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.

Design of a Patient-Accessible Electronic Health Record System in Mental Health

Patient accessible Electronic Health Records (PAEHRs) are increasingly implemented internationally. However, studies carried out in the mental health care setting report several practical and ethical challenges when introducing PAEHRs. In this paper we aim to explore the requirements of a PAEHR system in mental health. As part of a participatory design process, we collected qualitative data from service users and staff in a rural mental health day clinic setting, which can be summarized in the following themes: I) Function and way of the documentation; II) Impact on Treatment; III) Concerns about PAEHRs; IV) time of access to PAEHRs; V) Different views on what to share; VI) Access, Data Privacy and Special Features. Our study uncovered the complexity and special requirements and barriers to the design of PAEHR in mental health. While we are in an early stage of our study, we will continue this iterative process and adapt the PAEHR system to the specific needs of the users and domains.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Analysis of patient preferences on patient-provider interactions through the OpenNotes online portal in dermatology

Background: Many medical centers are beginning to use OpenNotes (ON) to empower patients. However, there is a lack of literature reviewing the ON system in dermatology and any differences in attitudes between men and women. If so, it is uncertain what concerns are more important to female patients. Given the complex lexicon of notes in dermatology, the outpatient setting of dermatology practices, and the often-complex nature of treatment regimens, investigation was merited.

Objective: This paper aimed to evaluate a survey of dermatologic patients on their attitudes toward the ON system.

Methods: From July through October 2015, 333 dermatologic patients at the Beth Israel Deaconess Medical Center completed an anonymous, voluntary, 25-question survey of the ON system while in the waiting room. Approximately 60% of respondents were female and 40% were male. Respondents were older, with 27% age >65 years, 21% between 56 and 65 years, 16% between 46 and 55 years, 17% between 36 and 45 years, 14% between 26 and 35 years, and 4% between 18 and 25 years. Eighty-five percent of respondents were white, and 73% had, at minimum, graduated from college.

Results: Patient response to ON was positive, with 93% agreeing ON is a good idea. Of the patients who accessed their own notes (69% of respondents), 99.6% desired continued access. In addition, 85.6% of patients felt ON allowed them to control their own health, and 70% reported increased confidence in their dermatologist. Nineteen percent of respondents thought ON presented a privacy concern.

Conclusion: The results showed that female patients strongly desire access to their medical records, but concerns about privacy and security exist. Preliminary analysis by a statistician did not find any statistically significant variations between men and women within the results of the survey. Due to the wide agreement in responses, it is unlikely that there are significant differences in opinion on ON between men and women.

"I think it's something that we should lean in to": The use of OpenNotes in Canadian psychiatric care contexts by clinicians

BACKGROUND

OpenNotes is the concept of patients having access to their health records and clinical notes in a digital form. In psychiatric settings, clinicians often feel uncomfortable with this concept, and require support during implementation.

OBJECTIVE

This study utilizes an implementation science lens to explore clinicians' perceptions about using OpenNotes in Canadian psychiatric care contexts. The findings are intended to inform the co-design of implementation strategies to support the implementation of OpenNotes in Canadian contexts.

METHOD

This qualitative descriptive study employed semi-structured interviews which were completed among health professionals of varying disciplines working in direct care psychiatric roles. Data analysis consisted of a qualitative directed content analysis using themes outlined from an international Delphi study of mental health clinicians and experts. Ethical approval was obtained from the Centre for Addiction and Mental Health and the University of Toronto.

RESULTS

In total, 23 clinicians from psychiatric settings participated in the interviews. Many of the themes outlined within the Delphi study were voiced. Benefits included enhancements to patient recall, and empowerment, improvements to care quality, strengthened relational effects and effects on professional autonomy and efficiencies. Despite the anticipated benefits of OpenNotes, identified challenges pertained to clarity surrounding exemption policies, training on patient facing notes, managing disagreements, and educating patients on reading clinical notes.

CONCLUSION

Many benefits and challenges were identified for adopting OpenNotes in Canadian psychiatric settings. Future work should focus on applying implementation frameworks to develop interventions that address the identified challenges.

Sharing Clinical Notes in a Canadian Mental Health Setting: Recommendations from Applying the Consolidated Framework for Intervention Research

During the COVID-19 pandemic, the OpenNotes movement presents an optimal solution for virtual engagement through the sharing of clinical notes within mental health care settings. Therefore, we conducted interviews to discover how mental health clinicians interact with patients using OpenNotes. We integrated The Consolidated Framework for Intervention Research to establish implementation recommendations. As both challenges and opportunities were identified, future research should address challenges to foster patient and clinician engagement in sharing clinical notes.

OpenNotes: Anticipatory Guidance and Ethical Considerations for Pediatric Psychologists in Interprofessional Settings

OBJECTIVES

The 21st Century Cures Act included an "OpenNotes" mandate to foster transparent communication among patients, families, and clinicians by offering rapid electronic access to clinical notes. This article seeks to address concerns about increased documentation burden, vulnerability to patient complaints, and other unforeseen consequences of patients having near-real-time access to their records.

