives from the idea that nurse-caregiver substitutes can be created by technology to support chronic disease self-care.

OBJECTIVE

This paper begins by arguing that TSN is a useful and viable approach to chronic disease self-care. The analysis then focuses on the empirical research question of testing and demonstrating the effectiveness and safety of prototype TSN supplied to patients with the typical complex chronic disease of coexisting type 2 diabetes and hypertension. At the policy level, it is shown that the data allow for a calibration of TSN technology augmentation, which can be readily applied to health care management.

METHODS

A 24-week, parallel-group, randomized controlled trial (RCT) was designed and implemented among diabetic and hypertensive outpatients in two Hong Kong public hospitals. Participants were randomly assigned to an intervention group, supplied with a tablet-based TSN app prototype, or to a conventional self-managing control group. Primary indices-hemoglobin A1c, systolic blood pressure, and diastolic blood pressure-and secondary indices were measured at baseline and at 8, 12, 16, and 24 weeks after initiation, after which the data were applied to test TSN effectiveness and safety.

RESULTS

A total of 299 participating patients were randomized to the intervention group (n=151) or the control group (n=148). Statistically significant outcomes that directly indicated TSN effectiveness in terms of hemoglobin 1c were found in both groups but not with regard to systolic and diastolic blood pressure. These findings also offered indirect empirical support for TSN safety. Statistically significant comparative changes in these primary indices were not observed between the groups but were suggestive of an operational calibration of TSN technology augmentation. Statistically significant changes in secondary indices were obtained in one or both groups, but not between the groups.

CONCLUSIONS

The RCT's strong behavioral basis, as well as the importance of safety and effectiveness when complex chronic illness is proximately self-managed by layperson patients, prompted the formulation of the empirical joint hypothesis that TSN would improve patient self-care while satisfying the condition of patient self-safety. Statistical and decision analysis applied to the experimental outcomes offered support for this hypothesis. Policy relevance of the research is demonstrated by the derivation of a data-grounded operational calibration of TSN technology augmentation with ready application to health care management.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02799953; https://clinicaltrials.gov/ct2/show/NCT02799953.

Parent Perspectives on Pediatric Inpatient OpenNotes

INTRODUCTION

169 U.S. health systems now engage in OpenNotes: a movement to share clinical notes with patients. Few studies have focused on releasing notes during hospitalization, pediatrics, or parents/caregiver perspectives.

METHODS

A focus group was conducted with eight parents with experience caring for a hospitalized child at a Midwest children's hospital. In the 2-hour session, parents were asked about their perspectives of the idea of sharing inpatient doctors' daily notes with parents during their child's hospitalization. Qualitative analysis was conducted to elicit themes related to the potential benefits and challenges of sharing inpatient notes.

RESULTS

The most mentioned benefits included notes providing information as a reference for improved family education/understanding, communication/continuity, and advocacy/empowerment. Challenges were primarily related to note content, impaired communication and negative impact on families.

CONCLUSION

Participants identified multiple potential benefits of and challenges to sharing notes with parents during their child's hospitalization but also acknowledged the impact on healthcare professionals who work alongside them.

The Views and Experiences of Clinicians Sharing Medical Record Notes With Patients

IMPORTANCE

The 21st Century Cures Act of 2016 requires that patients be given electronic access to all the information in their electronic medical records. The regulations for implementation of this law give patients far easier access to information about their care, including the notes their clinicians write.

OBJECTIVE

To assess clinicians' views and experiences with sharing clinical notes (open notes) with patients.

DESIGN, SETTING, AND PARTICIPANTS

Web-based survey study of physicians, advanced practice nurses, registered nurses, physician assistants, and therapists at 3 health systems in Boston, Massachusetts; Seattle, Washington; and rural Pennsylvania where notes have been shared across all outpatient specialties for at least 4 years. Participants were clinicians in hospital-based offices and community practices who had written at least 1 note opened by a patient in the year prior to the survey, which was administered from May 21, 2018, to August 31, 2018.

MAIN OUTCOMES AND MEASURES

Clinicians' experiences with and perceptions of sharing clinical notes with patients.

RESULTS

Invitations were sent to 6064 clinicians; 1628 (27%) responded. Respondents were more likely than nonrespondents to be female (65% vs 55%) and to be younger (mean [SD] age, 42.1 [12.6] vs 44.9 [12.7] years). The majority of respondents were physicians (951 [58%]), female (1023 [65%]), licensed to practice in 2000 or later (940 [61%]), and spent fewer than 40 hours per week in direct patient care (1083 [71%]). Most viewed open notes positively, agreeing they are a good idea (1182 participants [74%]); of 1314 clinicians who were aware that patients were reading their notes, 965 (74%) agreed that open notes were useful for engaging patients. In all, 798 clinicians (61%) would recommend the practice to colleagues. A total of 292 physicians (37%) reported spending more time on documentation, and many reported specific changes in the way they write their notes, the most frequent of which related to use of language that could be perceived as critical of the patient (422 respondents [58%]). Most physicians (1234 [78%]) favored being able to determine readily that their notes had been read by their patients.

CONCLUSIONS AND RELEVANCE

In this survey of clinicians in a wide range of specialties who had several years of experience offering their patients ready access to their notes, more than two-thirds supported this new practice. Even among subgroups of clinicians who were less enthusiastic, most endorsed the idea of sharing notes and believed the practice could be helpful for engaging patients more actively in their care.