Parent Perspectives on Sharing Pediatric Hospitalization Clinical Notes

Adolescent Use and Perspective of Hospital MyChart Bedside

BACKGROUND

Since the initiation and requirement of open access electronic health records (EHRs), research has shown benefits for adult patients and children's caregivers. Few studies have included the adolescent perspective.

METHODS

Hospitalized adolescents aged 14 to 20 years with an active Epic MyChart Bedside (inpatient portal device) account were recruited via convenience sampling. Participants were surveyed, assessing their understanding of the care plan, awareness and use of MyChart Bedside, and free-text responses. EHR information (age, sex, length of stay [LOS], race, ethnicity, insurance, chronic conditions) was paired with survey responses.

RESULTS

Thirty-two patients enrolled. No significant differences were noted in use based on sex, age, LOS, ethnicity, race, insurance type, or number of chronic conditions. Sixty-three percent were aware of access; of those, 55% used the tablet. Thirty-eight percent were unaware of access, and 83% indicated interest in using after learning about it. Free-text responses highlighted perceived advantages; 91% understood the care plan well. Overall offering of MyChart Bedside was low.

DISCUSSION/CONCLUSION

This exploratory study begins to address a knowledge gap by assessing hospitalized adolescents' perspectives on open access bedside EHRs. Use was limited by access to and awareness of the tool and did not appear to be impacted by various factors. Despite sample size limitations, this study is an important step in understanding adolescents' engagement with open access EHRs. Future work should include larger sample sizes, assess factors contributing to use, and evaluate whether EHR access in adolescence enhances understanding of their health care.

Electronic Communication Between Children's Caregivers and Health Care Teams: Scoping Review on Parental Caregiver's Perceptions and Experience

Background

Asynchronous communication via electronic modes (e-communication), including patient portals, secure messaging services, SMS text messaging, and email, is increasingly used to supplement synchronous face-to-face medical visits; however, little is known about its quality in pediatric settings.

Objective

This review aimed to summarize contemporary literature on pediatric caregivers' experiences with and perspectives of e-communication with their child's health care team to identify how e-communication has been optimized to improve patient care.

Methods

A scoping review following the Arksey and O'Malley methodological framework searched PubMed, CINAHL, Embase, and Web of Science using terms such as "Electronic Health Records" and "Communication" from 2013 to 2023 that discussed caregiver experiences and perspectives of e-communication with their child's health care provider. Studies were excluded if they were abstracts, non-English papers, nonscientific papers, systematic reviews, or quality improvement initiatives, or pertained to synchronous telemedicine. We conducted a two-step screening process by scanning the title and abstract and reviewing the full text by two independent screeners to confirm eligibility. From an initial 903 articles identified via the database search, 23 articles fulfilled all the inclusion criteria and are included in this review.

Results

Of the 23 articles meeting the inclusion criteria, 11 used quantitative methods, 7 used qualitative methods, and 5 used mixed methods. The caregiver sample sizes ranged from 51 to 3339 in the quantitative studies and 8 to 36 in the qualitative and mixed methods studies. A majority (n=17) used the patient portal that was self-categorized by the study. Secure messaging through a portal or other mobile health app was used in 26% (n=6) of the studies, while nonsecure messaging outside of the portal was used 17% (n=4) of the time and email was used 33.3% (n=8) of the time. In 19 of the studies, parents reported positive experiences with and a desire for e-communication methods.

Conclusions

The literature overwhelmingly supported caregiver satisfaction with and desire for e-communication in health care, but no literature intentionally studied how to improve the quality of e-communication, which is a critical gap to address.

Open Notes Experiences of Parents in the Pediatric ICU

OBJECTIVE

We examined how parents experience and navigate open access to clinical notes ("open notes") in their child's electronic health record and explored their interactions with clinicians during an ICU admission.

METHODS

We performed a qualitative analysis using semistructured interviews of English-speaking parents who accessed their child's clinical notes during a pediatric ICU (general or cardiac) admission. We included patient-parent dyads with an ICU admission ≥48 hours between April 2021 and December 2022, note access by proxy timestamp during the ICU course, and either patient age <12 years or incapacitated adolescent ages 12 to 21 years. Purposive sampling was based on sociodemographic and clinical characteristics. Phone interviews were audio-recorded, transcribed, and analyzed using inductive thematic codebook analysis.

RESULTS

We interviewed 20 parents and identified 2 thematic categories, outcomes and interactions, in parents accessing clinical notes. Themes of outcomes included applied benefits, psychosocial and emotional value, and negative consequences. Themes of interactions included practical limitations and parental approach and appraisal. The ICU context and power dynamics were a meta-theme, influencing multiple themes. All parents reported positive qualities of note access despite negative consequences related to content, language, burdens, and lack of support. Parents suggested practice and design improvements surrounding open note access.