METHODS

This topical review explores both extant literature, and case examples from the authors' direct experience, about potential responses/reactions to OpenNotes.

RESULTS

The ethics of disclosing medical information calls for nuanced approaches: Although too little access can undermine a patient's autonomy and the capacity for truly egalitarian shared decision-making, unfettered access to all medical information has significant potential to harm them. Suggested strategies for mitigating risks in premature disclosure include patient and provider education and "modularizing" sensitive information in notes.

CONCLUSION

The OpenNotes era has ushered in the possibilities of greater patient and family collaboration in shared decision-making and reduced barriers to documentation sharing. However, it has raised new ethical and clinician documentation considerations. In addition to clinician education, patients and families could benefit from education around the purpose of clinical documentation, how to utilize OpenNotes, and the benefits of engaging in dialogue regarding the content and tone of documentation.

Problems with the problem list: challenges of transparency in an era of patient curation

In recent years, the OpenNotes movement and other changes in healthcare have driven institutions to make medical records increasingly transparent. As patients have begun to question and request changes to their Problem Lists, clinicians have come to face the ever more frequent challenge of discerning which changes to make and which to refuse. Now clinicians and patients together choose the list of problems that represent the patient's current state of health and illness. As the physician's role slides closer to consultant and the medical paternalism of the twentieth century falls further into the background of our technology-infused present, who holds the power of delineating a patient's clinical identity? This paper examines the ethical and practical dimensions of this question and proposes a research agenda that aims to answer it. Such explorations are essential to ensuring that the physician remains relevant to patient's notions of health, illness, intervention, and healing.

How technology impacts communication between cancer patients and their health care providers: A systematic literature review

OBJECTIVE

To ensure the well-being of their patients, health care providers (HCPs) are putting more effort into the quality of the communication they provide in oncology clinics. With the emergence of Health Information Technology (HIT), the dynamics between doctors and patients in oncology settings have changed. The purpose of this literature review is to explore and demonstrate how various health information technologies impact doctor-patient communication in oncology settings.

METHOD

A systematic literature review was conducted in 4 databases (PubMed, Cochrane, Web of Science, IEEE Xplore) to select publications that are in English, published between January 2009 and September 2020. This review reports outcomes related to the impacts of using health information technologies on doctor-patient communication according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Reviews and Meta-Analysis guidelines (PRISMA).

RESULTS

We identified 31 studies which satisfied the selection and eligibility criteria. The review revealed a diverse range of HIT used to support communication between cancer patients and their HCPs in oncology settings. Outcomes related to communication were examined to demonstrate how technology can improve access to care in clinical settings and online. When technology is used effectively to support patient knowledge and shared understanding, this increases the patient's satisfaction and ability to manage emotions, make decisions, and progress in their treatment, in addition to increasing social support and building a stronger therapeutic alliance based on shared knowledge and transparency between clinicians and patients.

CONCLUSION

Technology-based solutions can help strengthen the relationship and communication between patients and their doctors. They can empower the patient's well-being, help doctors make better decisions and enhance the therapeutic alliance between them. Thus, using technology to enhance communication in healthcare settings remains beneficial if its use is structured and target oriented. Future studies should focus on comparing in-depth the difference between outpatient and inpatient settings in terms of the efforts required and the extent of the impacts from both clinicians' and cancer patients' perspectives.

Augmenting patient safety through participation by design - An assessment of dual monitors for patients in the outpatient clinic

BACKGROUND

Patients and physicians engaging together in the electronic health record (EHR) during clinical visits may provide opportunities to both improve patient understanding and reduce medical errors.

OBJECTIVE

To assess the potential impact of a patient EHR display intervention on patient quality and safety. We hypothesized that if patients had a dedicated display with an explicit invitation to follow clinicians in the EHR that this would identify several opportunities to engage patients in their care quality and safety.

MATERIAL AND METHODS

Physician-patient outpatient encounters (24 patients and 8 physicians) were videotaped. Encounters took place in a hospital-based general internal medicine outpatient clinic where physicians and patients had their respective EHR monitors. Following the visits, each patient and physician was interviewed for 30 min to understand their perception of the mirrored-screen setting.

RESULTS

The following 7 themes were identified (a) curiosity, (b) opportunity to ask questions, (c) error identification, (d) control over medications, (e) awareness, (f) shared understanding & decision-making, (g) data privacy. These themes collectively comprised a conceptual model for how patient engagement in electronic health record use, through a dedicated second screen or an explicitly shared screen, relates to safety and quality opportunities. Therefore, the double EHR screen provides an explicit invitation for patients to join the process to influence safety.

CONCLUSION

Desired outcomes include real-time error identification and better-shared understanding and decision-making, leading to better downstream follow-through with care plans.

General patients' expectations on online accessibility to their electronic health records in Japan

Allowing patients to access their electronic health records (EHR) online, that we call the patient open- EHR, may help patients better understand and remember their health information, leading to improved health outcomes. In Japan, such solution is not yet widespread, and general patients' expectations for such solution are not known. The OpenNotes initiative in the United States of America (USA) had done various studies concerning the intervention of sharing doctors' notes, which are part of the EHR, with patients. Our study objective is to explore general patients' expectations toward potential benefits and risks of the patient open-EHR solution if given chance to use in Japan. A cross-sectional study was done using an online questionnaire. One hundred and eighty-three general patients without previous experience using the patient open-EHR service, responded to our survey after being recruited through SNS and posters at a university hospital not offering the solution. Comparison with the result of the OpenNotes original study, conducted in a similar setting, was also done. The results showed that participants were, similarly to the OpenNotes results, positive about the system's potential benefits; 90% agreed on the system ability to help them better understand their condition and remember their healthcare plan. On the other hand, they were much concerned about the potential risks especially privacy; 62% agreed they would be worried about their privacy. Adequate measures to provide highly secured systems and to allow patients to be better informed about the use of their personal health records should be taken to comfort future users.

Patient Perception of Plain-Language Medical Notes Generated Using Artificial Intelligence Software: Pilot Mixed-Methods Study

Background

Clinicians’ time with patients has become increasingly limited due to regulatory burden, documentation and billing, administrative responsibilities, and market forces. These factors limit clinicians’ time to deliver thorough explanations to patients. OpenNotes began as a research initiative exploring the ability of sharing medical notes with patients to help patients understand their health care. Providing patients access to their medical notes has been shown to have many benefits, including improved patient satisfaction and clinical outcomes. OpenNotes has since evolved into a national movement that helps clinicians share notes with patients. However, a significant barrier to the widespread adoption of OpenNotes has been clinicians’ concerns that OpenNotes may cost additional time to correct patient confusion over medical language. Recent advances in artificial intelligence (AI) technology may help resolve this concern by converting medical notes to plain language with minimal time required of clinicians.

Objective

This pilot study assesses patient comprehension and perceived benefits, concerns, and insights regarding an AI-simplified note through comprehension questions and guided interview.

Methods

Synthea, a synthetic patient generator, was used to generate a standardized medical-language patient note which was then simplified using AI software. A multiple-choice comprehension assessment questionnaire was drafted with physician input. Study participants were recruited from inpatients at the University of Colorado Hospital. Participants were randomly assigned to be tested for their comprehension of the standardized medical-language version or AI-generated plain-language version of the patient note. Following this, participants reviewed the opposite version of the note and participated in a guided interview. A Student t test was performed to assess for differences in comprehension assessment scores between plain-language and medical-language note groups. Multivariate modeling was performed to assess the impact of demographic variables on comprehension. Interview responses were thematically analyzed.

Results

Twenty patients agreed to participate. The mean number of comprehension assessment questions answered correctly was found to be higher in the plain-language group compared with the medical-language group; however, the Student t test was found to be underpowered to determine if this was significant. Age, ethnicity, and health literacy were found to have a significant impact on comprehension scores by multivariate modeling. Thematic analysis of guided interviews highlighted patients’ perceived benefits, concerns, and suggestions regarding such notes. Major themes of benefits were that simplified plain-language notes may (1) be more useable than unsimplified medical-language notes, (2) improve the patient-clinician relationship, and (3) empower patients through an enhanced understanding of their health care.

Conclusions

AI software may translate medical notes into plain-language notes that are perceived as beneficial by patients. Limitations included sample size, inpatient-only setting, and possible confounding factors. Larger studies are needed to assess comprehension. Insight from patient responses to guided interviews can guide the future study and development of this technology.

OpenNotes in oncology: oncologists' perceptions and a baseline of the content and style of their clinician notes

Patients' ability to access their provider's clinical notes (OpenNotes) has been well received and has led to greater transparency in health systems. However, the majority of this research has occurred in primary care, and little is known about how patients' access to notes is used in oncology. This study aims to understand oncologists' perceptions of OpenNotes, while also establishing a baseline of the linguistic characteristics and patterns used in notes. Data from 13 in-depth, semistructured interviews with oncologists were thematically analyzed. In addition, the Linguistic Inquiry and Word Count (LIWC) program evaluated over 200 clinician notes, measuring variables encompassing emotions, thinking styles, social concerns, and parts of speech. Analysis from LIWC revealed that notes contained negative emotional tone, low authenticity, high clout, and high analytical writing. Oncologists' use of stigmatized and sensitive words, such as "obese" and "distress," was mainly absent. Themes from interviews revealed that oncologists were uncertain about patients' access to their notes and may edit their notes to avoid problematic terminology. Despite their reluctance to embrace OpenNotes, they envisioned opportunities for an improved patient-provider relationship due to patients initiating interactions from viewing notes. Oncologists believe notes are not intended for patients and altering their content may compromise the integrity of the note. This study established a baseline for further study to compare notes pre-implementation to post-implementation. Further analysis will clarify whether oncologists are altering the style and content of their notes and determine the presence of patient-centered language.