CONCLUSIONS

Parental experiences with open notes reveal new, unaddressed considerations for documentation access, practices, and purpose. Parents leverage open notes by negotiating between the power dynamics in the ICU and the uncertain boundaries of their role and authority in the electronic health record.

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.

Family Perception of OpenNotes in the Neonatal Intensive Care Unit

BACKGROUND

 OpenNotes, or sharing of medical notes via a patient portal, has been studied extensively in the adult population, but less in pediatric populations, and even more rarely in inpatient pediatric or intensive care settings.

OBJECTIVES

 This study aimed to understand families' interaction with and perception of inpatient hospital notes shared via patient portal in a community Neonatal Intensive Care Unit (NICU).

METHODS

 At the end of the NICU discharge education, completed in the patient portal before discharge, families were offered an anonymous survey on OpenNotes.

RESULTS

 Out of 446 NICU patients from March 16, 2022 to March 16, 2023, there were 59 respondents (13%). Race was primarily Asian (48%), and English was the predominant language (93%). Most families indicated that the notes were "very or somewhat easy to understand" (93%). Seventy-three percent of respondents felt much better about the doctor(s) after reading the notes, and 53% contacted the physicians about something in the notes. Six (16%) felt that OpenNotes were more confusing than helpful.

CONCLUSION

 To the authors' knowledge, this is the first study on NICU families' perceptions of OpenNotes, which indicated positive interactions with the doctors' daily progress notes and gave important suggestions for improvement.

Adolescent Access to Clinicians' Notes: Adolescent, Parent, and Clinician Perspectives

PURPOSE

In 2021, federal guidelines mandated that health-care organizations share clinicians' notes with patients to increase information transparency. While findings indicate advantages for adult patients, less is known about note-sharing from the viewpoint of adolescents. This study aims to identify adolescent, parent, and clinician perspectives on the anticipated benefits and concerns of giving adolescents access to clinicians' notes and strategies to support note-sharing in this population.

METHODS

We conducted six focus groups with adolescents, parents, and clinicians at a children's hospital from May to October 2021. A semistructured facilitator guide captured participant perspectives of note-sharing benefits, concerns, and strategies. Two researchers independently coded and analyzed transcript data using thematic analysis; a third researcher reconciled discrepancies.

RESULTS

38 stakeholders (17 adolescents, 10 parents, and 11 clinicians) described four benefits, three concerns, and four implementation strategies regarding adolescent note-sharing. Potential benefits included adolescents using notes to remember and reinforce the visit, gaining knowledge about their health, strengthening the adolescent-clinician relationship, and increasing agency in health care decisions. Concerns included notes leading to a breach in confidentiality, causing negative emotions, and becoming less useful for clinicians. Strategies included making note-sharing more secure, optimizing note layout and content, setting clear expectations, and having a portion of the note for clinician use only.

DISCUSSION

Stakeholders suggest multiple strategies to optimize the implementation of note-sharing to support adolescent patients, parents, and clinicians as hospitals work to comply with federal regulations. These strategies may reinforce the potential benefits and mitigate the challenges of sharing notes with adolescent patients.

Variation in pediatric and adolescent electronic health data sharing practices under the 21st Century Cures Act

OBJECTIVE

To describe real-world practices and variation in implementation of the Information Blocking provisions amongst healthcare organizations caring for pediatric patients.

MATERIALS AND METHODS

An online survey regarding implementation practices was distributed to representatives from 10 participating US healthcare organizations located in 6 different states. The survey was followed by structured interviews conducted through video conference. Information was gathered about implementation practices at each organization, with a focus on patient and proxy portal access to, and segmentation capabilities of, certain data classes listed in the United States Core Data for Interoperability Version 1.

RESULTS

All organizations had implemented the information blocking provisions at their institution. All organizations utilized different portal account types for proxies and users. All organizations reported the capability of sharing labs, medications, problem lists, imaging, and notes with the parent/guardian of the non-adolescent minor user with differences in how sensitive elements within the data classes were protected. Variability existed in how data was shared with the remaining user types.

DISCUSSION

Significant variability exists in how organizations have implemented the information blocking rules. Variation in data sharing and data access between institutions can result in privacy breaches and create confusion about completeness of data for patients and families.

CONCLUSION

Healthcare organizations have utilized varying strategies to comply with the information blocking provisions of the 21st Century Cures Act. Increased clarity from the Office of the National Coordinator for Health Information Technology on minor, adolescent, and caregiver privacy and improved segmentation capabilities from Electronic Health Record vendors is needed.